Book Reviews

Complete list of book reviews on the AIMS website

AIMS Journal, 2009, Vol 21 No 4

• Birth Stories for the Soul edited by Denis Walsh and Sheena Byrom; reviewed by Nadine Edwards
• Midwifery Models That Work edited by Robbie E Davis-Floyd, Lesley Barclay, Betty-Anne Daviss and Jan Tritten; reviewed by Nadine Edwards

Birth Stories for the Soul

edited by Denis Walsh and Sheena Byrom Quay Books 2009 ISBN-10: 1856423573 ISBN-13: 978-185642357 £24.99 Reviewed by Nadine Edwards Find this book on Amazon

This book is about providing supportive care to ensure that however birth unfolds, it is 'one of nature's marvels' rather than a 'medical event' (p 2). It covers a range of birth stories at home and in hospital, with accounts from women, their partners, siblings, grandparents, midwives and doctors. One chapter discusses the high rates of interventions in many obstetric units, even among healthy women and babies, how intervention rates vary between units, and how it is often unclear from women's birth records why interventions had been used. The chapter reports an interview with an experienced midwife that shows how difficult it is, even for those with many years' experience, to resist routine medical practices and maintain a belief in physiological birth and women's abilities to cope with pain and birth their babies using their own efforts in an obstetric environment. The stories themselves are extremely moving, tales of joy and empowerment, tales of healing after deeply traumatic previous bir ths: 'Adam's birth gave me some incredible gifts. It somehow made me feel stronger. I no longer allow people to take my power away' (p 29). There are tales of women's strength and courage; tales that show how the courageous, calm support of midwives who are genuinely 'with' women build trusting relationships between themselves, women and their partners; relaionships that can begin to (re)build the confidence women and partners need to overcome fears and anxieties that would not have even surfaced in conventional care.

The stories tell us how women and families can be so very deeply hurt, 'abused' and 'violated' by practitioners who can't or won't engage with them, who won't listen, and who impose or withhold interventions, because there are routines to follow, to the extent that the experience of birth 'ruined my life' (p 61). They also tell us that healing is possible and more likely when traumatised women are provided with one-to-one care from a midwife who can listen to their stories, respect their values and needs and give them time, space and support to create their own birth journeys. This enables them to work together and for the woman to draw on her midwife's experience and knowledge: 'During her labour I listened carefully to Saira, asked what she wanted and needed, and respected her wishes [...] Saira also listened to me and my suggestions - going out for a walk, leaving the pool to mobilise. The relationship we had developed [...] meant that we could trust and be honest with each other' (p 31). The difference this makes is stark: 'I cannot even begin to compare the experiences of the births of my children. They are so starkly different [...] I believe that Isla's birth was so wonderful for one reason only and that is the quality of the care we received' (p 39). While the stories range from home water births to caesarean sections in hospital the consistent variable needed for a positive experience is support thoughout pregnancy, birth and after birth from a known and trusted midwife. Midwives' stories confirm what midwives in other accounts say - that it is easier to look after women they know, and that: 'I don't have to start making a new relationship when a woman is in advanced labour and risk disturbing her labour's rhythm' (p 32). The joy that women, families and midwives articulate when midwives are caseloading and practising in birth centres gives midwifery and birth new depths of meaning. Women, families and midwives grow in confidence; and love rather than fear is generated.

Story after story emphasises the benefits of knowing a midwife who can provide emotional as well as midwifery support: 'essential if women are to have positive births, succeed with establishing breastfeeding and be well' (p 39). They demonstrate how this kind of care is needed and beneficial for young women, women in their 40s, women with physical and emotional challenges, women who struggle financially, as well as those who are better off.

There is a very distressing and moving chapter by and about a woman, her midwife and both their families, following a difficult birth. Both families were further traumatised by our culture of blame and litigation. Both were left isolated and hurt, and neither received the support, kindness and connection they needed. Litigation divides, and at best provides only financial assistance - but this is relatively rare.

The stories are shocking, inspiring, distressing, heartening, despairing and deeply, deeply moving. The impact of a traumatic birth experience and its potential for undermining self-esteem, hope, and family relationships compared with the empowerment of a positive experience are now so well documented by research and by women's, midwives', partners', and other's accounts, it seems unconscionable not to introduce caseloading midwifery, make more provision for home birth and Birth Centre births, and ensure that midwives have the training, skills and knowledge to provide women with care that is physically, emotionally and culturally safe for them. Childbirth and midwifery groups have been campaigning for this, there are midwives who want to do this - why are they being prevented from doing this?

As Sheena Byrom concludes: 'The benefits of a positive birth story are profoundly important for society as a whole, and therefore the responsibility to influence humanised birth extends beyond caregivers and receivers, to include commissioners and ser vice provider managers, in addition to politicians and policy makers' (page 127.) Once this is accepted, we can begin to look at how caseloading could be further developed in ways that are sustainable for, and acceptable to midwives.

Midwifery Models That Work

edited by Robbie E Davis-Floyd, Lesley Barclay, Betty-Anne Daviss and Jan Tritten University Of California 2009 ISBN-10: 0520258916 ISBN-13: 978-0520258914 £19.95 Reviewed by Nadine Edwards Find this book on Amazon

In 1997 Judith Rooks published Midwifery and Childbirth in America (Temple University Press), a groundbreaking compilation of midwifery literature, gathering together much of the research on the benefits on outcomes of midwifery care for women and babies. This new publication on Midwifery Models That Work, edited by long standing authors in the birth field takes that work further. It provides a clear, concise and readable overview and analysis about the harms of overly medicalised birth and about how and why midwifery models work on a broad range of outcomes, including decreasing mortality and morbidity rates for women and babies, increasing agency for women and midwives, increasing equality, sustainability and potentially strengthening communities.

The editors tackle the complexities of a global context in which women grapple with decision-making: the poorest women are often faced with inhumane medicalised practices in hospitals, lack of accessible, appropriate, timely skills and resources, and ensuing high death rates. Those in the richer world are "kindly" guided towards technological birth. While death rates are low, a caesarean section rate of over 15% is associated with increased mortality rates among these women and babies.

They describe increasing technocratisation of birth across the globe, where the sphere of practice of traditional midwives in poorer nations and that of midwives who challenge medicalisation in richer nations is increasingly reduced with consequent loss of skill and an infringement of the human rights of both the public and birth workers.

The main focus of the book however is positive and inspiring: a collection of midwifery initiatives from around the world that understand the importance of the woman mother relationship, promote physiological birth, usually strive towards full integration with health care resources, are well liked, and work at all levels. Midwifery in The Netherlands, New Zealand and Ontario give an overview of how midwifery models have been sustained and/or developed, and begin to tease out the need for vigilance and political activity to protect midwifery skills and knowledge. They highlight the dilemma of supporting agency and diversity among women and midwives, while retaining credibility and support within mainstream society.

This dilemma is particularly noticeable in North America, where in order to gain the legal right to practice, midwives are accepting a narrower sphere of practice by relinquishing breech births, twin births, and vaginal birth after caesarean births from their practice (see for example Mainstreaming Midwives: The Politics of Change edited by Robbie Davis Floyd and Christine Barbara Johnson published in 2006 by Roultledge). As midwifery becomes more mainstream, and moves from the fringes into the hospitals, it provides for many more women, but also tends to become more medicalised. We have ample evidence of this. The perennial problem of how midwifery engages with technology in a way that leads to reduced intervention, safe practice and support for all women is a continual challenge. Those women with complications who desire midwifery care are not infrequently abandoned in the interests of providing better care for most women.

Numbers of chapters discuss the need to respect cultural beliefs and practices, base care on the low tech skills of birth attendants, and to find ways of providing the right level of skills and technology, close enough to communities to be able to be of benefit when needed: 'Recovery and preser vation of traditional midwifery knowledge in interaction with technical - scientific knowledge is essential: this process contributes to the production of new knowledge and technology and greatly improved outcomes' (p401-2)

The benefits of trusting relationships between women and midwives and of holistic midwifery support during labour cannot be overstated: the normal birth rates, and lowered mortality rates speak for themselves in many of the chapters (see for example the excellent outcomes of the Albany Midwifery Practice in south London). What is surprising is just how far supportive, skilled midwifery care is able to impact on the disadvantages to health and well-being brought about by poverty. The relationships between midwives and families and the ensuing good experiences clearly strengthen communities and their abilities to both be more nurturing and to challenge unjust inequalities.

Many of the chapters show how leadership and a "can do" philosophy can bring about sustainable, positive change relatively quickly, and how this builds collectivity, cohesiveness and co-operation among practitioners which brings out the best in them and provides the best ser vice possible for families: the accounts of the Northern New Mexico Midwifey Centre and of the Mercy in Action are particularly inspiring.

These holistic midwifery initiatives provide places of learning where student midwives can acquire the knowledge and skills they need, deeply rooted in compassion and respect for women and babies: 'I have always said that my real teachers are the mothers and babies, and we want our students to realise and appreciate this fact' (p 350)

They help new midwives to understand that the apparent 'nothing' that midwives bring to childbirth, is in fact a rich and complex mixture of skills, vigilance, protection, and knowledge derived from all of the senses, balancing the needs of all those present, reading the woman during pregnancy, in labour and after birth, and negotiating with other care providers, in order to 'orchestrate' the best environment for the woman to birth her baby as Holly Powell Kennedy's chapter highlights.

The editors conclude that midwifery models are 'possible, sustainable, replicable and fragile', and that: 'Birth models that work improve the physiological, and the social outcomes of pregnancy and birth and save money for systems and families. They expose the need for the total reform of existing dysfunctional hegemonic models. They issue a clarion call to [...] replace birth models that don't work with those that do, at local regional, and global levels, in order to reduce maternal and perinatal mortality and morbidity, empower women and their families, and facilitate healthy birth and breastfeeding' (p 456).

It was a real pleasure to read such an uplifting and informative book. If enough people could be inspired by how these models work, would they begin to help us to change maternity ser vices for the better wherever we are?surprising is just how far supportive, skilled midwifery care is able to impact on the disadvantages to health and well-being brought about by poverty. The relationships between midwives and families and the ensuing good experiences clearly strengthen communities and their abilities to both be more nurturing and to challenge unjust inequalities.

Many of the chapters show how leadership and a "can do" philosophy can bring about sustainable, positive change relatively quickly, and how this builds collectivity, cohesiveness and co-operation among practitioners which brings out the best in them and provides the best ser vice possible for families: the accounts of the Northern New Mexico Midwifey Centre and of the Mercy in Action are particularly inspiring.

These holistic midwifery initiatives provide places of learning where student midwives can acquire the knowledge and skills they need, deeply rooted in compassion and respect for women and babies: 'I have always said that my real teachers are the mothers and babies, and we want our students to realise and appreciate this fact' (p 350)

They help new midwives to understand that the apparent 'nothing' that midwives bring to childbirth, is in fact a rich and complex mixture of skills, vigilance, protection, and knowledge derived from all of the senses, balancing the needs of all those present, reading the woman during pregnancy, in labour and after birth, and negotiating with other care providers, in order to 'orchestrate' the best environment for the woman to birth her baby as Holly Powell Kennedy's chapter highlights.

The editors conclude that midwifery models are 'possible, sustainable, replicable and fragile', and that: 'Birth models that work improve the physiological, and the social outcomes of pregnancy and birth and save money for systems and families. They expose the need for the total reform of existing dysfunctional hegemonic models. They issue a clarion call to [...] replace birth models that don't work with those that do, at local regional, and global levels, in order to reduce maternal and perinatal mortality and morbidity, empower women and their families, and facilitate healthy birth and breastfeeding' (p 456).

It was a real pleasure to read such an uplifting and informative book. If enough people could be inspired by how these models work, would they begin to help us to change maternity ser vices for the better wherever we are?