Churchill Livingstone, 2008
This is a tough book in several ways. It was first published in 2004 and now in a revised edition in 2008 it addresses probably the most crucial question in our understanding of how women give birth: what does normal, physiological birth look and feel like? There is plenty of debate on this question and I think anyone with an interest knows that the generally accepted view of what is 'normal' now includes interventions which are patently not normal although they may be common or indeed usual: induction and acceleration of labour ; ARM; episiotomy and epidural analgesia all are examples of this. But these essays add up to a powerful argument that, despite what we have observed as a radicalisation of ideas within Britain over the last 20 years reflected in government policy and a belief generally in the ability of women to give birth without intervention, what is happening is a 'normalisation' of a medical model in this country and worryingly in the rest of the world too. AIMS Journal Volume 20 Number 2 painted a sombre picture of childbirth practices in Europe and a future issue will examine how the rest of the world may be influenced to adopt Western practices.
In the first section, Ways of Seeing, Soo Downe and Christine McCourt tackle the difficulty of applying a research model based on 19th century science. They argue that although this is well suited to evaluating the efficacy of drug A as opposed to drug B this model is not so well equipped to tease out the complexities involved in normal physiological childbirth including the crucial social, psychological and spiritual aspects. These aspects are not optional 'add ons' either for women and their families, or for their midwives. So while we are relieved to see NICE collecting together research evidence so that our heath service can benefit both practically and, of course, economically from the best evidence available, we must also contemplate the limitations of the evidence that we have.
The gold standard of the randomised controlled trial, (RCT), has not helped us with such important and basic questions as the relative safety of hospital birth compared to home birth for women without complications of pregnancy. The NICE Intrapartum Guidelines might be useful in many ways but can't address this central question satisfactorily because the research doesn't really exist. There are no RCTs on home birth versus hospital birth nor, to take another example, are there any large scale RCTs on the benefits of routine ultra sound screening in pregnancy. The model of science employed has a tendency to investigate ever more advanced technical solutions to human problems. Alongside this it would be naïve to ignore the role of commercial interests in funding research; 'where health is framed by a constant expectation of danger there is money to be made in providing investigative, preventative or curative products to counteract the risks' - see Page 10. There is no commercial interest in investigating normal birth.
I had been looking forward to reading Nicky Leap and Tricia Anderson's essay on 'the role of pain in normal birth and the empowerment of women' so was pleased to find this in the first section: it met all my expectations. I agree that pain plays a big part in childbirth and has its uses and I think it would benefit every woman contemplating birth to consider their arguments.
The second section starts with a chapter which is a collaboration between the NCT and AIMS, written by Beverley Beech and Belinda Phipps. They look at women's birth experiences and the effects on their lives, including post traumatic stress reactions and deal with the definitions of normality and what they mean. This is a clear and, in my view, unarguable case which needs underlining. They outline the paradox that despite the successful campaigning over the last fifty years by childbirth organisations, we have witnessed not just the increase in caesarean sections but also the insidious acceptance of interventions which are not clearly of benefit. Subsequent chapters deal with midwives' practice, in the UK and in New Zealand and they underline how easy it is for midwives to be pushed, often against their wishes, into an acceptance of medical thinking and procedures.
The third section, 'Evidence and debate' concludes the book with some more optimistic writing on normality, for example 'Promoting normal birth: weighing the evidence' by Dennis Walsh. I particularly enjoyed reading the chapter, 'Foetal to neonatal transition: first do no harm', and its straightforward account of what harm is done to both mothers and babies by the usual early cord clamping and removal of baby. I have felt that many women expecting their first babies find it almost impossible to imagine the moment after the moment of birth and can be unprepared for the barbarity of a managed third stage. 'The current birthing environment is a contested context in which medicalisation remains the dominant construction of birth. There is increasing intervention in the birth process and increasing normalisation of intervention despite midwives' efforts to protect normal birth.'
The conclusion on reading this book is that labour and birth are being increasingly centralised in mega units and intervention rates are escalating all the time. A vicious circle of iatrogenesis feeding yet more litigation and yet more defensive practice is becoming apparent.
So I found this a tough book to read and the message is not very cheerful but this is a book which could equip midwives to be aware and prepared to fight. It is also a book that lays out for us what the nature of the task is to wrest the possibility of normal birth back as a real option for women in Britain.
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