By Tanya Cawthorne, MWomenChldH, LCCE, FACCE

A recent University of Reading study has generated considerable media attention, with some commentators arguing that women are being harmed by unrealistic expectations of achieving a “natural” birth.

Professor Erwin Loh, President of the Royal Australasian College of Medical Administrators, recently highlighted the study’s findings, suggesting that pressure from antenatal classes, social media and healthcare professionals to have a natural birth may be contributing to psychological harm when birth does not go according to plan. Birth Trauma Australia CEO Amy Dawes has similarly argued that “natural birthing ideology” has been harming women for decades.

It is an appealing narrative.

It is also one that risks diverting attention from what the evidence has been telling us for years about the real drivers of birth trauma.

The University of Reading study explored the experiences of 21 first-time mothers whose births did not meet their expectations. The researchers concluded that many women internalised feelings of failure, shame and self-blame when their births diverged from an anticipated physiological vaginal birth, proposing a concept they describe as “intensive birthing ideology.”

There is value in understanding this phenomenon. Some women undoubtedly experience distress when a birth unfolds very differently from what they had hoped for or prepared for.

However, a qualitative study of 21 women cannot tell us what causes birth trauma at a population level. Nor can it justify the increasingly common claim that advocacy for physiological birth, childbirth education, or so-called “natural birth” philosophies are major contributors to birth trauma.

When we examine larger and more representative bodies of evidence, a very different picture emerges.

The recent analysis (Keedle et al, 2026) of 1,213 submissions to the NSW Birth Trauma Inquiry found that the most commonly reported experience was not disappointment about an unplanned caesarean section, epidural or induction.

It was obstetric violence.

The researchers found that obstetric violence was the most frequently identified category, followed by lack of care and support. Physical trauma ranked third. Women described experiences of coercion, dismissal, dehumanisation, disrespect, neglect, lack of informed consent and abuse.

These findings should give us pause because they suggest that many women are not traumatised because birth failed to match an idealised vision. They are traumatised because the care they received failed to meet reasonable standards of safety, dignity and respect.

For decades, birth trauma researchers have consistently identified the same themes: loss of control, poor communication, coercion, inadequate support, lack of informed consent, and experiences of disrespect or abuse. The subjective experience of birth – not simply the clinical outcome – is what most strongly predicts psychological trauma.

This is not new information.

More than twenty years ago, Ellen Hodnett’s landmark review of women’s satisfaction with childbirth found that the factors most strongly associated with positive birth experiences were not mode of birth, pain levels, or whether labour proceeded exactly as planned. Women consistently valued being informed, being involved in decision-making, receiving continuous support, and maintaining a sense of control over what was happening to them.

The evidence has remained remarkably consistent for more than two decades. Women can experience a positive birth regardless of whether that birth involves induction, epidural analgesia, instrumental assistance or caesarean section, while others may experience significant trauma following an otherwise uncomplicated vaginal birth. This is because birth satisfaction and birth trauma are not determined solely by clinical outcomes or mode of birth.

Rather, they are strongly influenced by women’s experiences of communication, informed consent, respect, support, autonomy and safety. In other words, it is often not the intervention itself that women remember most, but the way in which care was delivered and the extent to which they felt seen, heard and involved in decisions about their bodies and their babies. The framing of a monolithic “natural birth movement” is particularly problematic because it creates a false dichotomy that bears little resemblance to contemporary maternity care or childbirth education.

Advocating for physiological birth where it is safe and appropriate is not the same as opposing medical intervention.

Promoting informed decision-making is not the same as promoting vaginal birth at all costs.

Supporting women’s autonomy means supporting the woman who chooses an epidural or caesarean section just as strongly as the woman hoping for a physiological birth.

Unfortunately, discussions about birth trauma too often descend into simplistic binaries: natural versus medical, midwife versus doctor, homebirth versus hospital birth, vaginal birth versus caesarean section.

These divisions obscure a far more important conversation.

Australia’s maternity system continues to grapple with significant structural challenges, including fragmented models of care, inequitable access to services, institutional racism experienced by First Nations women and culturally diverse communities, persistent gender bias within healthcare, and intervention rates that frequently exceed levels associated with optimal maternal and neonatal outcomes.

Yet these systemic issues receive far less attention than debates about women’s expectations.

If we are serious about reducing birth trauma, we should be asking why so many women continue to report experiences of coercion, neglect and disrespect within our maternity services.

We should be asking why continuity of care remains unavailable to many women despite decades of evidence demonstrating its benefits.

We should be asking why informed consent remains inconsistently practised.

And we should be asking why high-quality childbirth education remains inaccessible to many Australian families.

The irony is that some of the strongest evidence we have for reducing birth trauma comes from interventions that empower women rather than diminish their expectations.

Continuity of midwifery care is associated with improved maternal satisfaction, lower rates of intervention, increased trust in care providers, and better psychosocial outcomes. Women receiving continuity models consistently report feeling more informed, more respected and more involved in decision-making throughout pregnancy, birth and the postnatal period.

High-quality childbirth education also remains one of the most underappreciated tools available to improve women’s experiences of birth and reduce the risk of birth trauma. At its best, childbirth education does not promise women a particular type of birth, nor does it suggest that interventions such as epidurals, inductions or caesarean sections represent failure. Rather, its purpose is to prepare women and their partners for the realities of birth in all its unpredictability. Women who understand the physiology of labour, the indications for common interventions, the principles of informed consent and refusal, and the skills required to communicate effectively with care providers are better equipped to navigate whatever circumstances arise. They are also more likely to remain active participants in decision-making throughout their care, regardless of how their birth unfolds.

This remains one of the enduring strengths of Lamaze education. Far from promoting a rigid ideology of “natural birth”, Lamaze has spent more than six decades championing evidence-based childbirth education that prepares families for the full spectrum of birth experiences. Its enduring relevance lies in its recognition that birth is inherently unpredictable and that women are best served not by promises of a particular outcome, but by access to high-quality information, practical coping skills, and support to participate meaningfully in decisions about their care. After more than 65 years, Lamaze remains the gold standard in childbirth education because it focuses not on achieving a specific mode of birth, but on helping women approach birth informed, prepared and empowered, whatever path their birth may take.

This raises a more important question than whether women’s expectations are too high. The real question is whether our maternity services are consistently delivering the standard of care women have every right to expect. Women should be able to expect respectful, evidence-based care; meaningful involvement in decisions affecting their bodies and babies; genuine informed consent; continuity of care where possible; and compassionate support throughout pregnancy, birth and the postnatal period. These are not aspirational ideals or unrealistic demands. They are the fundamental principles of high-quality healthcare.

When women emerge from birth feeling unheard, disempowered, dismissed or violated, we should be cautious about attributing their distress to unrealistic expectations. Doing so risks shifting responsibility away from the systems, structures and practices that evidence repeatedly identifies as contributing to birth trauma. It reframes trauma as a problem of women’s beliefs rather than a problem of the care they received.

The thousands of women who contributed to the NSW Birth Trauma Inquiry told a very different story. Their accounts were not primarily characterised by disappointment that birth had unfolded differently from their plans. Rather, they described experiences of coercion, neglect, lack of support, inadequate communication, loss of autonomy and, in many cases, obstetric violence. Their testimony serves as a powerful reminder that the solution to birth trauma is not teaching women to expect less from maternity care. It is ensuring that maternity care does better.

Ultimately, the debate should not be about whether women are too invested in achieving a particular kind of birth. It should be about how we create maternity systems that respect women’s autonomy, provide evidence-based care, support informed decision-making and foster genuine partnership between women and their care providers. If we are serious about reducing birth trauma, that is where our attention should be focused. The message emerging from the evidence – and from the women themselves – is not that expectations need to be lowered. It is that women deserve better.

References

Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186(5 Suppl. Nature), S160–S172. https://doi.org/10.1067/mob.2002.121141

Keedle, H., Keedle, W., Thomson, G., & Dahlen, H. G. (2026). “We shouldn’t have to beg to be heard”: A qualitative framework analysis of the public submissions to the NSW Birth Trauma Inquiry. Women and Birth, 39, 102209. https://doi.org/10.1016/j.wombi.2026.102209

Matthews, R., Harman, V., & Finlay, K. (2026). “Gold standard” birth: Unmet birth expectations and the ought-maternal-self. Social Science & Medicine, 403, 119448. https://doi.org/10.1016/j.socscimed.2026.119448

New South Wales Legislative Council Select Committee on Birth Trauma. (2024). Birth trauma (Report No. 1). Parliament of New South Wales. https://www.parliament.nsw.gov.au/lcdocs/inquiries/2965/FINAL%20Birth%20Trauma%20Report%20-%2029%20April%202024.pdf