Birthing Outside the System

Dr Sheena Byrom OBE When I listen to or read accounts from women who feel distressed or destroyed by their childbirth experience, my usual positive optimism turns to rage, and intermittent gloom. I know, first hand, that having a baby has a life changing impact on women and can make or break their lives forever. When I read CITCM I revisited the anguish and anger; women are increasingly dissatisfied and disturbed following institutionalised childbirth, and they are choosing to reject it. And then there are the birth workers. They are the onlookers and actors also responding with adrenaline fuelled fight or flight responses and continuously jumping to the beat of the fear drum. This text splits open the shell of cover-ups to reveal a plethora of hidden agendas, underlying causes of harm - the impact that beaurocratic patriarchal maternity systems, based on risk agendas, have on women and families. Using the metaphor of the canary in the coalmine, this book not only shares research and personal accounts of violations of women's rights, but it offers solutions for a better way. I feel relieved that truths are being shared in a way that touches my spirit, my soul and my human being to the core, and that give me the impetus to continue to lobby for change. The research evidence is compelling, the stories are heart rendering. We have to sit up, rise up and speak up for maternity services to change. We need to create a storm around this book, encourage others to read it, inhale it in then exhale it out as forcefully as a dragon's breath. Eternal thanks to the editors for turning their frustrations into action, and to the chapter authors who share their lived experiences and knowledge for a better world. I salute you all. Dr Sheena Byrom OBE Midwife Consultant and Director - All4Maternity Dr Michel Odent Today, whatever the topic, we are in unprecedented situations. Homo has reached the limits of the domination of nature. A significant example: love hormones have been made redundant to deliver babies. It is as if we were close to the edge of a precipice. It is too late for procrastination. The only relevant strategy is to take other directions. What can we learn from mothers who find ways to escape from the dominant way of thinking? We must thank Hannah Dahlen, Bashi Hazard and Virginia Schmied for helping us to urgently clarify vital questions. Dr Michel Odent, Obstetrician, Director of the Primal Health Research Centre, Author of The future of Homo, Do We Need Midwives, The Scientification of Love and many more Dr Robbie Davis-Floyd This book takes an innovative look at what are culturally considered birthing extremes. It asks, why do so many women and families in varied cultures choose to birth completely outside of hospitals and clinics where the technocratic approach is hegemonic? These people's choice of unconventional freebirth or even of culturally accepted homebirths in low-resource countries where those are still normative constitutes a radical critique of the dominant system. That critique intensifies with the accounts of childbearers with complications medically considered high-risk-such as VBACs, breech and twin births-who resist this medical classification, redefining such births as simply variants of normal. A chapter on birth trauma demonstrates the emotional devastation that too often accompanies the inhumane and unnecessary interventions imposed on women who birth inside the technocratic system, and how freebirthers and others seek to avoid that trauma by utilizing normal physiologic birth as a vehicle for self-empowerment and healing. Critiques of the system are multiplying; to them, this out-on-the-edge book adds the telling perspectives of those who reject that system entirely. I highly recommend hearing their voices as spoken in these pages! Dr Robbie Davis-Floyd PhD, FSfAA Senior Research Fellow, Dept. of Anthropology, University of Texas Austin Author, Birth as an American Rite of Passage and Ways of Knowing about Birth: Mothers, Midwives, Medicine, and Birth Activism Professor Soo Downe OBE The fact that this well-written, comprehensive, thought provoking book is so timely is both shocking and reassuring. Shocking because it reveals the degree to which maternity services around the world have become blind to the impact of extreme risk aversion on the wellbeing of women and babies. Reassuring because, finally, the blindfolds have been removed: and because, rather than just pointing out the problems, the authors also provide solutions. I hope as many people as possible read the book, and that they conclude that the time has come to act. Now. Professor of Midwifery, UCLAN Rhea Dempsey #MeToo as a cultural moment inspires us to courageously speak and act in defiance of old 'power over' paradigms. It calls us to shape a new paradigm that honours respectful relationships and personal agency. Its reverberations are being felt in the birth culture. Refusing to be constrained within wounding power over structures some women - canaries - are birthing 'outside the system' and thereby warning us of an urgent need for change. Heeding the canaries' warnings, the contributors to this book are shaping the new paradigm by powerfully documenting the issues and mapping the necessary path forward. Rhea Dempsey, author of Birthing with Confidence Dr Sarah Buckley How do women perceive risk in childbearing? Do women really make dangerous choices for themselves and their babies? What is a safe birth? And how can we help women to feel safe? These critical questions are addressed by midwives, obstetricians, lawyers and birthing women themselves in this illuminating and important book. Dr Sarah Buckley GP and author of Gentle Birth, Gentle Mothering Dr Rachel Reed 'Birthing Outside the System: The Canary in the Coalmine' shines a light into the coalmine of modern maternity care. The editors have brought together a diverse group of eminent authors whose contributions create a comprehensive analysis of the current global situation. The editors deliver on their promise - the book is indeed a 'political opus' that will 'upend thinking and disburse assumptions'. However, the content also offers inspiration and practical guidance about how to create and sustain woman-centred maternity care. This is a call to action. We all need to work together to release the canary from her cage. Dr Rachel Reed, Senior Lecturer in Midwifery, University of Sunshine Coast, Australia Author of Midwife Thinking Blog and Why Induction Matters Professor Mary Renfrew This book is a wake-up call that we cannot ignore. It raises essential questions for those who work in health care, in education, in research, and in policy. Perhaps most importantly, it raises questions for the whole of society - all human beings are born, one way or another, so this concerns all of us. Health professionals may think that women who birth outside of the mainstream health system, with or without a carer, are being negligent or careless of their safety and the safety of their baby. What this book shows is that those decisions are often a response to previous damaging experiences of healthcare, and are not lightly taken. Women making these decisions may have the courage, or the support, or the total desperation to do so. But devastatingly, this book shows that these women are indeed the canaries in the coal mine, the visible sign of something much bigger. Many, many more women in many countries are giving birth inside systems that have not been designed to meet their needs, perhaps with staff who do not have the necessary knowledge, skill, or kindness. Women and their babies experience physical or psychological trauma as a result. This cannot - must not - continue. Why, and how, have such systems developed across the world? International, multidisciplinary chapter authors explore this and many other fundamental questions with evidence, intelligence, and illuminating personal stories. Causes are both systemic and individual. One factor is a lack of good quality education. Another is a narrow interpretation of safety and quality in which physical outcomes and the routine use of interventions are prioritised over respect for the rights of women and children, optimising normal physiology, and considering the full spectrum of physical, psychological, social, cultural, and spiritual aspects of health and well-being. The imbalance of power throughout the system prevents effective challenge and change. What can be done? Some national governments, regulators, and global organisations are already stepping up with shifts in policy and education, informed by evidence and with the significant input of women, families, midwives, and others, , . But this book demonstrates that more, much more, is needed if women, babies, and families everywhere are truly to receive respectful, kind, and effective care. Societal and professional barriers must be removed so that well-educated and effectively supported midwives are available and accessible for all. Service and education redesign must be informed by a radically different research agenda and co-created with women and families. Righting the widespread and longstanding wrongs that have caused this damage will take time and coordinated cross-sectoral action. This book makes an important contribution to informing, motivating and shaping such action. Mary J Renfrew BSc RN RM PhD FRSE Professor of Mother and Infant Health University of Dundee, Scotland Professor Holly Powell Kennedy Birthing outside the system: The Canary in the Coal Mine is a compelling and practical examination of health care which too often does not meet women's needs - it forces the reader to confront that we have failed mothers and babies with the imbalance of care and interventions, as Miller notes too much too soon often in high income countries and too little too late for those who truly in need. It echoes the saying if you've dug yourself into a hole, then stop digging - in other words in maternal health care, seriously consider actions to change systems to meet the World Health Organizations directive to assure a positive birth experience and using interventions only when supported by evidence and clinical needs. Bravo to the authors for their courage, critique, and intellectual expose! Professor Holly Powell Kennedy Helen Varney Professor of Midwifery Milli Hill For too long women who birth outside the system have been portrayed as mad, dangerous and irresponsible. This book finally turns the spotlight on the dangers of the system itself - in short, it moves us away from the default position of 'woman blaming' and forces us to ask what it is about the current mainstream birth system that feels so very unsafe to gathering numbers of women. This is a vitally important and deeply feminist book, that takes the radical step of actually listening to women's voices and suggesting that the maternity care system does so too, and as a matter of urgency. A vital book, built on the deeply feminist idea that we should trust and listen to women rather than portraying them as mad and irresponsible. Milli Hill, author of Give Birth Like a Feminist and founder of the Positive Birth Movement Associate Professor Denis Walsh I highly recommend this informative and ground-breaking book about women choosing to birth outside formal maternity care systems. This slowly increasing trend in high-income countries is telling the maternity services something hugely significant about current provision. The authors, with first-hand experience of women choosing this option and with decades of involvement in maternity services in Australia and internationally at a practice, research and strategic level, are ideally placed to lead us on this journey. Their book examines critical underpinning ideologies that are infiltrating maternity care and need to be exposed and reformed. Among the most significant are patriarchy and neoliberalism which are both disenfranchising childbearing women choices, undermining their agency and channelling them down a path of inappropriate medicalisation. This is a 'must read' for anybody involved in childbirth services. Denis Walsh Retired Associate Professor in Midwifery, University of Nottingham, UK Nicky Grace Canary in the Coalmine by Hannah Dahlen, Bashi Hazard and Virginia Schmied is a collection of writings that address the central theme of why some women reject, or are rejected by, mainstream maternity services. The accounts and analyses shine a light not only on the motivations and experiences of those who give birth outside the system, but on the system itself. Dahlen, Hazard and Schmied have succeeded in creating a text where scholarly, political and personal perspectives on birth are intertwined. We are called to take action, to react to the global maternity emergency, to take heed of the canary in the coalmine: the birthing mother who needs to be cared for, listened to, worked with. As I read, I wept and raged at the violence and oppression that women are routinely subjected to within mainstream maternity care. I also found myself - a radical, home birth midwife - questioning and challenging my own perceptions of midwifery history and my own practice. This is a good thing. We midwives and other maternity care providers must never become complacent but should be willing to adapt and change as new information comes to light. 'Canary in the Coalmine' helps us to do this, to work with women rather than against them, to provide what they need and not what we think they need. The text avoids the 'toxic positivity' that pervades so much of midwifery culture and is so damaging for midwives. But while realistic about the extent of the challenges and inequities we face, possibly the most brilliant aspect of 'Canary in the Coalmine' is that we are given practical, evidence-based solutions for change at local, national and global levels. This book can be used by women and their midwives, by politicians, maternity managers and policymakers to guide change in maternity services. I loved this book. Its sound intellectual and research-based roots mean it will be an essential academic midwifery and obstetric text, while the lively quality of the well-chosen writing ensures a wider readership for those involved in childbirth in all capacities. Nicky Grace Association of Radical Midwives Editor of Midwifery Matters Professor Lesley Page 'The canary in the coal mine' does indeed, as it aims, up end our thinking about maternity services. We are shown that our thinking, systems and practices in maternity care certainly need up ending. The diverse chapters, from all parts of the world, show why and how we need to change. I am acutely aware and deeply concerned about the inappropriate, disrespectful, abusive and traumatic treatment many women receive around the time of birth in much of the world, and of the extent and harmful effect of the parallel problems of too little too late and too much too soon. Let us all carry a canary, and by humanising birth for all women, their babies, partners and families, keep all our canaries singing. Professor Lesley Page CBE Visiting Professor King's College London Adjunct Professor University of Technology Sydney and Griffith University Queensland Honorary Research Fellow Oxford Brookes University Becky Reed The Canary in the Coalmine is an oh-so-timely reminder of the consequences of patriarchal maternity systems that continue to damage pregnant and birthing women, and cause them to turn away from the 'care' that is on offer. We alienate women at our - and their - peril, and history will not judge us kindly. Dignified respectful individualised healthcare costs nothing and leads to improved outcomes for mother and baby, as we showed in the Albany Practice in London. This comprehensive analysis of birthing systems around the world should make us all sit up and listen. It is a call to arms that must not be ignored. Becky Reed UK Midwife and author of Birth in Focus Professor Raymond De Vries A key concept in obstetric ethics is maternal-fetal conflict . Canary in the Coal Mine shows us that the real ethical problem in maternity care is conflict between mothers and the health system. The stories and the evidence collected here show in excruciating detail why mothers are choosing to avoid a care system that is at odds with their, and their baby's, best interest. Canary makes mothers (often the invisible partners in maternity care) seen and heard, and insists that we respect their choices as rational responses to a broken system. Raymond De Vries, Ph. D., Professor Center for Bioethics and Social Sciences in Medicine University of Michigan Medical School Professor Eugene Declercq The editors set out to spark a ...revolution to humanise childbirth for every woman, everywhere. They address, in an international context, some of the most the challenging issues in contemporary maternity care, from freebirthing and home VBACs to birth trauma and the oppression of midwives. In combining thoughtful, systematic research with powerfully told stories of women's experiences, they have laid a foundation for those seeking a truly women--centered maternity care system. Eugene Declercq, PhD Professor, Community Health Sciences, CT 4 Boston University School of Public Health Emeritus Professor Michael Klein Don't let the title scare you away. This is not a book promoting unattended home birth. It's about why women decide to avoid environments that seek to control and diminish her-shades of Margaret Atwood's Handmaid's Tale, in which women are seen as unreliable incubators. Today's woman is faced with a battle between two warring paradigms: 1. Birth is nothing more than an opportunity for things to go wrong. 2. Birth is a normal activity, that is growth promoting and maturational, an opportunity for women and their partners to live the transformative power of the experience, while being reasonably vigilant and taking action when needed. These two paradigms are mutually exclusive. Women described in this book wanted #2 and got #1 and vowed never to expose themselves to #1 again. It is required reading for all who seek to change a system governed by anxiety and obsession with risk management, that at the extreme leads to obstetrical violence. Michael C Klein CM, MD, FCFP CCFP FAAP (neonatal-perinatal) Emeritus Professor Family Practice & Pediatrics University of British Columbia Senior Scientist Emeritus BC Children's Hospital Research Institute, Vancouver British Columbia Renee Adair Unnecessary medical intervention before, during and after the birth of a baby and the indescribable harm to the women at the brunt of this abuse, is of epidemic proportions worldwide. Canary in the Coal Mine dives head first to furiously explore this contentious global train wreck and it does so with hard-hitting facts. As Alison Barrett states, it may seem wrong to worry about the harms of over treatment when people are dying from under treatment in less well-off countries but in good conscience, none of us can ignore the mistreatment of women anymore. This book will make you shout out loud in anger and hopefully scream for justice and change. Founder and Director Australian Doula College Charity Arm- Doula Heart Network Groundwork Program Indra Lusero This book has been a pleasure to read. It provides a global view of the reasons some people give birth outside the system, including the experiences of mistreatment and abuse they face within it. One of the most important things about the book is that it is written by people directly impacted; it is a delight to hear from providers who work in and out of the system and from people who have given birth in all sorts of places and ways. These salient voices provide critical insight into the key ingredients that would make perinatal care systems work better for everyone. Mx. Indra Wood Lusero, Esq. Attorney National Advocates for Pregnant Women New York Petra ten Hoope-Bender Every time a child is born, a mother and father also are born. Pregnancy and childbirth are unique opportunities in the lives of women, families and societies to develop and grow. Respectful quality care during pregnancy and childbirth is a mega cornerstone of that growth, but the choir of canaries in this book show us that women are not receiving what they need. However, changing systems is not enough - we also need to change attitudes. We need to set our hearts and minds to supporting and serving the whole woman, in her circumstances, with her needs, strengthening her capacities. At the heart of our work as midwives lie our skills in supporting and providing the enabling environment for women to make effective choices and to transform those choices into desired outcomes. Making and transforming your choices are the cornerstones of agency (World Bank), which in turn is crucial to advancing gender equality and empowerment. Coming through the life events that pregnancy and childbirth are, even if unpredictable, knowing you drove and were engaged in the care you sought and received, is a crucial part of the foundation for women's agency, and it impacts midwives' agency too. This agency can heal and strengthen our societies and our world. It is gold dust! Let it not go unused. Petra ten Hoope-Bender - Midwife, MBA Technical Adviser Sexual and Reproductive Health and Rights, UNFPA Co-lead of the Lancet Series on Midwifery and Co-author of State of the World's Midwifery 2011 and 2014 Former Executive Manager of the Partnership for Maternal, Newborn and Child Health (PMNCH), leading the transition from Safe Motherhood to Reproductive Maternal and Newborn Health Former practising midwife in the migrant quarters of Rotterdam, The Netherlands Henci Goer Using the personal and the professional, quotes and statistics, qualitative and quantitative research, literature reviews and case studies, this landmark work inexorably builds the case that pregnant women all over the world who flee mainstream obstetric management warn us of a toxic system whose hardwired inequities inevitably lead to widespread psychological, physical, and sexual abuse. Not content merely to expose and document its deficiencies, the contributors offer a blueprint for achieving a system that provides humane, woman-centered maternity care. The book should be required reading for every person involved in the regulation or provision of maternity care. For birth reform activists, read it and weep-and then go out and do something about it. Henci Goer Founder & Director of Childbirth U Author of Optimal Care in Childbirth: The Case for a Physiologic Approach Associate Professor Denis Walsh I highly recommend this informative and ground-breaking book about women choosing to birth outside formal maternity care systems. This slowly increasing trend in high-income countries is telling the maternity services something hugely significant about current provision. The authors, with first-hand experience of women choosing this option and with decades of involvement in maternity services in Australia and internationally at a practice, research and strategic level, are ideally placed to lead us on this journey. Their book examines critical underpinning ideologies that are infiltrating maternity care and need to be exposed and reformed. Among the most significant are patriarchy and neoliberalism which are both disenfranchising childbearing women choices, undermining their agency and channelling them down a path of inappropriate medicalisation. This is a 'must read' for anybody involved in childbirth services. Denis Walsh Retired Associate Professor in Midwifery, University of Nottingham, UK Michele Bratcher Goodwin, Chancellor's Professor In Birthing Outside of the System, the authors show how women have been relegated to the margins both as providers and patients. The book centers the concerns of the most vulnerable women and in doing so sheds light on how toxic maternal healthcare under-serves everyone. Director, Center for Biotechnology & Global Health Policy University of California, Irvine School of Law Statement from the New Zealand College of Midwives Why women are choosing to birth outside of the established mainstream maternity systems is a question that should concern all those involved in midwifery, maternity care, the human rights of women and maternal rights. This book has arrived at a time when the world is seeing a disturbing increase in birth intervention rates and increasingly frequent reports outlining some of the significant emotional, physical and social trauma experienced by women during maternity care. It is a political, cutting edge and timely book and the well-written chapters draw urgent attention to the continued lack of evidence-based, women-centred care within the mainstream maternity services of many countries, and which contributes to the mistreatment of women. At the same time the authors present their thoughts on how to move forward. The movement to humanise childbirth and mainstream maternity care systems has been midwifery- and human rights-driven This book represents a significant groundswell of work to prioritise responsive and respectful maternity care as if humanity depended on it - which it does. Maria Booker-Director Birthrights This book promised to shock, at times, distress, and most certainly exasperate - it doesn't disappoint. If you are not already part of the worldwide revolution to humanise childbirth - you will be by after reading Canary in the Coalmine . Dahlen, Hazard and Schmeid urge us to rethink our prejudices and see women birthing outside the system for what they are - women seeking solace and safety, fleeing rigid systems that do not meet their needs. It's time to listen to that canary and put respect and dignity at the heart of all maternity care. Maria Booker, Programmes Director, Birthrights Christen Sadler President of Lamaze International This book takes an unsparing look at maternity care around the globe from the perspective of women who opt out of mainstream maternity care. There are important lessons here for educators and clinicians alike, as well as constructive ideas for positive change in healthcare delivery. Christen D. Sadler, MSN, CNM, LCCE President, Lamaze International Professor Billie Hunter This thought provoking and challenging book is essential reading for all users and providers of maternity services. It sets out the challenges ahead, but also proposes solutions. For those already engaged in the quest to humanise childbirth it will provide a powerful source book, full of narratives and research conveying a vital message: that services must change to become authentically 'woman-centred' and responsive to the needs and wishes of all women. For those who may be less convinced of the urgency of this quest, the book should challenge assumptions and open minds. Professor Billie Hunter CBE Royal College of Midwives Professor of Midwifery, and Director WHO Collaborating Centre for Midwifery Development, School of Healthcare Sciences, Cardiff University, Cardiff, Wales UK Emeritus Professor Mavis Kirkham This timely book focusses on the experience of women who choose to birth outside the system and the witch-hunting of those who attend them. These women's choices are made largely because the system is rigid, broken and abusive. Authors from a range of countries and backgrounds make this a comprehensive and politically important book. Emeritus Professor at Sheffield Hallam University. Professor Caroline Homer AO Canary in the Coal Mine is a book that will, or at least, should challenge all of us who work in the maternity space. The stories, experiences and research presented throughout the book serve to shine a light on many of the issues we face providing services; hopefully services that woman want and need rather than services that we want or can manage to provide. You will likely be challenged, perhaps even become upset or defensive, maybe also irritated with, or afraid for, the decisions that some of the women you will read out make, especially if you do not agree with them! However, we all must get better at listening to women, listening to what they want, they need and what is important to them and listening to the solutions - some which are likely to take us out of our comfort zone. This book provides much for all of us to reflect upon. Caroline Homer AO Visiting Distinguished Professor of Midwifery Centre for Midwifery, Child and Family Health Faculty of Health University of Technology Sydney (UTS), Australia Co-Program Director Maternal and Child Health Burnet Institute Alecia Staines- Maternity Consumer Network Birthing outside the system or freebirthing is increasingly a choice women are making due to many reasons including lack of recognition for women to have human rights and choice in pregnancy, childbirth and postpartum. We are certainly noticing an increase in womens' desires to have a birth where they feel safe, in control, respected and autonomous in their decisions. It is well overdue to have light cast upon why women are birthing outside mainstream maternity care, often deciding no care provider is a safer option than our current institutionalized and rigid system. MCN is interested to read this book and to see more research supporting women's rights and which can go towards improving education and maternity care in Australia. Alecia Staines President Maternity Consumer Network, Australia Azure Rigney- Maternity Choices Australia As a lay 'woman' with no medical background turned maternity consumer representative, I truly needed this book to compartmentalise the themes we hear from thousands of women. They are telling our consumer advocacy groups the same stories that you have so eloquently described and included with peer-reviewed referencing. The research and succinct recommendations will assist activists to demand consumer engagement standard 2 is adhered to truly co-design woman centred maternity services. After reading this inspiring book, I'm certain, one day all pregnant women will have the model of care and place of birth they choose! My only recommendation is an audio book with the authors reading each chapter they have written, as I can imagine hannah and Bashi's, Mel and Jo's exact tone...but would really add to the senses! Azure Rigney President of Maternity Choices Australia (consumer group) Jennie Joseph Up until some 30 years ago the canary - a sentinel species - was still used in British coal mines to detect toxicity and warn miners before it hurt humans. Dead or injured women or babies, as a result of 'materno-toxic' environments however are a much less romantic image than the canary in that still famous saying, and embedded in the title of this timely and important book. We should not be surprised by the fact that so many women and their families feel that they would rather stay well outside the system during their childbearing year, fully aware of the inherent risks, fending for themselves, shielding themselves from perceived and all too often dangerous, inequitable, untenable, disempowering situations, circumstances and events - essentially, they would rather take their chances than succumb. So, 'free-birthing' birthing women have become a sentinel species and represent the canaries in the coal mine of institutional and iatrogenic toxicity that much of 'modern' maternity care has become. In our joint and deliberate quest to improve and save the lives of childbearing people, we need to consider that it is time to decolonize birth, recognize the racism, classism and sexism within our current systems and to once again center and respect the mother/baby/family and community. This book outlines the problem and offers solutions - and as always, listening to women is an excellent place to start. - Jennie Joseph LM, CPM, RM Midwife, Executive Director Commonsense Childbirth Inc, USA Terri Barrett My congratulations to the authors and contributors to this outstanding book. Without a doubt they have provoked thought and discussion, challenging their audience and inspiring each and every reader. The book builds upon the message that women and midwives have been consistently delivering to politicians and policymakers; a resounding disconnect between what women want and what the system believes that they need. As core providers of maternity care, this book is a call to action for midwives and ACM as the peak professional body. It is time to work collectively, united alongside consumers, to develop a system that ensures every woman receives care that is individualised, respectful and safe in her eyes. Thank you all for sharing not only your knowledge and wisdom but also your personal stories. Terri Barrett President Australian College of Midwives Dr Kathryn Gutteridge Giving birth for any woman is a leap into the unknown. What we do know is that we hear from women afterwards often that they are let down and disappointed. This book could and should remind us all that birth is precious and life affirming when we listen and work with women. A woman will never put her life or that of her unborn baby at risk if we listen to her needs. It is only when her back is against the wall that she is pushed to take action alone. Read this book and learn how we must give priority to women for it is they we serve. Dr Kathryn Gutteridge -President of the Royal College of Midwives, UK Mary Newburn What a book! The metaphor tells it like it is and makes this book stand out. The personal testimonies are so powerful. This international sharing of experiences and extensive academic research is overdue. The authors have nailed it. Birthing outside the system - why do women do it and what can we learn from it? These should be questions every maternity service asks. Community advocates, women and recent services users should have significant control over maternity services, and the wellbeing of all women should be a crucial aspect of assessing service quality. The push for more intervention is strong; it must be considered carefully and in full context, with informed debate. This book will make such an important contribution. Mary Newburn, consultant, service user researcher/Public and parent involvement lead