The cover of a new book on childbirth in Ireland features a nine-month old foetus curled in its mother's womb. It is taken from an 18th-century engraving of the dissection of a real woman who died in the ninth month of pregnancy.
Jo Murphy-Lawless, the author of Reading Birth and Death, feels the image captures the essence of her book which, she says, "emphasises death as a possible outcome of pregnancy".
That's hardly a message likely to appeal to prospective mothers and their families. But Murphy-Lawless explains that if they accept death as a possibility, that takes fear from women and allows them to take responsibility for their own pregnancies and births.
A research fellow at the Centre for Women's Studies in TCD, she contends that the Western science of obstetrics seeks to terrify women into complying with a whole range of technological interventions in birth by suggesting that if they do not comply they risk death of themselves or their babies. It thus overrides women's own instincts about pregnancy and birth, ignores millennia of collective knowledge, and seeks to subordinate the individuality of each woman and her pregnancy into an abstract notion of the female body. "How did obstetric science come to the extraordinary conclusion that no birth is normal except in retrospect?" Murphy-Lawless asks in her book.
In making this point she echoes the views of childbirth gurus such as Sheila Kitzinger in Britain, who have spearheaded a re-emphasis on the role of midwifery in childbirth and a resurgence in home births.
But surely the Irish statistics on the survival of both mothers and babies in childbirth, which are among the best in the world, mean we are doing something right, even if this means that the vast majority of babies are born in hospital, often with the assistance of obstetricians?
Murphy-Lawless disagrees that this improvement in outcomes over the past 40 years can be put down to the increased role of the maternity hospitals and obstetricians. Between 1955 and 1973, home births in the Republic fell from 33 per cent to 1 per cent. During this period, hospital consultants replaced GPs and midwives in caring for pregnant and birthing women.
"The consultants concluded that this was connected to a fall in maternal mortality and perinatal mortality. They were not connected," she insists. "There were other important sociological factors, like the control women had over their fertility and their general health profiles."
She points out that in the Netherlands, where home births, account for about one in three births, the statistics show they are safer than hospital births. In 1986, for example, the perinatal mortality rate in Dutch hospitals was 13.9 per 1,000, compared with 2.2 per 1,000 at home. It is not possible for babies identified during pregnancy as very high risk to account for this discrepancy, she says.
The increase in hospital births here has resulted in very high levels of technological intervention - at the expense of treating the woman in a holistic way from the outset of the pregnancy through to the birth, Murphy-Lawless says.
Her passionately held views do not come from a negative personal experience of childbirth (her son was born 23 years ago with the aid of induction, but without trauma), but from 25 years' experience as a sociologist and of involvement in the childbirth movement.
Statistics trip off her tongue: "Seventynine per cent of women in Ireland become mothers; 40 per cent of all Irish births are handled in the three obstetric teaching hospitals; 27 per cent of all deliveries are instrumental (involving suction, forceps or Caesarean section). Instrumental delivery runs at 45 per cent in the Coombe, 47 per cent in Holles Street, 60 per cent in the Rotunda. Caesarean sections account for 18 per cent of deliveries in the Rotunda, 12 per cent in the Coombe, 10 per cent in Holles Street."
Much of this results from the use of drugs - to induce labour and also for epidurals, which anaesthetise women during labour. These interfere with labour and can lead to complications, which in turn will increase the likelihood of instrumental delivery. She thinks that this is probably one of the reasons why only 30 per cent of Irish women are breast-feeding when they leave hospital, compared to 63 per cent in Britain.
"Irish women can't have worse breasts than other women in Europe, just as we can't have over 40 per cent of women in Holles Street with malfunctioning uteruses."
So what is the alternative? In the introduction to her book she outlines the practices surrounding birth of the Quecha women of Bolivia. Surely she is not advocating the repudiation of modern medicine in favour of folk medicine?
Not at all. Murphy-Lawless argues for an approach to pregnancy and birth which starts with the social context, and tailors care to suit the needs of individual women. At the centre of this must be continuity of care, where the woman has the help of a trained and experienced midwife from the onset of pregnancy to the birth and after.
Technology and obstetricians have their place, but it should be clearly delineated and, in general, care in pregnancy should be women-led. "Consultant-led care is appropriate for women with clearly-delineated problem pregnancies," she says. However, she believes the majority of women would be better served by a system which offered social support and continuity of care.
She points to the experience of programmes in New York's North Bronx and in Greece where integrated systems of care, incorporating social as well as medical care, produced very positive outcomes for women and for their babies. This included women normally at high risk, such as vulnerable adolescent women.
Such a system, she says, would also mean overcoming a problem identified earlier this year by the Commission on Nursing: the widespread demoralisation of midwives.
She believes we are at a turning point now in childbirth policy in the Republic and there is an urgent need for dialogue between obstetricians, midwives, policymakers and women involved in childbirth. She adds: "It is too important a moment not to get it right."
Reading Birth and Death by Jo Murphy-Lawless will be published by Cork University Press on Thursday. Hardback £45; paperback £15.95.