Book Reviews

Complete list of book reviews on the AIMS website

AIMS Journal, 2012, Vol 24 No 2

Born at Home, The Biological, Cultural and Political Dimensions of Maternity Care in the United States by Melissa Cheyney

Wadsworth, Cengage Learning
ISBN-10: 0495793663
ISBN-13: 978-0495793663

Reviewed by Nadine Edwards

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This book is the result of an impressive amount of work, largely based on interviews with home birth mothers and midwives, and statistics collected on home birth outcomes for a midwifery practice in the Mid West, USA.

The book discusses how women who plan to birth at home and the midwives who support them are marginalised, at best, and vilified, at worst. The author covers a brief history of midwifery and how it has evolved over the last decades. She defines medical and midwifery models of care, but also highlights the complexities of this and how practitioners usefully draw on both models. She advocates identifying common ground between midwives and doctors in order to promote collaboration and better care for women, especially when home to hospital transfers occur. If midwives and women are afraid to transfer because of hostility from hospital practitioners, and those receiving the woman feel that every home birth transfer is a 'botched' birth, the woman is less likely to receive expert and sensitive care.

The author describes how the US health system works against collaboration and how doctors who are open to midwifery care are prevented from supporting home birth midwives. As an obstetrician explained, it is difficult for doctors to change their practice, even in response to their own scientific research: 'our standards of care come down to us from ACOG - the supreme authority on how we are supposed to practice. It takes much more than new research to change a protocol once it has been established by ACOG.' (p47)

Themes covered include women's stories about how they came to plan home births and the antagonism they faced in order to do this, trusting relationships between women and midwives being at the heart of midwifery practice, the healing potential of home birth, the need for collectivity among those supporting home birth and midwives, and views on safety based in relationships: 'The closeness and depth of knowing that develops out of this approach means that midwives are often intimately acquainted with the physiological, emotional and social nuances of individual mothers and babies. They carry a depth of knowledge that comes from attending a small number of women in a continuous, individualised, and timeintensive manner, and this, midwives assert, makes them better able to identify complications and deviations from normal.' (p73)

Home birth midwives in the US risk a great deal. The author describes how a midwife lost custody of her children because attendance at home births apparently demonstrated 'social deviance' and a sign of an 'unfit mother'.

These midwives (who risk so much) are held in high esteem by the women they support. When the author was presenting her findings of the excellent outcomes of 602 home births over 15 years, a woman in the audience interrupted to acknowledge the midwives who had attended those births:

'They are our freedom fighters. They put their families and their livelihoods at risk every day to honor a woman's right to choose where she gives birth. They stand up against an all-powerful medical system so that our babies can be born gently and peacefully at home, and I think that we should stand up for them.' (p91)

Clearly the situation for women and midwives is untenable, and importantly, the author believes that the role of the researcher includes activism - moving from the 'ivory tower of academia', lobbying for new legislation and policies. She describes some of her work in this area and the challenges faced by activists (as we know all too well) and suggests ways of working to increase knowledge and collaboration.

The quotation below perhaps summarises the approach of skilled midwives who have the humility to acknowledge the benefits and limitations of midwifery and technology, and who attempt to balance these:

'Finding the balance... that's the art of midwifery' (p28).

Home Birth: The Politics of Difficult Choices by Mary L Nolan

Routledge 2011
ISBN10: 0415557550
ISBN-13: 978-0415557559
20.99

Reviewed by
Nadine Edwards

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This book covers the experiences of ten women who were deemed to be 'high risk', by conventional maternity care, but who nonetheless had home births. Five of the women had had babies before, and several women booked with independent midwives. The book is based on interviews with the women, and conveys their views and experiences in some depth. The author focuses on the importance of women's and midwives' agency, and the need for women who make decisions outside usual guidelines and policies to be supported. In setting the context, Mary Nolan discusses some of the political issues surrounding contemporary childbirth and the limitations of 'choice', suggesting that 'rhetoric about involving patients in their care as equal partners has outstripped the ability of the health service to configure itself as a democratic institution' (p57). She discusses the fear/risk culture of birth inhabited by women and midwives and promulgated by the circulating negative birth stories that undermine their confidence. In this setting, both women and midwives struggle when women make 'difficult' decisions. Women needed midwives to be their advocates and to support their decisions, even if they did not agree with them (which is what the Midwives Rules expects of them too). They found it exhausting to keep 'fighting their corner'. All they wanted was 'care which made them feel strong, confident and safe' (p116) from calm midwives, who believed in their abilities to birth their babies and could enable them to birth undisturbed - unless help was needed.

For midwives this clearly presents an increasingly intractable problem: while women value autonomy in their midwives, this is continually undermined by midwives being judged against medical rather than midwifery knowledge, and by 'difficult' decisions made by women being seen as a failure on the part of the midwife to provide enough information for the woman to make 'correct' decisions. It is almost impossible for midwives to support women, when they are so unsupported themselves.

Mary brings out this pitting of women and midwives against each other, and the difficulty of providing individualised care, in a culture of fear, risk, blame and guidelines. For women, this translated into midwives, supervisors of midwives and even senior midwives attempting to coerce them to follow usual procedures: 'They didn't want me to follow what I actually wanted, they wanted me to follow their procedures.' (p121) This book is powerful: it has an authenticity based on the women's own words, around which the author has built her narrative. It shows how women make careful decisions based on their own circumstances, and the profoundly negative impact of finding these decisions challenged at every turn. As Mary comments, 'It is hard to see what purpose is served by suggesting to women that they are not capable of giving birth, or how frightening them will lead to better outcomes. (p120) Yet, the lack of support and bullying some women were subject to, is staggering.

One point that is not made completely clear is about free birthing. Mary rightly points out that women have the right to birth at home. If the woman decides not to call a midwife, and invites family and/or friends to support her emotionally, this is is not illegal and her family and friends cannot be fined, unless they are pretending to be a midwife or doctor and/or take on that role. There are so many quotations that I would have liked to include, but the one below is particularly key to the home birth debate, sits well with AIMS philosophy and may hearten AIMS members:

'challenge is the lifeblood of improvement' (p17).

The Heart in the Womb by Dr Amali Lokugamage

Docamali Ltd 2011
ISBN10: 0956966705
ISBN13: 9780956966704
12.99

Reviewed by
Nadine Edwards

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Available from www.lulu.com
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This extremely readable book is fascinating. It is the story of how an obstetrician practising in a large obstetric unit in London came to plan a home birth. It describes a personal journey of moving from an intellectual understanding of why women need holistic care to help them grow through their pregnancies and births and become the mothers they want to be, to a very deep, embodied understanding of pregnancy and birth and what women need to support them through this vulnerable and potentially strengthening time. Amali Lokugamage lays the foundations for 'crossing a bridge to another birthing world' and weaves together a holistic approach, drawing on many fields, including modern medicine.

She describes how she became more drawn in to her own pregnancy, how she began to understand the connection between a woman and her unborn baby, and how decisions can flow from that relationship - if the woman is encouraged to listen to her body and her baby. She describes how difficult this can be in our fast moving, stressful culture, where women are expected to work until late in their pregnancies and where experts and technology provide the information about the woman's pregnancy and baby rather than the woman herself. The book moves between research and experience, and stresses the need to encourage women to move from rationality to confidence during pregnancy:

'Throwing facts and figures at women undoubtedly helps them to understand their choices, but it is more important that women are guided to unlock confidence in their bodies to embrace the process of birth. Without this, an almost virulent form of fear can sabotage their innate capabilities to birth well, quite aside from any genuine medical issues.' (p46)

The book describes how bureaucratic institutions with an emphasis on risk mitigate against holistic care and environments that support labour and birth - but that midwives are in a position to advocate for normalising birth. She describes midwifery practices in various parts of the world that provide holistic care with excellent results and high satisfaction rates for women. She explains how interventions, when carried out routinely might do more harm than good. While supporting the appropriate use of medicine and technology - her transformation through her own experiences of being a pregnant woman and mother have led to richer reflections - that encompass the miracle of birth, how the hormones released when labour and birth are undisturbed are crucial for women, babies, families and society, and what supports this intricate system. Undisturbed birth fosters 'love, compassion, nurturing, understanding, trust and co-operation', thus how children are born, 'shapes the collective thinking of our society as a whole' (p114): the need to think through how to best support undisturbed birth and minimise intervention in birth is urgent. Balancing benefits and harms (as Luke Zander again suggested at the recent Birthplace conference in London) seems very challenging for our 'risk averse' society but Amali's final suggestion provides a great deal of food for thought:

'A certain amount of strategising in professional life is necessary, but if this is also tempered with a more pragmatic approach, of taking life as it comes and having a receptive and flexible response to life's challenges, then it really helps one to negotiate life's chaos. Some of the most perfect solutions to life's problems are only visible in the moment and cannot be calculated.' (p118).

Amali Lokuganage (obstetrician), Sarah Buckley (GP) and Clare Willocks (obstetrician) have set up a network for doctors who support undisturbed birth.
www.facebook.com/groups/225233534204058/

Home Grown Babies DVD directed by Bernadette Bos

Goldhawk Media Limited
14.00

Reviewed by
Michelle Barnes

Available from AIMS
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Bernadette Bos is a former midwife and director of Home Grown Babies and other inspiring programmes about pregnancy and birth, including Home Birth Diaries, Special Babies and Pregnancy and Birth the Truth.

Over the years you may have seen Home Grown Babies on the TV but sadly this inspiring series has only ever been available on some obscure digital TV channel. Mainstream TV only seems to broadcast sensationalist stories which have no purpose other than to contribute to a growing fear of pregnancy and childbirth. Fortunately Home Grown Babies is now available on DVD and includes five stories of childbirth that will both inspire and empower you. The series focuses on home birth and covers different subjects including waterbirth, gestational diabetes, hypnobirthing, vaginal birth after caesarean (VBAC) and a positive caesarean section after transfer from a home birth.

Each story takes you through pregnancy, birth and the first few weeks post-natally, giving you a personal and realistic insight into what it's like to plan a home birth in the UK today. It highlights the national shortage of midwives and how this affects a woman's right to choose a home birth and also looks at the vital service independent midwives (IMs) provide.

I enjoyed following each couple through the ups and downs of pregnancy, labour and birth, but I particularly enjoyed Clare's beautiful home birth of her first baby, assisted by independent midwife, Virginia Howes. Bel's story was also very inspiring as she came a long way to have a home waterbirth, despite numerous obstacles, including being diagnosed with gestational diabetes and subsequently having to fight for her home birth.

Other stories include Nancy and Teewyn who used the hypnobirth technique to help them through their second attempt at a home birth. Nancy suffered a traumatic birth with her first baby after being transferred from home to hospital during labour. I was touched by how protective Teewyn was towards Nancy and how well he supported her throughout the whole process. This DVD is a great educational resource for parents-to- be, midwives, doulas, antenatal teachers and other maternity health care professionals and it comes with a handy information booklet which includes useful facts, figures and links to further inform.

I would highly recommend this DVD. A must see!

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