Book Reviews

ISSN 0256-5004 (Print)

Complete list of book reviews on the AIMS website

AIMS Journal, 2008, Vol 20, No 1

Until Our Hearts Are On the Ground edited by D Memee Lavell-Harvard and Jeannette Corbiers Lavell

Aboriginal Mothering, Oppression, Resistance and Rebirth

Demeter Press 2006
ISBN-10: 1-55014-461-8

Reviewed by
Gina Lowdon

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From Dementer Press
image of Heart on the ground

This was a difficult yet fascinating book to review. I feel very privileged to have read it and feel very strongly that I wish to write about it in a way that respects the editors, the writers, their perspectives and the difficult issues the book puts forward so clearly. I found this a profoundly thought-provoking book.

This book was not what I was expecting from the title. As a white, middle-class English woman I associate the word 'aboriginal' with the Aborigine peoples of Australia and therefore I was (somewhat naively) expecting the book to be about their mothering styles and practices. The book is in fact centred on the many different indigenous peoples, tribes and cultures of the lands we now know of as Canada. The word 'aboriginal' was chosen by the editors following much debate for its meaning of 'original inhabitants' and their descendants.

The book consists of 17 chapters written by different authors putting forward different views and perspectives on a common theme: what it means to individuals families and different nations to be colonised by a western European paternalistic culture. There are four sections: the first covers pregnancy and birth, becoming an Aboriginal Mother ; the second covers conceptions and practices of Aboriginal Mothers; the third looks at the role of the State in the performance of mothering; and finally the fourth section discusses literary representations of Aboriginal Mothering.

Whilst the book is centred on the experiences of colonisation of the many different indigenous peoples of Canada there are chapters looking at the experiences of the Australian Aborigines, the American Indians and, to a lesser extent, the African people's who were removed from their lands by western Europeans.

The book is essentially about a clash of cultures and the extensive and often tragic repercussions for women, children and contemporary society in its entirety. These women describe a cultural background where the survival and well-being of children are central and where men and women carry different but equal responsibilities, quite unlike those of the invading and colonising western Europeans, and in many respects western society today.

In their introduction the editors say that 'having identified this apparently endless diversity among Aboriginal mothers, how do we present a coherent perspective on Aboriginal mothering? Or indeed, is such a thing even possible?' My belief is that yes it is possible, and yes they did succeed.

The title of the book is taken from a Cheyenne Proverb: 'A nation is not conquered until the hearts of its women are on the ground. Then it is done, no matter how brave its warriors nor how strong their weapons.' I think the book needs to be read in order to begin to understand the depths of meaning to this title. Personally I think it sums up very well the different perspective of women from essentially matrilineal cultures. I think a corresponding phrase from our own patriarchal culture might be 'when our backs are against the wall'. Both relate to a fight for survival except that the first admits defeat whilst the second implies the fight is ongoing. Thankfully the book does demonstrate that the hearts of the women are not yet on the ground, all is not yet lost and much can still be regained.

This is undeniably an academic book, but it is well written and not at all difficult to understand, although the issues put forward are both profound and complex. I can thoroughly recommend this book to anyone who has an interest in cultural differences, social and racial discrimination, and most particularly anyone involved in child protection. This is a book that has important lessons for all women everywhere, regardless as to their culture, race, colour or social standing.

Am I Allowed? by Beverley Lawrence Beech

AIMS 2003
ISBN-10: 1874413150

Reviewed by
Moira Clark

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To order see the publications list on page 27 The Association for Improvements in the Maternity Services - AIMS - is a consumer organisation providing support and information about choices in maternity care. It campaigns for the recognition of childbirth as a normal process and for the rights of parents to have their wishes and decisions respected.

I picked up this book with no preconceptions (no pun intended!) as my sons, now aged 18 and 20, were born in France, so I have no personal experience of maternity ser vices in England. However, in my professional capacity (I teach ante and postnatal exercise and Pilates) and through my contact with the NCT (I am a Postnatal Leader and the branch MAVA agent) I find myself frequently in discussion with mothers about information and birth choices, and increasingly faced with questions preceeded by 'will my midwife/doctor let me...?' so I was interested in what this book had to say

My first thought was that, at £8.00, 84 pages plus appendices seemed a bit slim, however I started to read and suddenly found myself thinking 'I wish I'd known, or thought about, this when I was pregnant with my babies', as I found it a treasure-trove of surprising information.

The Government Document 'Changing Childbirth' published in 1993 recommended that 'women must be the focus of maternity care'. However, 15 years later, AIMS, still sees evidence that current care is frequently offered as a 'one size fits all' approach based on hospital protocol rather than individual need, and that screening and testing are becoming increasingly routine without clear evidence that this may be helpful. In addition many books, magazines and NHS classes seem to inform women of what they can expect from the system, rather than offering information to help them make an informed choice.

Women are encouraged to believe that compliance is the safest and best choice and most mothers, especially those expecting their first baby, will have little, or no, idea that they have alternatives, rights and options. 'Am I Allowed?' offers information to help expectant parents know more about their rights, options and choices from the moment pregnancy is confirmed, through choosing antenatal care and care provider, where and how to give birth and postnatal care. Throughout there are ideas for further thought, questions which parents might like to ask and suggestions of where to seek further information. The section on antenatal screening and testing gives detailed information about the different tests that may be offered, often with the automatic assumption that a mother will accept and comply, and makes the point that 'you have the right to refuse any test if you wish'. I was surprised to read about some of the pros and cons for some screening, which is now accepted as standard, such as ultrasound and dating scans.

I found further surprises in the section on choice of where to give birth. 'The decision about where to give birth rests ENTIRELY (author's capitals) with you', although 'choices may be restricted in some areas'. Clearly, one cannot ask for what is not there, although this book will encourage you to try to get as close as possible to what is right for you and available to you. Many women are automatically booked into the maternity unit of their catchment area hospital without any discussion about other choices that may be available to them. However 'you do not have to make a decision about where to give birth early in your pregnancy', and you are entitled to change any booking without explaining or justifying your decision, even late on in pregnancy. There is plenty of information about the different types of care and health care providers to help you make a decision about what might suit you best.

More surprises to do with Home Birth - 'Home Birth is shown to be a safe option, a fact acknowledged by the British Medical Association' and 'Home Birth should always be offered, regardless of where you live or your GP's opinion of home birth'. AIMS seem to feel that bias against home birth on the part of GPs and midwives may have more to do with lack of knowledge and experience and less to do with evidence of risk. 'Every woman has a right to give birth wherever she chooses, WHATEVER HER LEVEL OF RISK (AIMS' capitals, not mine!) and the decision is hers and hers alone'.

A very useful section of this book is to do with planning a normal birth, labour and birth procedures and attitudes, especially when giving birth in a large maternity facility, and water birth and caesarean section. It follows on to care and procedures for the baby immediately following the birth, and postnatal care, including leaving the maternity facility and contact with the health visitor. There is something here for every mother, however and wherever she chooses to have her baby.

If you would like more information to help you be aware of your rights and choices - then this little book is for you. I think it's great and I wish I'd had something like it 20 years ago! Oh, and £8.00? It's a bargain!

A Midwife's Story by Penny Armstrong and Sheryl Feldman

Pinter and Martin 2006
ISBN-10: 1905177046
ISBN-13: 978-1-905177-04-2

Reviewed by
Beverley A Lawrence Beech

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When travelling long distances it is always a good idea to bring along a book to wile away the hours. Little did I realise at the start of a flight to Brazil that Penny Armstrong and Sheryl Fieldman's book would be so fascinating that I ended up reading it, in one go, from beginning to end.

Penny trained as a midwife in the Highlands General Hospital, Glasgow, after a nursing course in Missouri in 1974. By the time she left Glasgow she had delivered 40 babies, three of them by the breech. In Glasgow, at that time, the medicalisation of birth was in full flood. The women were routinely subjected to: a catheter to the bladder, two probes in the vagina (one to measure contractions the other screwed into the baby's scalp), intravenous drip for the oxytocin and caesarean if they did not perform in time; but for six week of her training Penny tramped around the Glasgow tenements delivering babies often in the most awful circumstances, but learning about normal birth.

After qualifying Penny returned to America and, in order to get a license to practice in the USA, under took 16 weeks training at the Booth Maternity Center, Philadelphia - a progressive hospital that considered childbirth a normal, important, event. It was a total culture shock to the regimentation of the Highland obstetric system. The midwives were expected to think for themselves, be self-reliant, and assume complete responsibility for their work.

While musing, at the nursing station, over whether or not to buy Spiritual Midwifery (which she felt was probably a bit 'flaky') a telephone call was received from a GP 'out in the boonies' who wanted a midwife to join his private practice. Penny responded and the rest of the book is an account of her experiences living amongst, and getting to know, the Amish people. In the process she helped them birth their babies, learned about their culture and attitudes, got married and settled down, and gradually gained their confidence as 'their' midwife and shared their joys and sorrows

The book was un-put-down-able and in between giggles and tears, provoked by the moving stories of a variety of normal births; how Penny dealt with the problems that presented themselves; the loss of a baby, and the Amish's way of dealing with adversity, my flight to Rio seemed to last only a couple of hours.

Everyone should read this book

The Politics of Birth by Sheila Kitzinger

Elsevier Press 2005
ISBN-10: 0-7506-8876-9
ISBN-13: 978-0750688765

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Pushed: the painful truth about childbirth and modern maternity care by Jennifer Block

Da Capo Press, 2007
ISBN-10: 0738211664
ISBN-13: 9780-7382-1073-5

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Reviewed by
Jo Murphy-Lawless
School of Midwifery
Trinity College Dublin

Although the titles of both these books alert us to the increasingly fraught climate in which childbirth takes place, Sheila Kitzinger's title, The Politics of Birth, expresses for me the most important defining element for the serious issues facing women, their partners and families and caregivers about birth. Some bald statistics in a recent Guardian article have emphasised yet again how political childbirth is. The UK has seen

  • an 18% reduction in available NHS maternity beds per 100,000 of the population in the last ten years
  • a 12.5% increase in the birth rate since 2001
  • a mere 814 more full-time equivalent midwives since 2001 (according to the Royal College of Midwives)

In the Republic of Ireland, where I live and work, we have seen nearly 10,000 more births in 2006 than in 2001, with no genuinely significant increase in the capacity of our maternity services. We have no up-to-date government figures on the numbers of working midwives and so we rely on women's accounts to gain an understanding of how pressured a situation it is to give birth in overcrowded, understaffed facilities. The conditions that lie behind such global figures, namely the lack of political support for the values that should lead to top-grade maternity services, must contribute to an increase in medicalisation and the assembly-line approach, tantamount to a crisis in how birth is taking place.

Both these books explore one of the critical preexisting factors which has set the scene for this crisis, namely the disputed and often bitterly contested control of obstetric medicine over birth that has led to such extensive medicalisation.

Pushed is written by a journalist from the United States who has also edited the landmark Our Bodies, Ourselves, while Sheila Kitzinger's book is based on a series of articles she penned for various journals, including Birth and the British Journal of Midwifery.

Springing from Kitzinger's preoccupations with the increasingly complex social and professional problems that surround birth, she presents a heterogeneity of topics ranging from the indifferent support that can amount to institutional cruelty that confronts women asylum seekers to an exploration of touch in labour and birth, its importance when offered lovingly and supportively, its potential for abuse when women are pushed and pulled physically through an uncaring and overburdened service. With an anthropological eye, she cites the clock and the bed as central to the medicalised setting of birth, while she lets us see how birth plans are seen one way by women as a source of empowerment but how they are taken and reframed by hospital staff to limit and marginalise women's decisions, if not to create acute apprehension as with the example Kitzinger gives of information leaflets that ask women to decide if they wish to have an injection to prevent bleeding with no further information or context.

The issue of all births in hospital being treated within a high-risk model is held up for examination and Kitzinger draws on current evidence to interrogate the high-risk approach to birth. At the same time, it is not always made clear to the reader how she has chosen the evidence she uses. For someone familiar with the issues and debates this is not problematic but it could be confusing for the novice reader who might be attracted by the book's title. Indeed, as useful as many of the discussions are on their own, the book is frustrating overall. It lacks a cogent and well-organised introduction to anchor the reader who can be left puzzled by the choice of topics as well as by the frequently bitty and fragmented nature of a number of the chapters. As articles, they would have been interesting and informative but more work was needed to transform them into substantive pieces and knit together the underlying logic for their inclusion to make a truly useful book. There could have been a re-development of the chapter 'What's happening to midwives?' Placing it at the outset would help to identify that the politics of birth continue to turn on the contested boundaries between the obstetric and midwifery professions. As Kitzinger observes in the start to that chapter, the midwifery profession remains the linchpin of care in birth in much of Europe, however under-resourced it is. It is abundantly clear to many women and midwives that if we cannot begin to resolve the struggle for control of birth successfully in favour of the midwifery model of care, our experiences of birth will be increasingly traumatic with consequent short and long-term damage.

Writing about birth in the United States, Block's book paints a horribly vivid picture as to how traumatic this will be. Here a midwifery model of birth is deeply marginalised (if not outright illegal) and the central determining approaches to childbirth are the too-powerful industries of private health care and health insurance, alongside a conser vative and in the main ill-tutored obstetric establishment which sees birth as a business where one first insures against business risks and only as a very poor second purports to attend to the real needs of women and their babies.

Block's description of obstetricians dealing with a repeat caesarean section delineated by scar tissue and adhesions is a violent one but not gratuitously so, given that the rates of Caesarean section are soaring and that the man appointed President of the American College of Obstetricians and Gynecologists in 2000 has written on the importance of the Caesarean section as a 'prophylactic' operation. Although the book suffers from a journalistic narrative style, Block appears to have done her research well. She takes us to hospitals where over four in ten women are having their babies by Caesarean section. Block shows us how in a perverse manner as obstetrics tries to convince itself that Ceasarean section is a part of women's 'choices' in birth, by extension it concludes this should be a choice for obstetricians as well. She quotes one doctor 'At some time during the pregnancy, I'll say to the patient, "Have you thought about how you want to deliver this child?" and if she doesn't know what I mean, I'll tell her, "Well, it's 2006, if you want you can have an elective Caesarean section."' The extent to which the real hazards and damage of Caesarean births have been hidden from women while vaginal birth has been presented as an extreme risk to them and to their babies' wellbeing is truly overwhelming. Block gradually builds up a picture as to how the active mismanagement of labour (one might better describe it as the aggressive mismanagement of labour), with interventions led by the standard use of Pitocin ( 'The main thing is to have a nurse who is not afraid of Pit, who can actively manage a labour and be aggressive in turning it up on a regular basis' says one doctor while a second one declares 'When I hear I've got a nurse who will go up on the Pit, I know it's going to be a good day') make birth a living hell for women, one from which they emerge drugged, physically battered and psychologically traumatised while their babies are taken at once to a NICU. A 2006 conference by the government agency, the National Institutes of Health (NIH) on 'Caesarean Delivery on Maternal Request' displayed a scales weighing the 'risks' of what its expert panel called 'planned vaginal delivery' against the 'risks' of a planned section. Birth activists and responsible caregivers in the audience tried without success to draw attention to the fantasy of this juxtaposition, given that typically managed vaginal birth is extremely poorly managed with a swathe of technological and pharmacological interventions topped off with what one doctor termed 'heavily coached pushing'.

In this hyper-medicalised context, Block offers a useful introduction to the limitations to the Hannah study on breech births. There is also a wide-ranging exploration of VBAC and the distortions of the evidence on the rates of uterine rupture, which rates have held steady except and unless labour is complicated by the administration of Misoprostol for induction, a confounding factor that many obstetricians and bodies like the ACOG overlook. When Block turns to consider the position of midwifery in the United States, there is no less a gloomy picture, not least because this hyper-medicalisation of birth overdetermines overdetermines the legal climate in which midwifery attempts to practice. The accounts of midwifery carried out beyond the law make painful reading because this simply should not be happening. The descriptions of midwives in some states having to steal away in the night, after making arrangements via family members for necessary transfers to hospital and coaching them what to say to the authorities while removing any evidence that these have been attended labours, are chilling.

Birth in the United States, like so much else in that most consumerist of consumer societies, is preeminently an individual under taking, where if anything, a woman struggles even more than women in the UK or Ireland to find supportive birth contexts. We might characterise it this way: maternity services in the United States exemplify a policy model of maximum private responsibility where the national and state governments assume that individuals should sort out for themselves the type of licensed care they are prepared to purchase while public responsibility is limited to a regulatory framework for that licensing. This helps to explain why the doula has arisen as a phenomenon first in the United States. With no society-wide commitment to midwifery as a social good, an independent advocate for the individual woman must appear as a godsend. Yet the underlying issue is why this unacceptable state of affairs prevail: a woman cannot rely on her primary caregivers because there is no public commitment to force a wider level of accountability for the nature of these maternity services. Block never really gets to grips with this, limited perhaps by her cultural background in the United States, where private health care is king. What strikes me above all else is how birth care is treated as a commodity. There is a quote from one doctor who explains that certified nurse-midwives cost less in wages but because they spend more time with fewer 'patients' (sic), these 'patients receive fewer billable procedures, which brings in less revenue'.

And there, dear readers, is the crux of the matter. If you feel a shiver going down your spine at that mention of revenues, if it calls to mind the cost-cutting to the detriment of local maternity services to which many NHS trusts have been subject as the NHS has been inexorably moved towards a privatised market model, if it makes us aware in Ireland of the problems of continuing to secure full state backing for our fragile and newly-rooted midwifery-led services still on a pilot basis, rather than hospitals struggling to meet 'throughputs' with rapid turnovers of women, then it brings home forcibly the politics of birth. We need to widen our campaigns on this side of the Atlantic to ensure that those figures on the lack of resources I quote above are reversed, that birth, with midwives as the principal caregivers remains a social good, one which the state finances to the highest possible standards in a policy framework of maximum public responsibility. Otherwise, we will all of us, women and midwives alike, be condemned to frogmarch towards the kinds of bleak realities that Block has recorded.

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