By Stacy Fine
Web Interview - June 29, 2007
In August of 2003, the VBAC birth of my second child began at the Farm Midwifery clinic in Summertown, TN, attended by Pamela Hunt and Ina May Gaskin. I'll never forget the gold full moon of that soft humid night, and the natural sounds churning in the surrounding forest. My experience was deep and sexy. I was encouraged by the midwives to embrace labor's contractions as rushes. Indeed, this suggestion was transformative—pain turned to pleasure! While this labor progressed nicely, after 14 hours Ina May and Pamela said my cervical lip was not retracting. I decided to go to the hospital. Everyone present agreed with my choice. My husband and I followed Ina May's car out to Maury General Hospital in nearby Columbia, TN. A few hours later my beautiful 9 lb 5 oz baby boy was born. Becoming a mother and having an empowered second birth were radicalizing, pivotal experiences, reflected in the new direction of my writing—which has been mainly about music and fashion until now. The following interview with Ina May Gaskin originally appeared at www.feminist.com.
SF: How do you define "midwife"?
IMG: A midwife provides prenatal care and education, attends women as they give birth, and cares for them and their babies during the postpartum period. In hospitals, sometimes some of these jobs are performed by nurses or pediatricians.
SF: How did you become a midwife?
IMG: My first birth took place in 1966, and I was very surprised to find out that as a first-time mother, my obstetrician was unwilling to allow my baby to be born without medication. This was because he intended to use forceps (whether they were truly necessary or not), because most US obstetricians then believed that this was safer for mother and baby than allowing the normal birth process to take place. This idea was obviously revised a few years later, but I had no choice in the matter for this particular birth. Because I was a graduate student in English literature, I was aware that many women and babies had been injured during forceps deliveries. Besides, I was sure that women's bodies could function better than my obstetrician had been taught they could. That whole experience really opened my eyes to how little scientific evidence underlay the obstetrical beliefs and procedures that were commonly used. Around that time, I heard a few women tell their home birth stories. Invariably, these were empowering stories. I was awed by these women who found ways to give birth at home—most of them pressured a friend, who happened to be a labor and delivery nurse, to sit with them during labor. After hearing a couple of women's stories, I knew that I wanted a home birth myself and that if there were any way for me to become a midwife, I would like to be one. It wasn't long before I had a chance to observe my first birth. The woman refused to go to a hospital and wanted me to stay with her. Her husband was prepared to catch the baby. I was lucky enough to see what seemed to me to be a short, relatively easy labor that ended with a perfectly healthy baby. There was no time to be worried during labor because it went so quickly. There were several other women who were aware of this birth, and when it was finished, it seemed that they were ready to regard me as a midwife. So, one by one, these women gave birth, and after the birth of the third baby, I was offered a seminar in emergency childbirth by a generous obstetrician. That seminar prepared me for the birth of the fourth baby, who needed resuscitation at birth and his mother, whose bleeding had to be stopped just after birth.
SF: How did the Gaskin Maneuver come to be?
IMG: About six years after I began assisting at home birth, I had a chance to go to Guatemala to do some development work following a tremendous earthquake. While there, I met a midwife, who happened to be the district supervisor of indigenous midwives. These indigenous midwives were too poor to have been able to go to school, so they were illiterate. However, the district midwife, whose midwifery education had taken place in Belize, along the lines of the British model, told me that the indigenous midwives had a better technique than what she had been taught to deal with the much-feared complication when the baby's shoulders get stuck after the birth of the head. She told me that instead of twisting and trying to rotate the baby, they merely got the mother to turn over from her back to a hands and knees position with her back arched. This change of position usually solves the problem of stuck shoulders and the mother is able to push her baby out without further ado. Occasionally, additional maneuvers are necessary, such as delivering one of the arms. I have had several obstetricians tell me that the positional change was the only technique that freed a badly stuck baby.
SF: What are the big challenges midwives face today?
IMG: Currently, midwives in the US are attending only 10 percent of all the births. About 1 percent of these take place at home. When there are such low rates of midwife-assisted birth and out of hospital birth, there is automatically a great deal of fear and ignorance about allowing labor and birth to proceed without disturbance. Most nurses and physicians never see undisturbed birth during their training period. This makes them unlikely to allow it, even if their hospitals would allow such deviations from the usual way of doing things. Add to this a for profit medical industry, with little or no accountability built into the system and a situation in which insurance companies and hospital chains have more influence in creating medical policy in certain areas than physicians (and certainly midwives) have, and you have a recipe for too many interventions in birth and rates of infant and maternal mortality and morbidity that are getting worse instead of improving. Nationally and internationally, the biggest challenge is that women of the current generation no longer (for the most part) have a healthy fear of unnecessary surgery. This opens the door to an ever-increasing use of cesarean, which is now increasingly being performed for non-medical reasons, even though good data show that this trend could triple or quadruple maternal deaths. As the cesarean rate rises higher and higher, obstetrical skills that were once considered essential can no longer be passed on to the next generation of physicians, and with the loss of these skills, certain categories of births which could once have been delivered vaginally must be cesareans because of the lack of obstetrical skills.
SF: What are some new trends in midwifery?
IMG: One new trend in midwifery is that more and more nurse-midwives are beginning to attend home births in cities in which hospital midwifery practices have been closed down. For more information, see www.midwife.org Another is that certified professional midwives have become legal in two or three new states, bringing the number of states in which certified professional midwives can work up to 25. For more information about this, see www.narm.org
SF: Care to discuss your work with the Amish community?
IMG: Our midwifery center is located a few miles away from a large Old Order Amish community that consists of approximately 1500 people. Women in this community continue to plan to give birth at home. When we first moved to Tennessee, these women were assisted in birth by a family practice doctor (now deceased), who eventually handed his practice over to our group of midwives. Some of the women in this community give birth attended by our midwives, while others are assisted by midwives who have emerged from their own community (who were taught additional skills and procedures by our midwives in order to improve their safety standards). Women in this community are not allowed to practice any form of birth control, so it is common for women to have as many as 12-14 babies. Fortunately, cesareans are rarely needed for this group of women, as they place a high priority on their ability to give birth at home. (Amish people have no form of health insurance, as they will not accept any form of coverage that is means-tested).
SF: Why is labor important?
IMG: Labor is important, because during labor, both the mother's and the baby's body is prepared for birth. The levels of certain hormones rise and ebb during labor. For instance, the mother's oxytocin levels rise markedly just before the baby is pushed out of her body. This protects her against postpartum hemorrhage. High oxytocin levels in the mother (which are accompanied by higher levels in the baby, too) prepare the nervous systems of both to be attuned to each other. This creates a special "sensitive" period during which these special hormones remain at high levels in undisturbed birth, and this period is best spent by mother and baby in skin-to-skin contact with each other as the baby begins to nuzzle and nick the mother's breast or the two just look into each other's eyes and adore each other. The euphoria that follows an unmedicated labor is a very special time for anyone who is privileged to witness it. It's even better for those who get to experience it. When the mother experiences labor, she also has higher levels than usual of beta endorphin. This hormone then triggers another hormone, prolactin, which prompts her body to get ready for milk production at the same time that it prepares the baby's lungs for more efficient breathing. Labor also gives the baby's torso a good squeeze, which helps to dry out the lungs and make them ready for breathing air in the outside world. Cesarean-born babies typically have wetter lungs, which can mean a higher rate of needing breathing assistance at birth.
SF: If a woman is scheduling a section can she arrange to have some labor too? Is that safe?
IMG: This could be safe in certain situations. Far too many cesareans are scheduled these days for reasons that have nothing to do with the welfare of mother or baby. But let's say that the cesarean was scheduled because there was a total placenta previa. In that case, any labor would be dangerous to both mother and baby. If, on the other hand, the cesarean was scheduled because the baby was breech, it might be good for the mother and the baby to experience some labor together. For the baby, the difference is that labor helps the baby's lungs to be better prepared for breathing and it can help the mother pump up her beta endorphin levels so that she experiences less postpartum pain after the surgery. So, the short answer is: it depends on the reason for the scheduling of the cesarean.
SF: What are some current statistics regarding birth in America? What percentage of births are cesarean? Will that ever change?
IMG: Both maternal and infant mortality are currently rising in the US. Maternal death rates have not improved, according to the Centers for Disease Control, since 1982. That's a long time to have had no progress, despite all of the technological innovations that have taken place since then. Part of the problem in this sector is that the US has never created a system of accurate reporting of the data necessary to find out what mistakes we might be making so that we can analyze them and then make policy that reduces the likelihood of mistakes being repeated. The United Kingdom (England, Scotland, Wales, and Northern Ireland) have had such a system in place since 1952, which is probably why their maternal death rate is significantly lower than ours in the US. I don't know of any European country in which maternal death classification is done according to an honor system, but that is exactly what is done in almost every US state. There is no audit, and autopsies are less likely to be performed here than in European countries. The World Health Organization reported in 2003 that 30 other countries have recorded lower maternal mortality rates than in the US. This is even worse when you consider that most of these countries have national health insurance systems, in which accountability is built in. This means that there is a far greater likelihood of maternal deaths being accurately classified than in the US, where epidemiologists from the Centers for Disease Control have reported that maternal deaths in the US are "grossly underreported." The cesarean rate in the US was last reported to be 29.1%, which represented a rather sharp rise from the previous year. The World Health Organization has recommended that the ideal cesarean rate be between 10 and 15 percent, because when this rate goes beyond that upper limit, it begins to represent a danger, not a safety factor, to women and their babies. In 2000, I began working on what I call the Safe Motherhood Quilt Project, which was inspired by the "Names Project" for people who had died of HIV/AIDS. My goal for this project is that we in the US follow the model set out by the UK in its system of Confidential Enquiries into Maternal Deaths so that we, too, can begin to reduce instead of to increase, the rate of maternal deaths in this country. Our Healthy People 2010 goal is that the maternal death rate should be 3.3 deaths per each 100,000 live births (it is currently 12.1 deaths per 100,000 ive births, but please remember that this rate, by the admission of the CDC is "grossly" inaccurate; in some areas, the maternal death rate is 33-35 deaths per 100,000 live births). Please check out my website: www.inamay.com and click on The Safe Motherhood Quilt Project and once there, click on the Virtual Quilt.
SF: During my second pregnancy (attempting a VBAC) you recommended doing some birth art. Should every pregnant person do some? Why?
IMG: Doing birth art helps the pregnant woman connect with her right brain and helps to get her out of the more goal-oriented, control freak part of her brain-in short, the part of the brain that needs to be de-activated during the birth process. Doing art also helps her to visualize what she wants to happen, and this visualization, in turn, helps to bring that reality about.
SF: What are three things you tell your pregnant clients?
1-Remember that you are as well made as any monkey.
2-Don't forget to bring your sense of humor to your labor.
3-Smiling as your baby's head is coming out helps to relax your perineum and therefore makes it less likely that you'll tear.
SF: Who are your heroes?
IMG: Ignaz Semmelweis (who figured out how to save women's lives by making physicians wash their hands, but who was ignored during his own lifetime), Sojourner Truth, Nelson Mandela, Margaret Charles Smith (co-author of "Listen to Me Good", she died 2 years ago at the age of 99, was a grand midwife from Alabama), Howard Zinn, Grantly Dick-Read, Catharina Schrader (17th century Frisian midwife), Ann Hutchinson (17th century American colonial midwife), Jill Correy, Cesar Millan, Elizabeth Cady Stanton, Margaret Sanger
SF: Can anybody have a baby at The Farm?
IMG: There is a screening process for women wanting to come to the Farm Midwifery Center to give birth. It's best to go to the website www.thefarmcommunity.com and click on the Farm Midwifery Center to get contact information. There are a few medical conditions which would rule out an out-of-hospital birth and thus birth care at the FMC.
Stacy Fine is a writer living in Woodstock, NY and NYC. She hopes childbirth which is now banned from TV would be broadcast for people to see. Contact: firstname.lastname@example.org