Book Reviews

Complete list of book reviews on the AIMS website

AIMS Journal, 2010, Vol 22 No 2

The Faceless Caesarean by Caroline Oblasser

Riedenburg, Austria 2009
ISBN-10: 3837075605
ISBN-13: 9783837075601

Reviewed by
Gina Lowdon

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This book, written by mothers for mothers, also has much to offer the medical profession and anyone working in the maternity services.

The author conducted a survey questionnaire of 162 mothers, the findings of which make interesting reading and are summarised in the first part of the book. The main part of the book is centred around 60 of the responses and enables the voices of these mothers to be heard, placed in the context of brief details of their caesarean births, and accompanied by a black and white picture of their scar on the facing page.

I very much liked the fundamental grass roots reality of the book and the wide range of views and approaches to caesareans that are expressed by the mothers themselves. The women are faceless and nameless and yet their different characters, perspectives and views still come across very strongly; they are anonymous but still very real individuals.

As far as I am aware this is the only book to include photographs of the women showing their scars and I found the pictures very interesting. Caesarean mothers have a natural curiosity about how their scars compare with others and it isn't often that we have an opportunity to make such assessments.

The survey was conducted among women in Germany and the book has been translated which has given rise to one or two odd phrases and strange terminologies. One of the survey questions asks if the caesarean was 'prognosticated' which my dictionary informs me means 'foreseen'. However it is still understandable and I found the slight oddness added charm and a sense of communication on common ground with another country.

The book also contains a photo report of a caesarean section, giving a running commentary linked to a series of black and white photographs which are shown in a separate sequence to the commentary. This is a very sensitive way of presenting this chapter as, like many caesarean mothers, I actively avoided such information for many years. However some women are interested to know what actually happens from an operative point of view and this format gives the reader a choice of whether to just read the commentary or to view the pictures as well.

There are occasional inaccuracies in the book. For example, in an introduction by the Advocacy Director of ICAN, reference is made to 'the apparently shallow choice of a pop-star in the UK to schedule non-medically indicated surgery.' Every time I see this widely quoted reference to 'too posh to push' my sense of injustice is renewed. It takes no account of the standard medical advice that Posh Spice would undoubtedly have received as a slim size 8 with a breech presenting baby who went into labour before the date of her scheduled caesarean section. Personally I suspect that far from being 'too posh to push' she was infinitely more likely to have been 'conned and cut' like so many others.

This book has a richness of experience, and the words of these German caesarean mothers reflect the words of caesarean mothers worldwide. The realities of caesarean bir th are voiced without being sensationalised, trivialised, promoted or denigrated, giving a sense of what it is like to undergo caesarean surgery from those who have experienced it. It answers the question 'What is it like to have a caesarean?'

Caesarean Section, Understanding and Celebrating Your Baby's Birth by Michele Moore and Caroline de Costa

John Hopkins Press (2003)
ISBN-10: 0-8018-7337-1
ISBN13: 978-0801873379

Reviewed by
Gina Lowdon

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Given the title of this book, and the statement on the front cover that 'Trusted physicians reassure mothers and mothers-to-be: It's okay to say yes', I had high hopes that here was a book that would cover Caesarean Birth in a positive and supportive way.

There is a great need for information on caesarean bir th that can balance the campaign to reduce caesarean section rates to acceptable levels and put into perspective the accompanying media coverage that highlights the risks and consequences to both mothers and babies of caesarean operations.

Unfortunately I don't feel the book lives up to the promise made by its cover.

Whilst the cover proclaims, 'It's okay to say yes', this book does not pretend to support the growing number of women who express a preference for caesarean birth. The authors claim that maternal request for c-section is exceedingly rare in the United States or Australia but common in South America and increasingly so in Great Britain. They further state that: 'This book is not about this option.' So it's okay to agree with your doctor, but not okay to have your own opinions and needs.

Mothers struggling to come to terms with an unexpected or traumatic birth, many of whom would dearly like to be able to 'understand and celebrate' their baby's arrival, are also unlikely to find much in this book that will help.

The basic message is that 'doctor knows best', that every caesarean is necessary, and that 'the major point is that all of these c-sections are done for good medical reasons.' The authors feel that to lower the current caesarean section rate (CSR) would put mothers and babies at risk. There is no evidence to support this theory however, and the statistics simply don't add up. The World Health organisation (WHO) have stated there is no justification for a CSR above 10-15% - the upper figure only being added following the outcry from the Americas that a target set as low as 10% would not be taken seriously in parts of the world with the highest caesarean rates. A Guide to Effective Care in Pregnancy & Childbirth (2nd edition) states: 'The optimal rate is not known, but from national data available, little improvement in outcome appears to occur when rates rise above about 7%.' Clearly then, with a national rate of 24%, a large proportion of caesareans cannot be justified on grounds of safety - a fact this book fails to acknowledge.

There is little in the book that I would consider helpful to a mother wanting to understand why she needed a caesarean. The explanation that caesareans are necessary because 'nature' gets it wrong or 'does not cooperate' is woefully inadequate. Unfor tunately the predominant attitude is that caesareans are necessar y because the doctor has judged it so and the suggestion is made that women would do better to 'put faith in their ob/gyn not nature.' These 'explanations' are too superficial for many caesarean mothers who may be wondering why nature didn't cooperate or in what way nature got it wrong.

There is also no explanation that all 'emergency' caesarean sections are not in fact dire emergencies - an emergency caesarean is described in the book as 'one that is urgent' and 'is done to save the life of the mother or baby.' There is much confusion and misunderstanding of the terms 'elective' and 'emergency' and both The National Sentinel Caesarean Section Audit Report and the NICE Caesarean Section Guideline have recommended that all caesareans be classed according to four categories of urgency - only category one (often recorded as a 'crash' caesarean) is classed as 'an immediate threat to the life of the mother or fetus.' In the Audit report this category accounted for 16% of caesarean births, which is only around 3.5% of all births.

I was also disappointed at the lack of 'celebrating your baby's birth.' Obviously a healthy mother and baby are cause for celebration, but there are other aspects of caesarean birth that could be celebrated as well. There is no information on, or suggestions for, improving the experience of caesarean birth, which I find a glaring omission in a book with such a title.

Although both children of one the authors were caesarean-born and the other has given birth to seven children vaginally, the book is written very much from the doctor's point of view rather than the mother's. The book informs women of what will happen rather than offering or suggesting options.

It was worrying that in all the accounts of caesarean births in the book the babies seemed to leave theatre with partners just after the birth, leaving mothers alone on the operating table. There is no indication that this is not always the case although the book does say that general anaesthetic is used for most emergency caesareans (no longer the case in the UK and I would be surprised if it is in most places in the USA either). There is also no acknowledgement that the woman may need support during this time, let alone mention of adverse affects on bonding or breastfeeding, or the psychological consequences of separating mother and baby at such a time without over-riding medical need. Providing the baby does not need specialist paediatric care, and most caesarean-born babies don't, then normal procedure ought to be to lay the baby across the mother's shoulder, on her chest, or have her par tner hold the baby close by her. The 'sewing up' part of the operation goes much more quickly and pleasantly when you can pass the time baby gazing!

Apart from the general tone I found some aspects of the book concerning. Some of the opinions and views expressed (many as implied fact) lead me to question how research-based this book is, especially as there is not a single reference in the entire book. 'Trusted physicians' the two authors may be, and perhaps as such they do not feel they need to reference their book, but it is unusual today for books of this nature not to include full research references and sources of further information.

Several highly emotive but somewhat questionable links are made, reinforcing common misconceptions, which do not help, and may even hinder, an understanding of the real situation. Historical maternal and fetal death rates are linked to today's high caesarean rates with the statement 'caesarean bir ths represent births that, before modern obstetrical practice, often resulted in tragedy.' A similar link is made between high maternal and fetal death rates in non-industrialised countries with caesarean section rates in the western world. Whilst the facts are true there is no proven or even indicated correlation.

There is no mention of the improved living conditions, sanitation, and better diets that have played such an important role in lowering death rates of people of all ages, increasing child survival rates and reducing maternal and fetal death rates. Those of us living in western industrialised countries are quite simply healthier than previous generations and our less fortunate sisters in other parts of the world. Also, as discussed previously, there is no statistical evidence to justify the need or benefit for caesarean section rates over 7%.

Whilst the risks of caesareans are not ignored, the language used trivialises them. By contrast much is made of rare adverse consequences of vaginal bir th. Personally, I don't feel it is helpful to use rare circumstances to explain and justify actions taken in situations that are commonplace. Again, the statistics don't add up.

For example, 'failure to progress' is explained in terms of fistula and the claim made that few women in the developed world suffer these due to caesarean section. Whilst this is in part true as fistulas are rare in the developed world, the implication is that the large number of women who undergo caesarean section due to 'failure to progress' in labour are being saved from severe and debilitating forms of incontinence. Again, there is no clear evidence that this is the case.

Rates of postnatal depression linked to vaginal birth are quoted of 10-50% with discussion of a study (not referenced) of women in war torn Lebanon. Clearly the authors do not understand that research based on one set of criteria is not always applicable to another. Not surprisingly there is no mention of PTSD (post-traumatic stress disorder), linked to either vaginal or caesarean bir th.

Another statement that fur ther demonstrates the lack of balance in the attitudes of the authors claims: 'studies have shown that in the first six months after their first vaginal delivery, approximately 85% of women have some discomfor t in [the vaginal] area. For a woman who has a c-section her incision may trouble her for the first six weeks but generally not after that.' The studies referred to are not referenced of course and therefore the reader cannot verify their validity. I personally found the high percentage quoted difficult to accept as I know a great many mothers who have given birth vaginally and am not aware of any that have problems of this nature. In my 16 years of supporting caesarean mothers I can testify to the fact that unfor tunately many women are 'troubled' by their scars long after the 6-week check, an unfortunate few suffering long term pain necessitating regular pain medication months or even years post-caesarean.

In common with a significant proportion of obstetricians, the authors believe that 'c-section in itself poses fewer risks to the baby than vaginal delivery does.' The balance of risks does tend to depend on which risks are added to the scales though. One risk rarely considered is that of the baby getting cut. Two studies have now put this risk at around 1%. Also rarely taken into consideration are risks to subsequent babies - the safest way to be born is to be a second vaginally born baby. I know from my own reading of research that long term risks of caesarean section tend not to be taken into account as research is rarely carried out due to its lengthy nature and difficulties getting funding, however there is some evidence that caesarean-born adults are more likely to suffer breathing problems such as asthma.

It is clear too that the authors have little appreciation of the profound psychological impact of birth, both by caesarean and vaginally. Comments such as 'women may be disappointed with having a hysterectomy' and a case report comparing feelings of a woman who lost her baby due to caesarean scar rupture (a very rare event) to those she felt after her caesarean, clearly demonstrate the sort of lack of understanding women meet from medical professionals all to frequently.

Sadly, I cannot recommend this book. The authors fail to demonstrate any real understanding of caesarean issues and I have doubts over the validity of the research base and the conclusions drawn.

How to Avoid an Unnecessary Caesarean by Helen Churchill and Wendy Savage

Middlesex University Press (2008)
ISBN-10: 1904750168
ISBN-13: 978-1904750161

Reviewed by
Sarah Stenson

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This book, which has the subtitle 'For women who want a natural birth' is a small book, which balances factual information and some less usual birth stories.

This book has potential to be a useful starting point for women who are learning about birth technology and the current norms in Western birth culture, particularly women in the UK, as there are sections discussing the differences between NHS care and independent midwifery. It discusses the historical rise in caesarean section deliveries compared to relatively recent times, and some of the contributory factors such as the prevalence of hospital birth and continuous electronic fetal monitoring. It provides a starting point for examining how standard obstetric policies can make straightforward birth less likely than evidence (and indeed common sense) suggests it ought to be for healthy women and babies at term.

The book contains some information about the physiology of birth such as an explanation of the idea of Optimal Fetal Positioning, and breech birth is also discussed. For these matters to be fully considered fur ther reading would definitely be needed. Likewise, although this book states it is 'for women who want a natural birth', this is not a toolkit of coping mechanisms for labour - simply providing explanations of how epidural anaesthesia can make straightforward birth less likely, for example.

The birth stories featured provide anecdotal evidence and support for women planning vaginal birth where many women would have a caesarean, often through lack of information or support. I find it slightly strange that amongst these, there is an emphasis on breech bir th in par ticular, which in my opinion is a shor tcoming of the book, since only 3-4% of babies are breech at term and many more 'unnecesarians' are performed for failure to progress, for example. Stories where women have declined interventions and had normal, though long, labours would have been really inspirational and begun to dispel the narrow range of 'normal' that NICE and Trust policies would have us believe in.

This book, like its VBAC counterpart, is a starting point and unlike the VBAC handbook, I believe this book may have captured a useful niche in the market. In my opinion, it has most potential to enable first time parents to consider their decisions carefully, although strangely I wonder whether the direct title may unfortunately make it less likely to be read by that target audience as the sense that the system does not work for them is often not always understood until after their first birth. I would be interested to hear from women who have read this book as part of their birth preparation and understand how or if this has influenced their decision making and birth outcomes.

Vaginal Birth after Caesarean by Helen Churchill and Wendy Savage

Middlesex University Press (2008)
ISBN-10: 1904750214
ISBN-13: 978-1904750215

Reviewed by
Sarah Stenson

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This book, prefaced as 'The VBAC handbook' is a small book, with pages 7-39 taken up with factual information such as the risks of VBAC and repeat caesarean, VBAC success rates and so on, with the bulk of the book being taken up with seven VBAC success stories.

I found this book to be a strange mixture of ideas, tone and language. Despite a note about using empowering language at the star t of this book, the language flits between medicalised and involved, to vague statements which do nothing to enhance women's understanding of how birth works, such as 'women report that when you are able to move around in labour it helps your labour to progress.'

Rather than long sections of text about percentages of women who wished to have their baby by CS or vaginally, I think a shor t section explaining how the pelvis works would be much more empowering to women considering VBAC and has far greater potential to make VBAC a reality. Equally, the images used are poorly chosen (there is one picture of bir th in the whole book and this features a woman being passed her baby in a semirecumbent position.) In a book with images, it would have been nice to use those which suppor t the ideas in the book rather than reinforce the current norms of medicalised bir th culture in the UK.

The second section of the book contains seven VBAC stories, varying in location, care-givers and number of prior caesareans. This could be a great eye opener for some women, who are just setting out on their VBAC journey and finding out what is possible with support and preparation. However, I wonder if women who have been told after their second (or third, or fourth...) caesarean that vaginal birth after multiple caesareans is not 'allowed' would even pick up a book entitled 'Vaginal Birth after Caesarean' so as to discover what other mothers have done. I feel that to normalise the safety of vaginal birth after more than one caesarean, our language needs to start honouring it as a possibility.

These are just a few examples of how the book appears haphazardly thrown together, without a clear purpose. There is a lot of useful information in this book that if more cogently and cohesively presented could be an excellent star ting point for women who are not well informed about VBAC, but it is certainly not 'the VBAC handbook.'

For a similar price, I would recommend the AIMS publication Birth after Caesarean which has a more woman-friendly and empowering approach whilst packing in the same, if not more, information.

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