Book Reviews

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AIMS Journal, 2013, Vol 25 No 2

Where Have All the Mothers Gone? Stories of Courage and Hope during Childbirth among the World's Poorest Women by Jean Chamberlain Froese

Fresh Heart; 2nd edition 2011
ISBN-10: 1554523028
ISBN-13: 978-1554523023
Publisher's recommended price 21.00

Reviewed by
Kate Simpson

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As someone who worked in Uganda, albeit for only a short time, this book helped make sense of some of the more political thoughts I had during my time there.

The book offered an excellent insight into how mothers are at risk from their environment, rather than birth itself, but it would have been very much enhanced by actually exploring how the conditions under which these women were living, becoming pregnant, birthing and raising their children affect their life expectancy and their safety. It is a shame that for many of the stories the part of the situation that was highlighted was the poor access to medical care, without mentioning that if the women were healthy, safe, well-nourished, freed from genital mutilation and with access to sanitation and clean water in their day-to-day lives, they would need a lot less rescuing with medical attention.

It struck me that if one in 30 women in the world's poorest nations actually die from birth, this is indeed appalling. The stories, however, highlight how women are being deprived of the most basic of needs and this is the real concern. When women are endangered because roads are being blown up in war zones, thus denying them a safe transfer in the event of an emergency, that has nothing to do with the safety of the birth process; the woman would have been in equal danger from a roadblock had her injury been a knife wound or a snake bite.

Women are experiencing deadly postpartum haemorrhage because they are seriously anaemic. This is not due to the woman not caring for herself or any danger inherent in pregnancy or birth, but because of the economic and social climate in which she lives. Things such as the land not being irrigated adequately to offer her a healthy diet and inadequate access to clean drinking water are deadly, yet this book makes no mention of that, preferring instead to blame pregnancy and birth. Women are working hard at, or even below, the very limit of adequate nutrition, and it is the poor nutrition that is taking its toll, not the physical work or pregnancy.

Undoubtedly there are some very dedicated professionals who are working to save women and babies, but they are saving them from the catastrophic effects of poor living conditions, war, economic and environmental disasters, corrupt governments and a general devaluing of women and children, rather than from the dangers of birthing itself.

The tradition of herbal remedies amongst birthing attendants is probably less of a concern than the use of modern medical methods amongst those who have not had access to basic education, are unable to read instructions and have no hands-on wisdom to guide safe use. This is not because birth, traditional medicine or traditional attendants are dangerous, it is the volatile cocktail of low education due to control of government monies combined with only part of the technology needed to complete a task. Again this is more like the situation where tractors are provided without fuel, preventing their proper use, than it is a statement on the safety of childbirth or traditional attendants.

This book indeed highlights not the need for increased medicalisation of birth, but the acknowledgement of all those things that hinder the woman from safe birthing process, and if help is needed, how man again hinders this assistance. Sadly, this book does not explore these themes in any depth, and for me, that is a major omission.

For this country, there is much to learn. With a mind trained for critical analysis, if in the worst-case scenario suggested by this book, 1 in 30 (3.33%) women were really to die from birth itself (rather than environmental factors affecting birthing women), then why is our caesarean surgery rate 25%, almost 10 times that rate when we are well-nourished, safe and well-housed? Given even the most cautious of practice, on the basis of evidence presented in this book a 5% caesarean rate would be just about justifiable to 'save' women's lives. This evidence strongly suggests that the high-income countries' high intervention rates are quite possibly the reasons behind their high caesarean rates, rather than the 'risky' business of birth itself.

In all, a book with more questions than answers, but an interesting read all the same.

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