Book review: Dynamic Positions in Birth

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AIMS Journal, 2021, Vol 33, No 3

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Dynamic Positions in Birth (2nd edition): A Fresh Look at How Women's Bodies Work in Labour By Margaret Jowitt Published by Pinter & Martin Ltd 2020 ISBN: ‎ 978-1780666907 224 pages At time of writing, the paperback is £10.49 on Amazon Find this book on Amazon

Review by Verina Henchy

Margaret Jowitt first published Dynamic Positions in Birth in 2014, and since then, Margaret has continued in her quest not only to understand why so many women birth in the supine position (when it is a commonly held belief that birthing ‘upright and forwards’ helps a birthing body to work efficiently and effectively), but also to do something about it. In this new edition, Margaret asserts that the majority of women in the UK still give birth in the semi-reclined position^[1], thus not working directly with the force of gravity. As such, the book speaks to an issue which continues to demand attention.

Margaret suggests that current mainstream obstetric culture (where the word “obstetric” is derived from the Latin stet ob or “stand before”) continues to place the bed centre stage of so many births today, pays only lip service to the emotional aspects of birth, and works with guidelines that are based on ‘obstetric numerology’ (Margaret’s phrase to describe modern maternity care). This is not a recipe for success when it comes to offering high-quality maternity services.

The new edition of this book begins with an in-depth chapter on ‘birth furniture,’ which includes some interesting illustrations of ancient stools, chairs and tables all designed to support the process of birthing in upright positions, positions which subsequent academic research has shown to be beneficial to the mother. The very thorough chapter on research in this area explores the gap between physiological science as we know it and medical practices, concluding that researchers have very little interest in the physiology of birth and that physiology tends to be poorly understood, disregarded, unknown or forgotten. In further chapters, Margaret goes on to explain the function of the uterus and the mechanics and physiology of birth, and explores how obstetric technology may often be the very reason why the physiological process of birth so often goes awry in a hospital setting.

In my opinion, this updated version is not very different from the original, and as an owner of the original, I see no need to rush out to buy this replacement. The additional short chapter that has been added to discuss the potential role of the clitoris is based on supposition and challenges the notion that it has the function of giving female sexual pleasure, suggesting instead that its function is to activate the fetal ejection reflex in birth. If you don’t know the full anatomy of the clitoris (and let’s face it, the full anatomy of the clitoris wasn’t thrust into the public eye until the Australian urologist Helen O’Connoll brought its wondrous structure to our attention in 2005^[2]2), then this chapter is a worthy read. I draw my own conclusions about whether or not ‘vaginal orgasm is relatively rare’!

Review by Jo Dagustun

Most people would perhaps assume that the UK maternity services base their work on a deep understanding of the physiology of reproduction. Margaret’s book is an important reminder that this is sadly not the case. In this second edition of her book, Margaret Jowitt – a self-declared lay person, albeit with decades of experience campaigning for improved maternity services – raises many important and interesting questions about the physiology of labour and birth in her mission to improve how the maternity services understand, and thus support, labour and birth. As such, she sets an important research agenda: indeed, it is rather disconcerting to realise that our maternity services seem to assume that they can operate well without answering the research questions laid out here.

Margaret has an authentic authorial voice: as a reader, if you are willing to follow her lead, she will take you on a journey of reflection, with many thought-provoking questions along the way. Margaret is not afraid to pose questions to herself and is upfront about how some of the background reading in this area is really quite complicated. You may find yourself disagreeing with the text at times or even a little frustrated, with questions that might have been attended to in the text (I made quite a list!). However, it is important to remember that this book is not intended to be an academic text: instead, it is a highly thoughtful “outsider” intervention in a research area that seems to have got well and truly stuck. I look forward to seeing how researchers take up Margaret’s challenge to better understand birth physiology, to drive improvement in the maternity services.

For me, this book offered a first “tour” of birth furniture through the ages. I was fascinated by the idea that an unborn baby might have reflexes to aid its exit from the womb – I had previously only considered these reflexes in the context of breastfeeding. I am still doubtful about Margaret’s assertion about the lack of knowledge about birth physiology as evidenced in medical textbooks – but there again, I hear this complaint too about midwifery education, and this would certainly seem to explain many of the everyday practices that we know are not conducive to supporting the physiological process of labour and birth. I became curious about the drivers of uterine rupture. I was pleased to read an account of early labour that considered the function of early contractions and how these could be more productive with some attention to maternal positioning, rather than an account that simply dismissed them as ‘uncoordinated’ (with the implication that they are useless!). I liked the way that Margaret was unafraid of offering controversial material: at one point, for example, she likens the requirement to lie in a supine position for foetal monitoring – when concerns have been raised about the unborn baby – as ‘tantamount to fetal abuse’ (p. 145).

Thank you, Margaret, for continuing to bring your passion and energy to this important topic. But most of all, thank you for valorising the skill, knowledge and agency of the mother-baby dyad. Birth physiology is too important an issue to be left to the “self-styled experts”: they have let us down, and it is thanks to “ordinary women” asking “ordinary questions” that we will surely make progress on this important topic. AIMS campaigns for a physiology-informed maternity service, and reading this book certainly seems to confirm the need for this campaign.

Verina Henchy and Jo Dagustun are both AIMS Volunteers.