Book Review: Birthing Outside the System: The Canary in the Coal Mine

ISSN 2516-5852 (Online)

AIMS Journal, 2020, Vol 33, No 1

Complete list of book reviews on the AIMS website

Birthing Outside the System: The Canary in the Coal Mine

Edited by Hannah Dahlen, Bashi Kumar-Hazard and Virginia Schmied

Published by Routledge 2020

ISBN: ISBN 9781138592704

484 pages

Publisher’s recommended price £120 (hardback) or £36.99 (ebook)

Buy this book on Amazon

Birthing Outside the System book cover

A note from AIMS Book Review Editor, Jo Dagustun

Once in a while, birth activists around the world hear about a book in preparation that lifts our hearts. In late 2019, this was one such book, and it’s a pleasure to offer here a review by two AIMS Volunteers: Gemma McKenzie (who is currently studying for a PhD, reads and produces academic texts for her day job) and Virginia Hatton (AIMS Publications Volunteer).

In offering this review, we wish to send a strong message of thanks to the authors and editors of this book for ensuring that this “serious academic text” is also highly accessible to – and useful for – those outside of the academic world who seek to “support all maternity service users to navigate the system as it exists, and campaign for a system which truly meets the needs of all” (wording taken from the AIMS mission statement, 2017).

As Virginia notes below, the price of this text is high: this partly reflects the extent of its content, but also the academic book market in which and for which it is primarily produced. It might be assumed that most readers will likely be accessing it for free via their university library. We very much hope that this does not put you off. We would instead urge you to request that this book is purchased by your local public library, so that it is easily available to everyone in your local maternity service improvement community, or perhaps opt to purchase the ebook over the more expensive hardcover version.

A review by Gemma McKenzie

Where to begin with this incredible book? I had initially believed it to be about freebirth and had envisioned an afternoon curled up on the sofa with a cup of tea and my YouTube log fire blazing on the TV while I indulged in an exploration of the subject. But this is not a book about freebirth; it is 450 pages of jaw-dropping, anger-inducing, galvanizing text that makes you want to get out of your armchair and join the battle to protect human rights in pregnancy and childbirth. The way in which autonomy, bodily integrity and abuse were explored made me want to dive into the pages for more information while simultaneously looking away in despair.

This is no holiday read to enjoy on a sun lounger; the book contains trauma, racism, misogyny and injustice, but is also peppered with rays of light that illuminate good practice and genuine efforts to improve the maternity system. It is also truly international and shifts discussion on birth away from the countries we are perhaps most familiar with – the UK, USA and Australia – and delves into the maternity experiences of women in the Netherlands, Hungary, Jordan, India and Russia. Alongside expected perspectives such as those of midwives, obstetricians and birth workers, the writing comes from a range of people including Aboriginal women in Australia, a lawyer, and an anthropologist.

Unusually for an academic book, the authors are painfully honest about their own birthing experiences. This serves to humanise them in a way we don’t typically see in research texts. We see that the authors are real people who have experienced highs, lows, joy, loss and grief. Their lived experiences add depth to their academic work and we can then better understand the passion behind their words.

It would be impossible for me to present all the precious nuggets of information contained in this book. But there are a few things that stand out. One is the term ‘bait and switch’, which appeared in chapter 10 with regards to birth choices in Eastern Europe and Russia. This is a term I had never heard before, but it means that prior to labour, health care professionals falsely assure women that their birthing preferences and requests will be met. The ‘bait’ is the false assurance that ensures that a woman complies, and the ‘switch’ occurs when the woman arrives at the hospital where she finds that those requests and preferences will not be honoured. Although this was written about Eastern Europe, I know from my own birthing experiences that this tactic is alive and well in the UK. I find it incredibly useful to know that there is an actual term and available vocabulary to describe this behaviour, and that it has been recognised as a phenomenon that needs to be challenged.

There were also passages in the book that made me stop in my tracks due to their poignancy. These were moments when I wanted to slam my finger down on the page and shout ‘Yes – I agree entirely!’ Whilst I could probably quote huge sections of the book, I will limit myself to three short examples. The first comes from the chapter by Kaveri Mayra and Bashi Kumar Hazard. Writing about the Australian system, they state that:

Women are groomed to seek permission in relation to their own bodily autonomy. (p.203)

In a second example, author Bec Jenkinson writes:

Being able to decline recommended care is an acid test of woman-centred care… (p.321)

And finally, in reference to the ‘trick question’ of what are people’s rights during birth, authors Farah Diaz-Tello and Bashi Kumar-Hazard respond:

…the most important right possessed by a person giving birth is the right to be afforded all the same rights with which every other human being is endowed. (p.283)

I could go on and probably list another 20 quotes. But I won’t. Instead, I will urge you to get hold of this text and read it from cover to cover. I guarantee there will be sections in this book that will stir your emotions and stimulate your mind. If you have given birth, there will be passages that you will be able to relate to and other areas where you will be exposed to totally new ideas. I have read hundreds of articles and books on childbirth and maternity care – but without doubt this is one of the best.

Supplementary review by Virginia Hatton

I had the good fortune to start reading this book over Christmas and I wholeheartedly echo Gemma’s judgment that this is an essential read for birth workers and birth activists. The intertwining of personal birthing experiences of the authors with sensitively conducted interdisciplinary research sets a new standard for books about birth and maternity care.

This book gave me a new understanding of birthing people and midwives’ autonomy, and the language and tools to support their autonomy in my own community.

What is autonomy?

We all need to feel a sense of control over our own lives, or at least, our own behaviour. Autonomy can equate with individual choice, but is more complex than merely selecting from available options and is not necessarily individualistic. When autonomy is satisfied, we experience willingness, volition and responsibility for our own behaviour. When autonomy is frustrated, we have a sense of being controlled by outside forces or of losing the ability to determine our own behaviour or what happens to us. Women who free birth point to feelings of autonomy when they describe themselves as both responsible and able to make decisions and be in charge during their births. (p.49 emphasis added)

Autonomy, competence and relatedness are not just the needs of a handful of women. They are the innate requirements of all women. (p. 50 emphasis added)

Before reading this book, I associated ‘autonomy’ with words such as ‘confidence’, ‘empowerment’, and ‘informed decision making’. I thought of autonomy as something that birthing people ‘exercised’. I’d never thought of it as something to be ‘satisfied’, as in the quote above. Reading this book deepened my understanding of how autonomy is upheld in UK human rights law and central to national maternity strategies. It also increased my awareness that autonomy is not only something that women exercise, but also something that can be taken away by health care providers and midwives. Examples of this include lack of choice in decision making, lack of consent for procedures and coercion (including social services threats, ‘dead baby card’, influencing family members, repetitive discussions of risks)1. Therefore, whenever these situations come up in meetings and communication I have with my local maternity services, I’m going to start reminding those involved that these actions also took away the birthing person’s autonomy, something the law protects and that maternity care is meant to satisfy.

My only criticism of the book is that it is expensive, and this could limit access to the important messages it holds. I’d encourage AIMS members to see if their local libraries can purchase a copy or access it through an interlibrary loan. In addition, the many health care acronyms from around the world at times posed a challenge to myself as a lay reader. However, this was far outweighed by the benefit of hearing diverse voices from many countries, particularly ones we do not read about as much in UK birth literature.

As an AIMS volunteer it was also heartening to see the AIMS Journal cited in the references and to know that our time and effort as volunteers in keeping the Journal going is contributing to these important international conversations about birth. I highly recommend this book and look forward to discussions about it with other AIMS members in the future.

1 Birthing outside the system, p. 83

AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email or ring 0300 365 0663.

Latest Content


« »

On message - What can we learn from…

AIMS Journal, 2020, Vol 33, No 1 By Sophie Martin We all have continuous internal monologues running day and night 1 . Much of what the voices in our heads say is a refle…

Read more

Getting to grips with the first Ock…

AIMS Journal, 2020, Vol 33, No 1 By the AIMS Campaigns Team Donna Ockenden and her team’s first – interim – report was published in December 2020. It starts to lay bare h…

Read more

Editorial: Salutogenesis - Putting…

AIMS Journal, 2020, Vol 33, No 1 By Alex Smith The theme for our March edition of the AIMS Journal is Salutogenesis. Salutogenesis is a term introduced by sociologist and…

Read more


« »

AIMS 60th Anniversary Event - Confe…

POSTPONED FROM JUNE 2020 Making a difference past and future The purpose of the day is to celebrate what Birth Activists in general and AIMS in particular have achieved,…

Read more

AIMS Annual General Meeting 2020

This year’s AGM will be an online meeting, so we plan to keep it to two hours. However, there will be the opportunity to stay, chat and socialise with friends and colleag…

Read more

Latest Campaigns

« »

Report on the But Not Maternity/Nat…

AIMS and our partners in the But Not Maternity Alliance and National Maternity Voices organised a webinar for MVP/MSLC representatives. The purpose was to raise awareness…

Read more

Press release: We have a roadmap fo…

AIMS and our partners in the But Not Maternity Alliance have issued a press release on the nationwide status of maternity restrictions highlighting the huge variation bet…

Read more

AIMS Submission to the Violence Aga…

AIMS has responded to the call for evidence to inform the Government’s Violence Against Women and Girls (VAWG) strategy 2021 to 2024 Violence Against Women and Girls (VAW…

Read more