Book Reviews

AIMS Journal, 2002, Vol 14 No 4

Choice in Birth Care: The Place of Birth by Kirsi Viisainen

Reviewed by Nadine Edwards

University of Helsinki, 2000

This retrospective study from STAKES National Research and Development Centre for Welfare and Health (Research Report 115) examines the outcomes of births in Finland, women's views on birth care, and the views and experiences of Finnish parents who had home births during the 1990s. The first section explains the methodologies used, how birth care in Finland has moved from home to hospital, the organisation of current maternity services and Western research on the outcomes of home births.

The author concludes - as others have done - that home birth is as safe as hospital birth for healthy women and babies in terms of perinatal mortality rates. It holds added benefits for some women because they receive fewer interventions in the home compared with similar women in hospital.

Kirsi identifies the different belief systems about birth as being either medical or alternative. She identifies that the main point of diversion is where risk is located - in the pregnant body (medical) or in techno/medical practices and hospitals (alternative). She describes parents in her study as holding complex views and suggests that their views are socially constructed and heavily influenced by medical ideology. Yet, parents are also able to articulate their own meanings - the centrality of the woman, her need for a peaceful birth environment over which she has control, and trust in her body.

As in other studies, women choose home births for a variety of reasons: for some, it's the first choice; for others, it's a result of concern over the risks of medicalisation or a response to traumatic previous experiences of hospital birth.

The second part of the book comprises five published papers. The first examines the incidence of accidental out-ofhospital births in Finland and their outcomes, and suggests that the closure of small hospitals in rural areas impacts on their number and their poorer outcomes. The second looks at outcomes of births in different settings in Finland and concludes that small maternity units have good outcomes. The third examines women's preferences and, like UK surveys, suggests that many more women than actually plan home births and births outside of obstetric units are interested in these alternative birth settings.

The fourth is based on interviews with parents who had home births. Unlike Robbie Davis Floyd (1992) and Emily Martin (1989), who called their participants 'natural birth idealists', Kirsi describes her women as pragmatic. They discuss birth in medical terms and expect to use the biomedical system for their own ends. Elsewhere, she describes women's desires for natural births, their individuality, and their reliance on intuition and trust in their bodies.

Where women place themselves on the resistance/acceptance spectrum of medical ideology is debated keenly in feminist literature. We are complex individuals defying categorisation, but my own study (Edwards, 2001) suggested that, where the biomedical model is coercive, women are cautious about expressing resistance or appearing irresponsible. They deliberately acquire the language of medicalisation to enter into debates with practitioners. The women in my study tended to express alternative views over the course of several interviews. As researchers, we are also limited by the same cultural constructions, and my experience suggests that it is initially easier to introduce and listen to women within the framework of a biomedical model than outside it.

The fifth paper, also based on interviews with parents, identified three types of risk - medical, iatrogenic and moral - and discusses the 'moral' risk of planning a home birth in a hospital birth-based culture, where parents face the perception that a home birth is inherently risky. Risks for them included losing control and being subjected to interventions that prevent the flow of birth in hospital. They drew on intuitive knowledge to reduce fear and increase confidence.

Kirsi suggests that while Finnish obstetricians and policymakers have drawn the safety/risk boundary between home and hospital, the parents felt that they were responsible and were willing to live with the consequences of birth wherever their babies were born.

So, in weighing up the safety/risk equation, parents considered safety and risk from a broader viewpoint, and questioned some of the assumptions on which the medical model of birth is based, while drawing on their own intuitive awareness and trust in the birth process as a legitimate form of knowledge on which to base decisions about place of birth.


Have the Birth You Want by Gill Thorn

Reviewed by Suzanna Nock

Hodder & Stoughton, 2002

Find this book on Amazon

In the introduction, Gill Thorn says "for many women, a satisfying birth, easy or difficult, means retaining a sense of personal control. Losing the power to control your own life is something that cannot be put aside easily; and the resentment it leaves behind can be hard to get over."

Of the book's nine chapters, the first covers how childbirth has gone from being a normal part of life to where women today "submit to more and more intervention to avoid smaller and smaller risks". Another chapter investigates feelings and fear, risk and how we assess it. We are all affected - sometimes afflicted - by other people's emotional baggage; your mother, sister, friend, GP, midwife have had experiences that colour their attitudes and perception of risk.

Sadly, there was no mention of post-traumatic stress disorder in the very short section on previous traumatic births.

The chapter on birth choices lists home births first, which is "open to every woman, regardless of her age, medical history, or whether it is her first baby". Gill identifies the problems in getting a natural birth in hospital, and the role of AIMS in providing information and support. She also identifies some of the problems in arranging a home or water birth, and deals sympathetically with elective caesarean sections.

In 'Making it happen', the scenarios are very unrealistic, suggesting that all you need is to be "politely persistent" and all opposition will melt away. There is, however, a useful guide on affirming your rights and assertiveness techniques.

The chapter on preparations has more than the usual list for a hospital bag, as it includes a variety of other preparations, like getting film for your camera, and practicing labour and birth positions. She also looks at mental and physical preparations - how to manage your thoughts, perineal massage, breathing and relaxation as well as a useful list of reminders for birth partners.

The 'Birth Day' chapter includes going overdue and alternative therapies, natural birth, birth with technology and caesarean section (all with useful additional tips).

Gill discusses choice and control, but doesn't mention that you can ask to be attended by someone else, though she does point out that "you can refuse any treatment, but you cannot force her [the midwife] to treat you the way you want". It should also be said that you can ask for alternative treatments and are entitled (under the Patient's Charter) to ask for explanations of the benefits and risks of every treatment. Again, the dialogues seem rather idealistic, and could lead to unrealistic expectations of how a labouring woman may be treated.

The 'After Birth' chapter describes after-birth feelings, and includes information on post-caesarean recovery, sleep deprivation and partners. Gill suggests that you ask for a debriefing session before you leave hospital after a traumatic or complicated birth. However, health professionals may find it hard to take criticism.

The solution offered for a bad birth experience is to "go back to the midwives or consultant", which can take months; it may also not be appropriate to refer women back to the very people who hurt them. I would have preferred more suggestions for independent sources of help and support.

The section on complaining was too short and did not include useful information like the structure for making complaints, the review procedure and the role of the ombudsman.

The final chapter contains birth stories about home and hospital births, and independent midwives - all of which provide food for thought whatever your birth plans.

In the final analysis, I would give this book to my sister, but I would have to supplement it with a book on patients' rights (and the AIMS helpline number).

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