Death Before Birth represents Robert Woods' most recent and largest contribution towards understanding the historical patterns of fetal mortality and the related topics of midwifery, fetal pathology, maternal health, and induced abortion. At its heart, this book is a documentary history of stillbirths, examining whether obstetrics and midwifery or maternal health lead to improvements in fetal health. Much of the analysis is concentrated on historical Great Britain, which is clearly Woods' expertise, but there are also sections on Scandinavia and the United States, as well as discussion regarding France, Italy, and Spain.

The book proceeds not chronologically, but topically, through the issues surrounding fetal health and mortality, its levels and trends, what the actors involved have learned and improved over time, and potential explanations for why stillbirths have been successfully reduced in developed countries. This is not an exhaustive study of the history of stillbirths, but it is nonetheless an impressive work. While much research has studied causes and effects of maternal and infant mortality, the study of fetal death, its causes, and the history of efforts to prevent it has, but for this book and previous publications from Woods, been largely ignored. This is likely due to the paucity of data regarding stillbirth registration outside of the Scandinavian states. Great Britain and the United States only started officially recording stillbirths in the early twentieth century, and while data coverage is slightly better for France, Italy, and Spain, the definition of what constituted a stillbirth changed over time.

Given these limitations, Woods has worked hard to shed light on historical fetal death patterns across the different countries. He is particularly concerned with determining historical stillbirth trends in England to check their turning points with changes in midwifery practice or maternal health conditions. To this end, he uses maternal and neonatal mortality data published in E. A. Wrigley et al.'s book English Population History from Family Reconstitution, 1580–1837 (Cambridge: Cambridge University Press, 1997) and creates stillbirth estimates for the seventeenth, eighteenth, and nineteenth centuries using a variety of structural relationships.

In Chapter 4, six potential historical stillbirth series are estimated using the maternal and early neonatal mortality data (Table 4.5, p. 96). The first two sets of estimated stillbirth series are obtained by inflating the maternal mortality rate by 1.8 in the first, and the endogenous mortality rate by 1.5 in the second. Endogenous mortality is itself an estimate based off of infant mortality, calculated by regressing mortality on days old and using the estimated intercept. The last four series involve estimates obtained from regressing stillbirths in 1931 against either neonatal mortality rates in 1931 or maternal mortality rates in 1931 in different sets of English districts and applying the estimated relationship backwards in time. There is substantial variation in the stillbirth estimates across the different series, and aside from discriminating based on prior expectations, there is a bit of arbitrariness and ambiguity over why the two series based off the maternal and neonatal regression estimates were preferred over others. Additionally, the original data published by Wrigley et al. (1997) was based on a subset of English parishes and no explanation is given for why that set of geographical units was not used in calculating the relationships between maternal mortality, neonatal mortality, and stillbirth rates in 1931. Woods uses these estimates to argue that stillbirth mortality in England improved dramatically during the eighteenth century, but during the nineteenth improved only marginally, and that this coincided with substantial improvements in midwifery and the subsequent lack thereof. Given that, whether estimations of English stillbirths during the nineteenth century were consistent with the wave-like increase and decrease pattern exhibited by Sweden, Denmark, and Norway during nineteenth century should have been evaluated.

However, this is a fairly minor shortcoming when taken in context of the entire work, and Woods deserves praise not only for his efforts to try to understand what stillbirths might have been in England in the seventeenth, eighteenth, and nineteenth centuries in the absence of data, but also in composing such a detailed history of English midwifery in Chapter 5 so that he might compare changes in one to the other. Woods has done a great deal of research on the history of English midwifery and obstetrics, and this book does a very good job of characterizing the technological changes through its evolution over the last three hundred years. He examines historical textbooks to determine how and when knowledge in the field advanced, and quotes case notes from a variety of practicing midwives to understand the equipment in use and how these practitioners dealt with difficult cases.

Although it is not the final chapter, Chapter 7 summarizes much of the analysis laid out in the first six sections. It is this chapter that is perhaps the most interesting from a policy standpoint, as it is here where Woods tests the plausibility of different explanations offered by medical historians, demographers, and other social scientists for declining stillbirths. He dismisses the claim made by E. A. Wrigley in his article, “Explaining the Rise in Marital Fertility in the 'Long' Eighteenth Century.” (Economic History Review 51, no. 3: 435–64) that improvements in maternal nutrition accounted for the decline in stillbirth mortality. Woods disputes this based on there being little evidence that female health improved prior to the twentieth century. Instead Woods identifies improvements in obstetrics and midwifery as well as reductions in maternal infections as being responsible for improving fetal health outcomes, however acknowledges that there is no way to determine by how much either of these two factors affected stillbirth mortality. Overall, this book is an excellent resource for those looking to not only understand changes in fetal mortality throughout historical Western Europe and the United States, but also the evolution of midwifery and obstetrics and how they might have contributed to the improving maternal, child, and fetal health outcomes across different areas.