Reviewed by Nadine Edwards
In this diverse group of publications, the authors approach their subjects from very different perspectives, but bring them together to provide an interesting and consistent overview of obstetrics and social midwifery in North America.
Diana Scully's readable and shocking book was first published in 1980. It is based on her observational studies of obstetrician/gynaecologists' training in North American hospitals. In this new edition, Michelle Harrison, author of A Woman in Residence, suggests that the book could legitimately have been called Men Who Still Control Women's Health: The Continued Miseducation of Obstetrician- Gynecologists. Scully examines the little-known history of gynaecology, which is both insightful and horrifying. Her description of the pathologising of women's abilities to create new life is not for the faint-hearted.
Her sociological investigation into the fields of obstetrics and gynaecology shows how the discipline is imbued with the beliefs of the day, and that not only are technological values imposed on women's bodies, but that current moral values are encoded in its practices.
She demonstrates how the socialisation of doctors in training leads to their 'seeing' women and their bodies in dehumanising ways-to the extent that women who 'see' things differently are disliked. She also notes that, although nursemidwives go some way towards humanising the system, they are unable to change its underlying beliefs or practices.
The emphasis on speed and efficiency combined with practitioners' need to practice and a fear of uncertainty create a multifaceted agenda which leads to more, rather than less, aggressive/invasive action. As a doctor in training remarked, "If I section her, I don't have to worry about it" (p 193).
As others have, the author draws attention to the closed nature of medicine and the lack of outside regulation, the erroneous beliefs that women's bodies are defective, and the normalising impact of obstetric ideology, training and institutionalisation. It is a fascinating book and Diana Scully could be forgiven for one or two lapses in her critical analysis. For example, the assumption is that a more ethical approach would resolve some of the inherent problems in medical practice. While it would certainly improve the situation, it would not address the issue of differences between people. Childbearing women make decisions from different standpoints, and with different and complex concerns in mind.
In addition, the author skilfully and thoughtfully documents the control of women's gynaecological health, the abuse of medical power and how this is perpetuated through the 'miseducation' of doctors. But the problems are wider than this. We need to understand obstetric ideology as part of a broader ideology if we want to effectively challenge the basis on which it exists.
Judith Pence Rooks' book is a breathtakingly detailed and extensive overview of past and current midwifery education and practice, including the outcomes of midwifery care in a great variety of settings. It covers the definitions of a midwife and midwifery, a history of western midwifery, early nursemidwifery, and how changes in midwifery reflected social movements in the 1960s and 1970s. It looks in detail at maternal and child health, healthcare systems, midwifery knowledge, place of birth, the course of nurse-midwifery, and the development of direct-entry midwifery, safety and cost issues. She ends with an overview of midwifery in Europe, Canada, Australia, New Zealand and Japan, and how midwifery may develop in the future.
This is not a book to read in an evening! You could easily dip into it-though reading it from start to finish gives a broader understanding of some of the controversies surrounding birth today, and how midwifery has and can contribute to safer, more empowering experiences of birth for women and their families. Woven into the research is an understanding that there are different ideologies around birth, that childbearing women and their families have different needs and that midwives are a diverse group of women educated in a variety of ways.
The important messages here are that thoughtful midwifery does a great deal of good and decreases harm, and that creating different pathways through the education and training of midwives ensures that very different groups of women may be able to contribute to the health of women and babies, and that a greater range of knowledge and skills is developed.
There is a wealth of information in this publication, and the author has carried out an impressive task in bringing it all together. Yet inevitably, even with 548 pages, there is some glossing over of issues and, when the author discusses the British situation, you may be sceptical about some of the claims. It is also written largely within a scientific framework- and has limitations because of this. All in all, however, it's a wonderful book to read.
Juliana van Olphen-Fehr's very moving book follows her journey from the mid-1970s to the late 1980s as she experiences birth and motherhood, trains to become a nurse-midwife, develops an increasing awareness that birth practices directly affect women's and babies' emotional and physical health, and moves into political activism.
During her long journey towards becoming a home-birthmidwife, she initially engages with systems and institutions. She witnesses women unable to give birth in the inflexible, interventionist medical system in which she and they are secondary to the norms and practices of the institution. She witnesses uncaring, unethical attitudes towards women and midwives. She also finds like-minded health practitioners who, like herself, attempt to do good by stealth.
This book is passionate, insightful and powerful. It is as moving as it is horrifying. It also demonstrates how an entrenched medical system can have a detrimental effect on alternative birth ideologies. Midwifery practice may become less flexible as it negotiates the medical belief that its practices are unsafe. And if midwifery models become more rigid, women will have little choice but to comply with their philosophies and practices. Such themes make this book honest, clear and impossible to put down.
Peter Schlenzka's study considers the safety of both medical and midwifery approaches to birth. In a comprehensive, retrospective review of the literature, and through his own research on outcomes for births attended by doctors and midwives, he lends yet more support to the claim that a social model of birth does not result in more deaths of women and babies, but can reduce the level of physical and emotional harm perpetrated by the routines of medicalised birth.
More important, he makes the point that this is the case even though midwives are trained and are practicing within a hospitalised/medicalised culture. He therefore articulates what the previous publication told us by implication-that continuing to develop a social midwifery approach to birth may further improve outcomes.
The study itself confirms that there are slightly better outcomes when natural birth approaches are used-at all levels of risk-and the author comments that: "We need to keep in mind that the natural approach, while operating today in the United States under suboptimal conditions, still is able to produce these results. We would expect the natural approach, when being part of a shared maternity care system and supported by society's beliefs to produce even better results" (p 174).
It's always interesting to read the views of those who have moved through a medical education and have come to see its limitations and potential for harm. North American obstetrician- gynaecologist Thomas Strong takes a critical look at what obstetrics has achieved, and what it currently has to offer pregnant women and their babies. The book is based on research-based evidence and suggests that many antenatal tests and procedures are ineffective, and may lead to further ineffective and unnecessary interventions.
The author provides many examples of where prenatal care has failed to improve outcomes, and focuses on one of the most intractable problems-prematurity among babies. He asserts that the incidence of prematurity and low birthweight have increased, rather than decreased, over the last decades, despite the aggressive obstetric approach to it. Like all of the other authors mentioned here, he points to research showing that outcomes are improved by providing good midwifery care.
He criticises the financial and maternity-services structures that encourage poor care, lack of equitable access to good care during pregnancy, lack of emotional support for pregnant women, the over-medicalisation of prenatal care, and the mindset that women's health only matters when they are vessels for unborn children. He suggests that prenatal care should be integrated with better healthcare in general for women .
This is a fascinating analysis that remains within a medical framework. It is hard-hitting in its own field, relatively sympathetic to women and families, but less impressive when the author attempts to explain some of the complexities of poor pregnancy outcomes. Nevertheless, this is essential reading and should provide parents with the kind of information they need to make decisions about pregnancy care.
Reviewed by Gina Lowdon
St George's Healthcare NHS Trust, London
I was pleasantly surprised by this 14-page leaflet, which provides information for women who are planning an elective caesarean at St George's Hospital in London.
It is informative without being prescriptive. The risks are acknowledged, but not overemphasised. The writing style is simple and easy to read without being patronising.
This leaflet provides information on what happens before, during and after the operation, including areas where options are available. Reasons for procedures are explained and the reader is given a good idea of what is likely to happen, when, and why.
Recovery is covered in a realistic way, including practical information and tips for dealing with some of the 'discomforts'. The only criticism I have is that there is no mention of the possibility of having a second birth-supporter (such as a doula/antenatal teacher/friend) in addition to "your birth partner", who is assumed to be a 'he' (and presumably the baby's father).
I would also like to have seen some indication that women could self-refer back to their consultant if they so choose. Now that the six-week postnatal check is commonly carried out by GPs, consultants are receiving the impression that caesarean section is a 'trouble-free' form of birth. We know that women suffering post-caesarean recovery problems have a great deal of difficulty getting them taken seriously, let alone diagnosed or treated. Under the current system, consultants remain totally unaware of the incidence or scale of such problems, even in the relative short term.
A lot of useful, practical information has been included in this leaflet and women planning a caesarean will find very helpful. There are also good sections, such as 'Making a Birth Plan' and 'Further Information', which are important for getting women to think about the procedure and providing them with somewhere independent to go if they have questions. It was good to see AIMS mentioned both in the text and under 'Further Information'.
Editor's note: St George's quarterly CS rate is down (from 23.9 per cent to 18.3 per cent) along with induction rates (17.5 per cent to 12.2 per cent) compared with the same quarter last year, according to the Chair of the MSLC. The CS rate drop has largely been achieved by abolishing the admission trace. These changes have been facilitated by a new consultant midwife at the hospital.
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