Review

Labour policy

Where to be Born: The Debate and the Evidence
Rona Campbell and Alison Macfarlane
National Perinatal Epidemiology Unit, 1994 (2nd ed)

This is a well-researched, readable and important book about a very contentious subject: where to have a baby.

It is intended for ‘staff and users’ of maternity services. Building on the first edition, it examines the policy debate, the evidence relating to the risk of death for mothers and children, ill-health, variations in care, and adds new sections on the influence of evidence, the role of the midwife, the economics of care, and parents’ views. Although it is not a technical ‘overview’, it is clearly based on a thorough knowledge of the evidence. The glossary and sources of advice are useful, and the references allow the reader to follow up topics in more detail.

The history of changes in policy is particularly interesting. It shows how the pressures from the professions, users and politicians have brought us the current position. By highlighting research published at the time policy decisions on home births were taken, the book demonstrates the weak link between evidence and policy. It also shows that, once set, policy is very difficult to change, whatever the evidence.

This particular debate is often oversimplified into ‘home versus hospital’ but the authors avoid this polarisation and present evidence about a wider range of services, such as Domino schemes and GP units (of various sorts), as well as home and hospital. What is surprising is that so little research has been done; with over 600,000 births a year, more evidence should be available.

I have a number of minor suggestions on how the book might have been improved: more could have been made of international evidence; chapter summaries might have helped; some tables could be a little clearer - but these are matters of personal taste.

Major faults are, however, very difficult to find. One is that the book does not directly address the problem of deskilling which might now threaten any growth of community obstetrics. My main concern is that the book will only be accessible to a minority of users. I would not, however, want to put readers off; try it, you will find something in it. Even if the more technical sections (which are relatively short) are not to your liking, the rest of the book, particularly the conclusions, is very readable.