Upright birth equals better outcomes. Why isn’t this the norm?

I wonder about the blind belief in medicalised birth that keeps some practices in play when both the obvious and studies show that it’s more detrimental to the birthing mother.

The position in which women give birth is one of those. “Despite evidence supporting benefits of upright and flexible sacral positions during labour, most women continue to birth in supine positions.”

In this latest study, Upright positions during the second stage of labour and birth outcomes: A prospective observational study (Tinker et al., 2026), they find that a physiological position, i.e. upright, squatting, hands-and-knees, birth stool, etc, resulted in fewer instrumental deliveries.

“Women who birthed physiological more frequently adopted all-fours position or used a birth stool, whereas those who had an instrumental birth were more often in semi-recumbent or lithotomy positions. For every 10% increase in time spent in upright positions during the active second stage, the likelihood of physiological birth increased by 26%. Conversely, each 10% increase in time spent in a supine position there was a 30% increased likelihood of instrumental birth.”

While this study assessed the rate of instrumental deliveries as it relates to maternal positioning, we have information from 10 years ago that compares physicians with a 100% supine (on her back) delivery protocol with midwives who facilitate the position of the mother’s choosing (Terry et al., 2006) Unsurprisingly, women who birthed with a midwife in an upright position had significantly less perineal trauma. Less than 1/4 of the women in the physician-supine group had an intact perineum after birth whereas more than 1/2 the midwife-upright group had an intact perineum. The physician-supine group also had more severe perineal trauma, perhaps in part due to their use of episiotomy.

Despite the evidence for the benefits of upright physiological birth, why do most women continue to give birth on their backs? Perhaps in part it’s due to the high use of epidural analgesia that limits a woman’s mobility. But more realistically, it comes down to how physicians are trained and entrenched cultural norms of medicalised birth.

In searching for birth simulators, 100% of my results involved a supine simulator where practitioners would develop skills predicated on the patient being on their backs. Have a look at this “advanced” obstetrical training tool. It explains a lot.

Indeed, encouraging a mother to birth in a physiological position that benefits her and her baby could leave the “skilled” attendant at a loss since they are not routinely taught these skills. An untrained attendant is a risk factor for poorer outcomes, which is what we’re seeing.

I have witnessed women “just say no” to birthing on their backs - to no avail. The training and culture of institutional birth will more often trump maternal rights when it comes to “safety”. And for practitioners unskilled in upright physiological birth, a mother on her back is the safer approach - for the attendant.