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BIRTH 36:4 December 2009


Birth Models That Work

Robbie E. Davis-Floyd, Lesley Barclay, Betty-Anne Daviss, and Jan Tritten, Editors University of California Press, 2009 484 pp, $33.00, pb The editors of Birth Models That Work recognized that some good news was needed. At a time when medical intervention in birth is the norm, cesarean delivery rates are skyrocketing, and birthing women and their babies experience unnecessary risk, this book outlines pockets of effective, respectful, and sustainable maternity care that combine the best of obstetrical care with the best of contemporary scientic research, ancient wisdom, basic common sense, and compassion to create systems of knowledge, skills, and practice that truly serve mothers, babies and families (p. 1). The book highlights 15 models that t into four broad sections, including national/regional models, local models in developed nations, local models in developing nations, and a section that outlines models in progress. The editors, composed of internationally recognized researchers, educators, authors, and midwives, use the introduction to set the stage for why successful birth models need to be showcased by describing the very real and dangerous practices that occur in maternity care. The case is made that most birth practices around the world fail because they cause collateral damage to mother and baby (p. 1). In developed countries, the editors argue that access to technology results in a reliance on interventions to manage birth. With the escalating rise in technological birth, unmedicated, natural births are increasingly rare. This factor creates an additional problem of establishing informed consenttruly informed decision-making about birth options is almost impossible when the alternatives to a medically controlled birth are mostly unavailable.

354 In developing and low-resource countries, the editors provide examples demonstrating that women experience abuse, little or no support, unsafe surroundings, and a lack of basic access to safe maternity care. They highlight the loss of traditional midwives and customs, and the risks of . . .importing Western biomedical models into developing countries without adequate resources to provide even a semblance of humanized practice (p. 7). The inclusion of the unique struggles in developing nations was profound and absolutely crucial for a full understanding of the enormous challenge to normalize birth and reduce morbidity and mortality around the world. The editors then shift the focus to good news stories around the worldcompelling models that have demonstrated success. The stories are told by a range of individuals who lend voice to a variety of different care providers, government employees, researchers, and grassroots workers. Each chapter outlines different components that led to success at all levels of action. There are examples of paradigm shifts (macro/cultural), policies that inuenced positive change (systemic/political), and successful grassroots maternity care practices (micro/community). Regardless of whether or not a practitioner, politician, or consumer can facilitate the adoption of one of these models in its entirety, a rich selection of successful initiatives is available that can shift thinking, change practice, and raise awareness. Five main themes are expressed in the birth models presented: (1) the importance of respecting and working within unique cultural characteristics; (2) the need to be creative and take advantage of receptive political climates; (3) the courage to be nimble and creative to garner support; (4) the signicance of grassroots mobilization and advocacy; and (5) the need for a paradigm shift to normalize natural birth. 1. Cultural uniqueness: The Dutch Obstetrical System, the Samoan Midwives Stories, and Maternity Homes in Japan demonstrate successful models, largely due to the cultural uniqueness of the settings. Given that particular cultural factors were such dominant forces in these models, this factor could make it hard to wholly replicate them in other settings. But the message from these models is that we have the responsibility to seek opportunities in our own countries where, as Raymond De Vries states, . . .cultural values and policy objectives can be used to promote the safe, sane approach to birth offered by midwives (p. 48). 2. Politically strategic: Several models describe using moments of political receptivity to gain momentum toward normalizing and humanizing birth. It was not necessarily the concern for women and babies that engaged political will, but international embarrassment over high cesarean delivery rates (in the example of

BIRTH 36:4 December 2009

Brazil), economic pressure within the publicly funded health care system (in New Zealand), or very public court cases that elevated concern about community midwifery, resulting in recommendations to regulate the midwifery profession (in Ontario, Canada). 3. Nimble and creative: Transformational change rarely results from one single initiative followed from beginning to end. The Northern New Mexico Midwifery Center is an excellent example of a grassroots-driven birth center and a midwifery college that has evolved for over 30 years in response to the needs of the community and the desire to legitimize the midwifery profession. The CASA Hospital and Professional Midwifery School in Mexico shows us a nimble and creative way to gain legitimacy within the community. The model showcases a social service agency that evolved to provide . . .choices for women across the reproductive spectrum: the choice when to have children, the choice of how they would be born, and the choice about how they would be cared for when mothers had to work (p. 306). This model includes a maternity hospital staffed by midwives, a midwifery school, and a community health center for a range of health and social needs including a daycare, library, and youth programs. 4. Grassroots mobilization and advocacy: The transformation outlined in many of these models owed from consumer demand for change supported by grassroots advocacy. Of particular note is Small Really Is Beautiful. This model describes the local community advocacy campaign to save a birth center in England from being closed. Their campaign culminated in a rally of an estimated 2,000 people, eventually resulting in ongoing funding and support for the center. 5. Transformation to normalize natural: Three models truly focus on trusting and promoting natural birth as opposed to the focus on reducing interventions. In Teamwork, Ricardo Herbert Jones, an obstetrician in Brazil, discusses the factors that contributed to his personal paradigm shift. In two decades his practice changed completely from highly interventionist to one of support for natural birth and home birth. Particularly insightful was his insistence that normalizing and humanizing birth can only take place within a transformed society, and he describes strategies needed to make broad societal transformation (p. 299). The Albany Midwifery Practice, in southeast London, strongly promotes home birth, and midwives strive to keep natural birth at the forefront in all of their client interactions by . . .instill[ing] in women and their families a condence in the birth process and the idea that birth can and should be a joyful event (p. 150). In Orchestrating Normal, we read examples of how midwives in the United States orchestrate the normalan intentional decision to purposefully, and sometimes colorfully, illustrate that birth is normal and safe. A question the author

BIRTH 36:4 December 2009

355 in transforming the childbirth experience would nd something in Birth Models That Work to inspire action. It is an important read for maternity care professionals, educators, researchers, activists, and childbearing women. Brenda Kent, BSc, MPH Candidate Faculty of Health Sciences, Simon Fraser University 1374432 Ave Surrey Vancouver, British Columbia, Canada V4P 2B8

leaves readers with is: how do we convince women they. . . own birth and that their bodies are trustworthy (p. 434)? This model is a brilliant example of how to do just thatto focus on normalizing childbirth and inviting everyone around to trust birth. Some chapters could have beneted from greater elaboration on the sustainability of the models and further explanations on how success was measured. More detail about the impact of the childbirth experience on childbearing women would have also been helpful. Given the signicance of the consumers experience in successful birth models, as well as their role in advocating for change, greater emphasis on this factor would provide richer insight into the models. In their concluding chapter, the editors outline the signicance of the midwifery model of birth as a common thread throughout the successful initiatives. This book demonstrates how a strong vision and a handful of passionate leaders can make enormous change possible. These diverse success stories served to cultivate a much-needed sense of cautious optimism toward improving birth culture everywhere. Anyone interested

Michael C. Klein, MD, CCFP, FAAP, FCFP Emeritus Professor of Family Practice and Pediatrics University of British Columbia L309B4500 Oak Street Vancouver, British Columbia, Canada V6H 3V4