A Guide to Effective Care in Pregnancy and Childbirth.

One of the new additions on the required reading lists for IH/IBP childbrith educator and childbirth assistant trainess, A Guide to Effective Care in Pregnancy and Childbirth, has the potential to be one of the most valuable books on the childbirth professional's book shelf. This book is organized into 50 chapters, each covering an aspect of care in pregnancy and childbirth. The editors' purpose in collecting the data presented was to formally evaluate the validity and efficacy of various forms of care. They write, "Unless this is done, effective froms of care will not be recognized as such, and brought into use as promptly as possible; ineffective or harmful forms of care will not be detected efficiently, and may therefore do harm on a wider scale than necessary" (p. 3). The data from which the summaries in this book are derived come from a 1,500-page, two-volume book, Effective Care in Pregnancy and Childbirth, and a computer database, The Oxford Database of Perinatal Trials. Chalmers, Enkin, and Keirse spent 10 years systematically reviewing the effects of various components of perinatal care. They culled through 30 years' worth of studies in the Medline database and in more than 60 journals. They consulted with more than 40,000 obstetricians and pediatricians in 18 countries. They then conducted a statistical synthesis of the data in ways that would reduce bias and random error. The result was the 1,500-page work noted above. From that, they distilled this book in an effort to make the information accessible to anyone involved with women in the childbearing year as well as the women themselves.

What is remarkable about this book is the editors' willingness to expose the many forms of care (often routines in the Western medical world) "that should be abandoned in light of the available evidence." For instance, the list included such things as "failing to involve women in decisions about their care," "involving doctors in the care of all women during pregnancy," "advising restriction of weight gain during pregnancy," and "limiting the duration of second stage of labour arbitrarily." These are the sorts of "strange" ideas that the midwifery community has been advocating for years! It is nice to see them substantiated by the mainstream obstetrical data.

But what about the areas in which we disagree? For example, on the list of "forms of care with unknown effects which require further evaluation, the editors list "nutritional advice and/or supplementation with respect to pre-eclampsia" and "non-pharmacological methods of pain relief" ("non-pharmacological" meaning things like movement and position changes, counter-pressure, touch, and massage). At first this appears to indicate that a couple of our basic premises are invalid. Some of our trainees have written asking whether "these guys ever heard of Tom Brewer"! In actuality, what the editors are saying is that according to the studies reviewed and analyzed, they did not find clear or statistically supported findings--pro or con--and recommend further evaluation. It is also important to remember that the sources used were predominantly medical journals and databases; not midwifery, nutrition, or birth education sources. In fact, the editors invite readers to bring any errors or omissions to their attention for inclusion and correction in future editions.

What about the various procedures that are listed as "reducing negative outcomes" and are procedures with which many of us of the holistic perspective (versus technocratic--see Robbie Davis-Floyd, Birth As an American Rite of Passage, University of California Press, 1992) disagree? Examples of these would be "routine ultrasonography in early pregnancy" and "electronic fetal monitoring + fetal scalp sampling vs intermittent auscultation." If the text is read carefully, it becomes clear that these procedures are not recommended across the board. These procedures are only recommended to reduce very specific negative outcomes. In the examples above, ultrasonography is recommended only because it does "reduce induction of labour for post-term pregnancy" and EFM and scalp sampling do reduce the incidence of neonatal seizures. But as the editors themselves state, "these welcome effects are sometimes achieved at the cost of increasing unwanted effects." They later state, "A reasonable 'rule of thumb' for deciding whether a particular outcome should be regarded as substantive is to ask whether parents regard it as important" (emphasis added). Doeso't that souod like IH/IBP's advocacy of the rights of parents to make their own best choices?

Overall, A Guide to Effective Care in Pregnancy and Childbirth is an invaluable addition to any birth professional's book shelf. It is thorough, easily understood, and frequently validates the holistic/midwifery/woman-centered perspective. It gives us all an excellent tool with which to objectively evaluate forms of care our clients receive so that we might help them to become better informed.

--Reviewed by Catherine Stone.