Making informed decisions on childbirth

of her book, Margaret Jowitt – a self-declared lay person, albeit with decades of experience campaigning for improved maternity services – raises many important and interesting questions about the physiology of labour and birth in her mission to improve how the maternity services understand, and thus support, labour and birth. As such, she sets an important research agenda: indeed, it is rather disconcerting to realise that our maternity services seem to assume that they can operate well without answering the research questions laid out here.

Margaret has an authentic authorial voice: as a reader, if you are willing to follow her lead, she will take you on a journey of reflection, with many thought-provoking questions along the way. Margaret is not afraid to pose questions to herself and is upfront about how some of the background reading in this area is really quite complicated. You may find yourself disagreeing with the text at times or even a little frustrated, with questions that might have been attended to in the text (I made quite a list!). However, it is important to remember that this book is not intended to be an academic text: instead, it is a highly thoughtful “outsider” intervention in a research area that seems to have got well and truly stuck. I look forward to seeing how researchers take up Margaret’s challenge to better understand birth physiology, to drive improvement in the maternity services.

For me, this book offered a first “tour” of birth furniture through the ages. I was fascinated by the idea that an unborn baby might have reflexes to aid its exit from the womb – I had previously only considered these reflexes in the context of breastfeeding. I am still doubtful about Margaret’s assertion about the lack of knowledge about birth physiology as evidenced in medical textbooks – but there again, I hear this complaint too about midwifery education, and this would certainly seem to explain many of the everyday practices that we know are not conducive to supporting the physiological process of labour and birth. I became curious about the drivers of uterine rupture. I was pleased to read an account of early labour that considered the function of early contractions and how these could be more productive with some attention to maternal positioning, rather than an account that simply dismissed them as ‘uncoordinated’ (with the implication that they are useless!). I liked the way that Margaret was unafraid of offering controversial material: at one point, for example, she likens the requirement to lie in a supine position for foetal monitoring – when concerns have been raised about the unborn baby – as ‘tantamount to fetal abuse’ (p. 145).

Thank you, Margaret, for continuing to bring your passion and energy to this important topic. But most of all, thank you for valorising the skill, knowledge and agency of the motherbaby dyad. Birth physiology is too important an issue to be left to the “self-styled experts”: they have let us down, and it is thanks to “ordinary women” asking “ordinary questions” that we will surely make progress on this important topic. AIMS campaigns for a physiology-informed maternity service, and reading this book certainly seems to confirm the need for this campaign.

by Sophie Janters

Publilshed by Sophie Janters ISBN 978-1532812989 224 pages Current Price £10 on Amazon

Review by Georgia Clancy

Vantiers is, by her own admission, not a specialist on the topic of pregnancy and birth. She does, however, have a PhD in geophysics and scientific research experience, which she says has given her the confidence to carry out an exploration of the medical literature surrounding maternity. In Making Informed

Decisions on Childbirth: One Scientist’s International Perspective (2016), Vantiers seeks to pass the knowledge of this personal exploration, as well as her own and others’ experiences, on to expectant parents.

The book, which is an interesting and accessible read, is written as if a friend were recounting their childbirth story and uses the author’s personal knowledge of pregnancy and birth as a launchpad from which to explore a myriad of topics. With the goal of facilitating informed decision-making, Vantiers discusses topics such as pregnancy and birth preparation, the tension between respectful care and ‘best’ care, consent, interventions, pain relief, gestation time, medicalisation and what happens after birth. The author references scientific and academic literature, but also offers the reader her own thoughts on many ‘what if?’ scenarios along the way.

Vantiers herself favours a ‘natural approach’ to childbirth and takes a cautious approach to medicalised practices:

I am not an advocate of ‘natural is always better’. Rather my motto is ‘natural is safer in the long-term unless significant benefits outweigh the possible unknown risks’. In other words, if the most recent (bio)medical research shows only a marginally better outcome or no difference at all for a certain intervention, don’t use it! (p.7).

Just as it is worth cautioning against the use of interventions in birth, it is also worth cautioning against the privileging of natural childbirth ideology, which can make women who do not, or cannot, fit in to this discourse feel like failures if they have medicalised care. Indeed, Vantiers herself acknowledges that she would have asked for an epidural if her labour had been slow and the pain had been set to continue (p.32), highlighting the subjective nature of decisions in pregnancy, birth and motherhood and how perspectives can change depending on the circumstances.

In lieu of being an ‘expert’ in birth in the traditional sense, Vantiers strives to provide relevant and current references to support her writing and thus offers the reader a springboard from which to engage in the scientific literature itself. Her discussion and consideration of scientific evidence is based on her time living in the UK, US, France and Belgium. Peppered throughout the book are musings from Vantiers’s husband and stories from her “international group of friends and family” (p.5) stemming from eight Western countries.

The stories from Vantiers’s friends and family have

Verina Henchy and Jo Dagustun are both AIMS Volunteers

clearly had a profound effect on her perspective, though unfortunately we do not find out much about this group, such as whether their experiences represent distinct or diverse communities and so in turn how their experiences might relate to the experiences of others. Vantiers focuses on the difficult births of two friends in particular, one in Canada and one in France. Whilst these stories help to bring the writing to life, they are, of course, individual experiences, which may or may not be indicative of practices in particular countries, and are infused with the author’s own thoughts. Rather than adding to the ‘international perspective’ of the book, they serve to highlight some of the complex and often competing ideologies and practices of birth which women must navigate and negotiate whilst on their own maternity journey.

The overwhelming take-home from this book is that women will encounter a myriad of choices and options during pregnancy and birth and that Vantiers feels that it is “always better to be prepared for the worst and hope that it doesn’t happen” (p.25). Whilst equipping yourself with information is empowering for some, the expectation that women should be doing this may be overwhelming for others at a time when they are undoubtedly already doing the best they can. Indeed, the onus must not just be on women to learn how best to work the system, but also on the system and those working within it to improve. There may be limitations on how many different situations women can mentally prepare for and the technical information they can consume in order to continuously be making informed decisions about their care, especially if they are already in labour experiencing pain and fatigue. This is why a key element of a well-functioning maternity service is to support informed decision-making, so that women can feel in control of their birth and positive about their experience, regardless of how plans might change.