Normality and Goalposts

The question of normality is an important one when it comes to birth and midwifery. I’m always interested to see studies which set out to better understand what ‘normal’ looks like in particular areas. Often, these note that ‘normal’ is not well understood. That’s a key thing to remember in health care. And maternity care. Especially when we consider that the decision about whether something is normal or otherwise can have massive implications for women, babies and families.

The findings of such research enable us to further reflect upon the concept of normality, an area much-debated within midwifery and further afield. As Holly Powell-Kennedy pointed out, ‘‘‘normal,’’ as it pertains to childbirth, is problematic. Normal is defined as ‘‘regular, usual, typical, ordinary, and conventional; physically and mentally sound; free from any disorder; healthy.’’ It is a word that dichotomizes—if you are not ‘‘normal,’’ then you must be abnormal, atypical, disordered, unhealthy, or irregular—and who wants those labels?’ (Powell-Kennedy 2010:199).

The problem of goalposts

This commentary highlights the problem that arises when we create goalposts – or markers around what we consider normal. The creation of a space which is determined to be normal (or, to continue using the metaphor, the goal) necessarily and unavoidably creates another space (everywhere except the goal) which is, for whatever reason, deemed to be NOT normal.

Yet there is a vast difference between the use of a goal in, well, say football, and the use of a similar kind of defined space in relation to birth. I can’t imagine that many Premiership referees would support a petition for goalposts which are individually flexible depending on the team, yet the need for flexibility is often debated when we consider the definition of what is normal in birth.

The defining of normal space itself is probably inescapable, however. Many people, including myself, have questioned the usefulness of population-level goalposts. But these are an inevitable feature of systems of maternity care where guidelines and shared understandings are a necessary means of maintaining order. And even those midwives who work autonomously and outside of systemic guidelines need to have criteria for determining whether a woman’s experience is normal or otherwise. Thus studies which consider normality are vital, especially as we have little understanding of what normal really looks like in some areas.

Flexibility is key

So flexibility is key, for a number of reasons. Not least of which is the fact that normal can encompass a vast range and vary among different people. Even when ‘normal’ is accepted to encompass a range, though, there still have to be a cut-off points.

But the difficulties continue. People can fall inside the range but be in need of help. Just as one can fall outside the range and be okay. And definitions of normal aren’t always quantifiable or shared. One of the first things that a woman and a midwife will talk about, for example, is the so-called ‘due date‘. Even in an age where most women end up having their due date determined by technology, this still usually entails a conversation about the woman’s last menstrual period. A question frequently asked by midwives is whether this last menstrual period was a normal one. We ask this in order to determine (among other things) whether it was actually a menstrual period or whether it might have been an implantation bleed.

A midwife who I interviewed about this topic a few years ago shared how, when asking women whether their last period was a normal one, she asks each woman to describe what a normal period was like for her. Not, she stressed, because she felt she knew better. Not because she would tell the woman that her idea of normal was incorrect. Because she had learned over the years that women have such a vast range of bodily experiences. So it’s easy – unless we ask for clarity – to make erroneous assumptions about what the concept of normal means to an individual woman.

“Normal” urine output after caesarean

A few years ago, I wrote about a couple of studies which had explored this area. There are countless more, and it’s always important to look at the bigger picture and not just individual studies, but they are both good examples of why we need to know more about what ‘normal’ looks like.

Mackenzie et al (2010) considered the question of what ‘normal’ urine output looks like after a caesarean. They recognised that it is deemed important in practice to monitor women’s urine output after caesarean section because of the potential for this surgery to interfere with women’s physiology. Women are given large volumes of intravenous fluids, for instance, and anaesthetic drugs can impact them in myriad ways. But no-one really had any evidence that could help them decide what was normal after such surgery. The goalposts were either non-existent or they were determined by individual practitioners. (And, like it or not, the practitioners are the equivalent of referees in this metaphor.) In the absence of evidence, practitioners had no option but to base their knowledge on experience. But experience may or may not be representative. Mackenzie et al’s (2010) study thus set out to attempt to determine the location of the goalposts and found, even in a small sample of women, that the range of experiences was wide.

“Normal” postpartum sleep

A study by Montgomery-Downs et al (2010) was equally interesting, albeit for different reasons. They considered the question of what constituted normative longitudinal sleep in the first four months of the postpartum period. As the authors of this study acknowledged, it’s really difficult to measure every aspect of women’s sleep. One of their findings initially seemed surprising; they suggested that women with new babies spend more time sleeping than we might think. But then there’s an important caveat: this sleep, however, is highly fragmented. Which isn’t ideal. Fragmentation is an important feature of sleep and it’s increasingly recognised as being key to a person’s well-being.

These results also relate to another key aspect of the normality debate. In order to be helpful, we need to be measuring and monitoring the right elements of women’s experiences. If we accept the findings of this study, for instance, they suggest that it may be more useful to focus on the quality of a woman’s sleep. Something which needs to be determined in part by the woman herself. Which is interesting, because, in modern culture, the power to define normal has generally lain firmly in the hands of the professional referee.

A springboard?

As I’ve already noted, looking at individual studies isn’t enough when we are trying to learn about an area. There are other aspects to both of these conversations. There are studies that show different things, and many other elements that midwives, doctors and others will take into account in both of these areas. But my point isn’t about the results per se. I’ve shared these examples to show how critical thinking can help us to explore this aspect of so-called normality. Perhaps such findings can help provide a springboard. We need to further explore how women can engage in defining and determining normality with us. Ideally, in a way which is flexible, which acknowledges the range that exists in nature and which draws upon the useful aspects of this notion without causing unnecessary stress and intervention when missing the goal incurs an unwarranted penalty.

References

Kennedy HP (2010). The problem of normal birth. Journal of Midwifery and Women’s Health 55(3):199-201.

Mackenzie MJ, Woolnough MJ, Barrett N et al (2010). Normal urine output after elective caesarean section: an observational study. International Journal of Obstetric Anesthesia 19(4):379-83.

Montgomery-Downs HE, Insana SP, Clegg-Kraynok MM et al (2010). Normative longitudinal maternal sleep: the first 4 postpartum months. American Journal of Obstetrics and Gynecology 203(5):465-6.