Book Review: Optimal Care in Childbirth, by Henci Goer and Amy Romano

This dense and fascinating book presents a huge amount of evidence and a highly articulate argument for a physiological model of birth, starting from the premise that pregnancy and birth are healthy, normal experiences for the majority of women, and only where risk exists, does medical management become appropriate.

This approach fits nicely with my own philosophy of pregnancy and birth, and is well-supported by short analyses of the research in each chapter. Other reviewers have pointed out that the evidence is somewhat cherry-picked, as is always the way in the context of books on birth. It seems to be categorically impossible to have a truly objective reading of the evidence on this subject, and few people with any real knowledge seem to occupy a middle ground on the spectrum from hardline birth skeptics who can only allow the medical model, and advocates of straightforward physiological birth. Both groups tend to be very blinkered about research that contradicts their point of view.

Optimal Care in Childbirth gives a good insight into the source of this deep opposition between the two philosophies. Within the medical model, pregnancy and birth are presented as intrinsically dangerous and difficult. The historical background to this assumption is well documented. In the 21st Century western world, overall levels of risk, particularly to the mother, are very low; and this results in a narrow focus where almost the sole positive outcome to be achieved is a live baby and mother. Strategies are therefore devised to minimise the maximum potential risks, and preventative procedures become routine. This leads to an assumption that the medical approach is the norm, which has a knock-on effect on the research available. The more women who give birth by caesarean section, for example, the greater the belief in the medical community that birth is difficult and dangerous, and the more deskilled midwifery becomes.

There is no doubt that childbirth is complex, variable, and human; and the outcomes of childbirth are soft, complex and variable too. Goer and Romano define the optimal outcome as:

“the highest probability of spontaneous birth of a healthy baby to a healthy mother who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and who goes on to breastfeed successfully.” [p21]

However since the language and thinking of research is based in the medical model, the basic assumption is that non-intervention in childbirth equals risk, rather than the other way around. Optimal Care in Childbirth recommends reserving medical intervention for those women who would genuinely face greater difficulty without it, rather than protocols that offer it routinely in order to reduce risks that are already small.

The chapters of the book cover all the main topics of relevance to anyone working in childbirth (it is probably not a book aimed at pregnant women, who might get similar but more accessible information from Ina May Gaskin’s books). The chapters cover caesarean birth, induction of labour, care during labour, birth, postnatal care, and midwifery practice. Each chapter includes a mini-review of research and strategies for optimal care. It is a very practical book and an important resource for midwives, obstetricians, doulas and antenatal educators.