Excerpt from "Birth Matters: A Midwife's Manifesta"
by Ina May Gaskin
Chapter 1
The Importance of Birth and Birth Stories
Birth matters. It matters because it is the way we all begin our lives outside of our source, our mothers’ bodies. It’s the means through which we enter and feel our first impression of the wider world. For each mother, it is an event that shakes and shapes her to her innermost core. Women’s perceptions about their bodies and their babies’ capabilities will be deeply influenced by the care they receive around the time of birth.
No matter how much pressure our society may bring upon us to pretend otherwise, pregnancy, labor, and birth produce very powerful changes in women’s bodies, psyches, and lives, no matter by which exit route—natural or surgical—babies are born. It follows then that the way that birth care is organized and carried out will have a powerful effect on any human society. A society that places a low value on its mothers and the process of birth will suffer an array of negative repercussions for doing so. Good beginnings make a positive difference in the world, so it is worth our while to provide the best possible care for mother and babies throughout this extraordinarily influential part of life.
Birth also matters because the journey through pregnancy and birth offers an irreplaceable way for women to explore their deepest selves—their minds, bodies, and nature. Such a journey of self-discovery can help them prepare for the hard and underappreciated job of motherhood in a world now full of historically unique and complex challenges. There is a sacred power in the innately feminine capacity of giving birth. It is one of the elemental, continuing processes of nature that women have the chance to experience, and it is the one act of human creation that is not shared by men. Why would we not want to explore this territory?
My use of the word “sacred” as applied to birth in this book is intentional and nonreligious. It implies that birth is an event important enough to warrant special consideration from those who are involved in the care of women during this time of life. It indicates that disrespect of the power of giving birth creates profound disharmony and ignorance in the world.
Giving birth can be the most empowering experience of a lifetime—an initiation into a new dimension of mind-body awareness—or it can be disempowering, by removing from new mothers any sense of inner strength or capacity and leaving them convinced that their bodies were created by a malevolent nature (or deity) to punish them in labor and birth. Birth may be followed by an empowering joy, a euphoria that they will never forget, or by a depression that can make the mother a stranger to herself and everyone who knows her. There is an enormous range of “birth effects,” depending on each woman’s experience, her lifestyle, the state of her health during her pregnancy, the choices she is able to make regarding the maternity care available to her, and the way she is treated when her time comes.
Traditional cultures throughout the world have always considered birth to be within the domain of women. Because only women give birth, indigenous cultures that were widely separated from each other all considered it obvious that women were the people most qualified to decide what sort of care was necessary during pregnancy, birth, and the newborn period. Even in those tribal cultures in which men had important roles to play around the time of pregnancy and birth, women—and in particular, those serving as midwives—had (and in some remote places still have) a great deal of influence in mapping out what these male roles ought to be.
What a contrast there is between these kinds of assumptions and those that are entertained by much of the public in the US. Here and in a growing number of countries, women have very little, if any, decision-making power about how they will be treated during pregnancy or birth. These are the countries in which midwifery either doesn’t exist anymore or is so marginalized as to be without influence. This kind of extremely medicalized maternity care has become common in urban areas of Mexico, Brazil, China, Venezuela, and Thailand, for example, where rates of C-sections have risen to four or five times more than the rates considered safe by the World Health Organization (WHO). In 1985 and again in 2007, the WHO convened consensus conferences to review scientific evidence on technologies used in childbirth. These conferences made a series of recommendations, including that the rate of C-sections should never be more than 10 to 15 percent of all births.1 Many private hospitals in the countries mentioned above have cesarean rates of 90 to 95 percent. The doctors who were my mentors during the 1970s would have been horrified to know that such high rates of surgery could be allowed to happen for no medical reason in any country, because they knew that unnecessary surgery puts lives at risk—the opposite of what medical care is supposed to do.
Just after I was given a tour of a birthing room at a high-volume Brazilian hospital in 2004, I had a chance to witness a scheduled C-section. The nervous husband of the mother-to-be and I peered through the window in the door of the operating room as we stood in the corridor outside. Trembling with fear, the mother lay on the T-shaped operating room table, her arms outstretched and tied to the table at her wrists. A nurse quickly shaved and swabbed her belly. There were no words of comfort given the mother through her ordeal. It seemed clear to me that while she was terrified of having the C-section, she must have been even more scared of experiencing labor or she wouldn’t have agreed to the surgery. This hospital did have a birthing room, but I was shown the log of births that had occurred in it for the previous month, and only two women had made that choice. Several hundred others had opted for C-sections that were rarely medically indicated. I found myself wondering if this mother knew anyone who had given birth the way her grandmothers or great-grandmothers had. She must not have known that it could be within her capability to give birth vaginally without harm to herself or her baby, or that a joyful birth was a possibility.
Watching her, I remembered the lecture on birth that I had been invited to give to a roomful of psychology students in Brasília a couple of days earlier. Each one of the women students who were mothers had had C-sections. When I told the class that it was possible for women to give birth vaginally without anesthesia and to enjoy such experiences, most looked at me in disbelief. When I showed them a photo of an unmedicated woman giving birth with a look of ecstasy on her face, only the men in the class had the courage to look at it. Several seemed interested in knowing more. What took me aback was that each of the women closed her eyes and refused to take even a glimpse of the photo, even though I had assured them that the woman had required no stitches and lost no blood during the process of giving birth. Unlike some US women of the same age whom I had previously shown the photos, these young Brazilian students had become so deeply afraid of giving birth that any sense of curiosity about how this woman’s body had accomplished it was overwhelmed by fear and a superstitious and unquestioning faith in technology. That’s real fear.
[Look of Ecstasy Image TK]
While it is true that in several of the countries with high C-section rates many healthy women are actively choosing to have C-sections that aren’t medically necessary, it can be argued that in the majority of such cases, their choices aren’t truly choices because they are based upon superstitions about technology and surgery, coupled with erroneous assumptions and fears about their own bodies and the process of birth. The same goes for those women who submit to choices made by their husbands or other family members, and those who have been persuaded by popular media and rather recent cultural fashions with no scientific basis that C-sections are safer than vaginal birth. In most cases, this is not true, and C-sections come with greater dangers for mother and child. It is time for people to be educated about this fact. Too much surgery is dangerous, and this is one of the reasons for the relatively high maternal death rates in the countries mentioned above. In contrast, countries that trust the natural process of birth and where midwives attend most of the births have better results. Finland, Iceland, Norway, Denmark, Sweden, the Netherlands, Belgium, Germany, the four countries of the United Kingdom (UK), and at least twenty-eight other countries all do better in this respect than we do in the US, although even these countries are being affected by the increasing use of birth technologies that tend to undermine the confidence of many women in their innate ability to give birth. When cesarean surgery becomes the norm for birth, maternal death rates inevitably rise.
We now find ourselves in a situation in the US and in many other parts of the world where women are increasingly being denied what is perhaps the most powerful and primal experience a woman can have: the right to give birth without the use of medical interventions unless these prove necessary. Women have been taught to believe that they must sacrifice themselves in important ways in order to have a baby—that the greater good for the baby means that the mother must submit herself to greater risk, even if that means a C-section for which there is no medical reason. For instance, many women are taught to think that it is automatically dangerous to a baby to be born vaginally if the cord is wrapped around the neck, when in fact almost all babies with the cord around the neck (perhaps one-fifth of all births) can safely be born vaginally. Others are taught that there is something so inherently dangerous about being forty-two weeks pregnant that justifies the induction of labor, even though that often leads to a C-section; in fact, an “estimated due date” is a guess that turns out to be wrong more often than most people realize.
My intention in this book is to call for greater involvement of women in the formulation of maternity care policy and in the education of young women and men about birth. Women who are fully informed about the capacities of women’s bodies should lead the way, and all women who care about social justice and human rights should be involved. The way a culture treats women in birth is a good indicator of how well women and their contributions to society are valued and honored. Of course, fathers, husbands, brothers, and all other men who care about the women in their lives need to be involved as well. This should happen in every country, but it is particularly important that the involvement of a partnership of mothers and midwives be increased in those countries in which there are either too few of the interventions that are sometimes needed during the process of birth or too many of these interventions, because both kinds of system errors cost women their lives.
I do want women who have already had C-sections to know that I am not judging them for having had surgical births. I understand that there are a lot of complicated reasons for having C-sections, and I make it a point to refrain from sitting in judgment on other women’s choices. At the same time, much of the information that is dispensed about C-sections is incomplete or distorted, and this can lead to women making choices without all of the facts.
The latest figures indicate that all is not well with motherhood in the US—the maternal mortality rate has risen sharply at the same time as maternity care costs per capita have escalated to levels two to three times as high as those in nations of comparable wealth. Some of our cities have maternal death rates that are worse than those in countries with far fewer resources; Costa Rica, Cuba, Bulgaria, Croatia, Hungary, Macedonia, and Slovenia are just a few examples of countries that are spending their resources designated for maternity care in a better way.
My intention in this book is not to persuade those women who want to avoid pregnancy to change their minds—far from it. But I do want to convince even women with no interest in motherhood that the right to a positive and safe birth is just as important as the right to choose whether or not to have a child. I do think that there is great value in taking a deeper look at motherhood and trying to discover what it might have to do with women’s empowerment. We need to deepen our understanding of where we have been as women in the past and how the past has shaped and often distorted our knowledge of our bodies and ourselves, especially in the realm of pregnancy and birth.
The Philosophy of the Natural Birth Movement
The natural birth philosophy that had its origins in the 1950s and 1960s in the US and continues today in many countries around the world is based upon a fundamental respect for nature that recognizes that nature mostly gets it right in birth. According to this philosophy (I’m actually more inclined to say “observation”), pregnancy is not an illness in need of treatment, and nature’s design of women is not considered flawed. The late Professor G. J. Kloosterman, an influential and eloquent Dutch obstetrician, perhaps said it best when he wrote: “By no means have we been able to improve spontaneous labor in healthy women. Spontaneous and normal labor is a process, marked by a series of events so perfectly attuned to one another that any interference only deflects them from their optimum course.”2 Such a philosophy, of course, does recognize that a pathological or dangerous complication can occasionally develop even in healthy women, and that the application of a powerful technology (surgery, for example) can be lifesaving in these instances. However, it excludes the introduction of powerful technologies either preventively or preemptively.
The guiding principles of the Coalition for Improvement of Maternity Services (CIMS) explain the natural birth philosophy quite well:
• Normalcy: treat birth as a natural, healthy process.
• Empowerment: provide the birthing woman and her family with supportive, sensitive, and respectful care.
• Autonomy: enable women to make decisions based on accurate information and provide access to the full range of options for care.
• First do no harm: avoid the routine use of tests, procedures, drugs, and restrictions.
• Responsibility: give evidence-based care used solely for the needs and in the interests of mothers and infants.3
Another set of principles related to natural birth was drawn up at the International Conference on Humanization of Childbirth held in Fortaleza, Brazil, in 2000. These principles fill out a vision of a better way for babies to be born:
• Humanized birth means putting the woman giving birth in the center and in control so that she, not the doctors or anyone else, makes all the decisions about what will happen.
• Humanized birth means understanding that the focus of maternity services is community-based (out-of-hospital) primary care, not hospital-based tertiary (specialist) care.
• Humanized birth means midwives, nurses, and doctors all working together in harmony as equals.
• Humanized birth means maternity services that are based on sound scientific evidence, including evidence-based use of technology and drugs.4
Women who share the natural birth philosophy want the opportunity to labor in a way that emphasizes human connection rather than monitoring by a machine. They know that surgeons and medical technology are necessary sometimes but not infallible, and that, given the realities of human greed, ambition, impatience, institutionalized ignorance, and gullibility, it makes sense to trust the processes of one’s healthy body over the promises of miraculous cures and remedies—no matter how respected and authoritative the source may apparently be. As the late indefatigable researcher and writer Barbara Seaman put it, “Some women want to let their doctors do the worrying for them. But for those of us who don’t, it has been extremely difficult to get honest health information.”5
The Importance of Birth Stories
The influence that birth has on a society is powerful, but it’s also subtle, because most of its initial effects are laid down in the private spheres of human activity in technological societies—in hospital maternity units, birth centers, and, more rarely, homes—out of the sight of most people. Because of its private nature, birth is much more mysterious to civilized people than it is to people who live in cultures in which birth occurs in homes and villages where encouraging stories are still shared about pregnancy and birth, and members of the village not only witness labor and birth but celebrate it collectively. In the same way, people in urban cultures no longer have the chance to observe the chains of cause and effect that emanate from each pregnancy and birth. The result of this is that most of us don’t have direct ways of knowing how much variety there is in the ways women can give birth, without risking or endangering themselves or their babies.
As long as I have been writing and lecturing about birth, I have found it helpful, even necessary, to tell positive birth stories. This is one of the best ways for women to learn the kinds of things that may help or hinder labor and birth. Stories teach in memorable ways. In that sense, they are much more valuable than rote learning and memorization.
Stories have always been a medium of education amongst humans. When I encounter a story that reveals something about labor or birth that is new to me, I don’t automatically dismiss it as untrue or irrelevant simply because I am unfamiliar with the phenomenon it reveals. In some cases, I have learned that the cultural blindness that highly industrialized societies have developed surrounding birth keeps us from observing behavior that used to be commonly known and is still commonly known in areas of the world where women retain control of birth.
A story that I heard from a friend before I had ever even witnessed a birth served as this kind of eye-opener for me. This was Mary’s first pregnancy, and her baby was due any day. She was one of those women who trusted her body and felt strong and able to be on her feet doing things, no matter how pregnant she was. She and her baby’s father were working in different parts of the city that day, and she didn’t know until day’s end when she rejoined him at home that he had had to leave work early because of violent abdominal cramps that had made him wonder for the next several hours if he had appendicitis. That concern was abandoned, however, when Mary’s massage of his belly rather quickly quelled his pain. Shortly after both had eaten a meal, she began to experience cramps and thought she might have a stomach flu. Worried that this flu might start her labor, she decided to sit on the toilet, in hopes of finding some relief there. Within a few minutes, she cried out to him, “Come help me! Everything’s coming out!” When he came running, their baby fell into his father’s waiting hands. That was the first time I had ever talked to someone who gave birth without realizing that she had been in labor.
Hearing Mary’s story reminded me of what I had read about couvade (from the French for “hatching or brooding”), the term used by anthropologists to describe customs from tribal societies all over the world that recognize that the psychological ties between parents-to-be during labor and birth are deeper than civilized people believe possible. In one typical account, an anthropologist described the phenomena he observed among tribal people of the Congo, noting that as the mother’s labor begins, her husband apparently falls ill, complains of stomach pains, and loses his appetite. “Men know the instant of the birth of their children because at that instant their symptoms disappear,” wrote the anthropologist. “A few men suggest that these symptoms may be due to worry about wife and child, but numerous cases are also cited in which a man is far away from home, falls ill suddenly, recovers just as quickly, and then learns of his wife’s delivery at these very moments.”6 This account closely matched Mary and her husband’s story and that of a birth I attended some years later—the fourth birth for a couple that I had helped before. In this latter case, unlike their three previous labors, during which the mother had experienced the sensations of labor, the father-to-be was the one who felt the pain of labor. This was not an act for either of them, and none of us could analyze why it happened for them in this way when it hadn’t for their previous three births, but the father’s pain left just as soon as their baby daughter was born. What was significant for me about both of these cases of couvade was that none of the parents involved had ever heard of the phenomenon before experiencing it.
While stories can’t let women know what their own experience will be like, they can illustrate how wide the range of normal behavior is. Virginia, who lived next door to me while I was getting my bachelor’s degree in literature, told me one that I found valuable. She was a tiny woman with a husband who towered over her. It’s worth remembering, by the way, that in those days, unless you were a medical or nursing student, there weren’t any books or photographs available to prospective parents of what labor and birth look like. When Virginia was nearly ready to give birth, her belly looked impossibly huge to me, and I worried for her. I wondered how the baby could possibly get out. I remember her stopping by my place before she left for her doctor’s office for what she hoped would be her last prenatal visit. About three hours later, she returned home with her baby in her arms. “What happened?” I asked, amazed that she could have already given birth.
“Well,” Virginia said, laughing delightedly with her accomplishment, “My doctor examined me because he thought that might tell him when I might start to have the baby, but the exam put me right into labor, and she was born in only twenty minutes. I couldn’t even get my socks off!”
That story was an eye-opener for me, but I didn’t doubt a word of it. It was pretty deeply ingrained in Midwesterners like Virginia and I not to exaggerate. I was so excited to learn that a woman could give birth as easily as an animal that I forgot about how improbable it had looked to me a few hours earlier. Virginia’s story and her eyes, shining with excitement and accomplishment, showed me what was possible for a woman who had never given birth before.
There had been almost nothing to read about birth in the libraries that I had access to as a teenager, but I did find Dr. Grantly Dick-Read’s classic Childbirth without Fear, which I devoured at the age of sixteen. From it I learned something that rang true to me: much of the pain experienced by women in birth can be attributed to fear and to a lack of knowledge about the true physiology of birth. Fear leads to muscle tension, which can lead to more fear and increasing muscle tension unless the cycle is broken. Part of what made Dick-Read’s book interesting was that he told personal stories about painless births he had witnessed—births that had completely surprised him because he had previously observed and therefore assumed that all births had to be extremely painful. Witnessing those painless labors prompted him to drastically rearrange his ideas about birth and to incorporate ways of educating women in how to lessen fear of birth and pain. He recommended deep, slow breathing during labor and other techniques for achieving a state of calmness and deep relaxation. He said that women who led sedentary lives would have more difficulty giving birth than peasant women who lived and worked outdoors. “The office worker tends to have more trouble than the fisher-girl, the farmhand or the riverboat woman,” he observed.7 He provided ways for urban women to overcome any difficulties caused by a largely sedentary lifestyle. Another recommendation he made—one that I subsequently found helpful both in my own labors and while assisting other women in labor once I had become a midwife—must have stuck in my mind from that first reading of his book. It had to do with the forehead muscles of a laboring woman, and it was this: women who could completely relax their facial muscles would be able to go through labor with maximum ease. I still find this advice to be useful and true. What I didn’t know until much later was that most obstetricians in the US and the UK (Dick-Read’s country of origin) during the sixties were far from comfortable with his ideas and methods. Their discomfort with his theories probably stemmed in part from the fact that his book was addressed to women, not to his fellow physicians, but it’s also safe to say that most obstetricians are skeptical upon hearing that labor and birth can be experienced without pain, fear, or pain-numbing medications. It’s not easy for surgeons—and it’s important to realize that obstetricians are surgeons—to have a chance to witness such births. In fact, as I’ll explain in more detail later, it’s not possible for most US maternity nurses these days to witness a physiological labor that is allowed to proceed without intervention, either during their training or when they are employed in a maternity ward.
As a medical student, Dick-Read was also used to witnessing births that were extremely painful, so he was surprised the first time he had the opportunity as a medical student to observe a painless birth. As he describes in Childbirth Without Fear, it happened in a dingy tenement in the outskirts of London in 1911, and the only sour note during the entire labor came when the laboring woman turned down his offer of anesthetic gas. “It isn’t supposed to hurt, is it, Doctor?” she asked him when he inquired afterwards why she had refused his offer. A few years later, his stint as a battlefield surgeon during World War I gave him the chance to see two more such labors, both of which took place outdoors near the surgical tents where amputations and other operations were carried out. Neither woman spoke English, but each made it clear that she chose to be near medical help just in case she had a complication, but that she didn’t want anesthesia or to be told what to do. Each woman very calmly delivered her baby and placenta without any assistance and then picked up her baby and walked away after a few moments of rest.
Still another story taught me how Native Americans recognized the spiritual and emotional needs of women and their families around the time of birth. I got a glimpse of what the sanctity of birth meant in a practical sense in 1978, when some of the people from my community in rural Tennessee took part in the Longest Walk, during which Native Americans from all over the country walked from California to Washington DC. The Walk was a national demonstration organized to protest and lobby against several bills before Congress that a coalition of tribal leaders felt would further weaken treaties and land rights. When it reached Ohio, a young woman in early pregnancy began to miscarry and one of my midwife partners drove her to a local hospital. Once the miscarriage had happened and she was able to leave the hospital, she asked for but was refused her baby’s body. According to her people’s traditional practices, she needed to bury her baby with the proper ceremonies. However, she and my partner were unable to convince anyone at the hospital to release the body to them, because according to mainstream US culture, her baby hadn’t yet reached the stage of viability, so was not entitled to burial. When the mother and my friend returned to the encampment and Ernie Peters, chief of the Walk, and the other elders were told what had happened, it took them only minutes to gather up a delegation of men to drive to the hospital to reclaim the body. This time, whatever was said quickly convinced hospital officials to release the tiny body, and the proper ceremonies and burial were performed before the walkers resumed their eastward journey. I wondered how many women belonging to the mainstream culture who suffered miscarriages would have appreciated some sort of cultural recognition of their loss—the kind of attention this Native American woman received after hers. I knew that I would have.
Notes
1. World Health Organization, “Having a Baby in Europe,” Public Health in Europe 26 (1985): 85.
2. G. J. Kloosterman, “Why Midwifery?” The Practicing Midwife 2, no. 2 (Spring 1985): 5–10. See the text at www.inamay.com/?page_id=249.
3. For further information on the Coalition for Improving Maternity Services and its mission, see www.motherfriendly.org.
4. M. Wagner, “Fish Can’t See Water: The Need to Humanize Birth,” International Journal of Gynecology and Obstetrics 75, supplement (2001): S25–37.
5. Barbara Seaman, “Dear Injurious Physician,” New York Times, December 2, 1972.
6. Judith Goldsmith, Childbirth Wisdom from the World’s Oldest Societies (Brookline, Massachusetts: East West Health Books, 1990).
7. Grantly Dick-Read, Childbirth Without Fear: The Principles and Practice of Natural Childbirth (London: Pinter & Martin Ltd., 2005), 192.
Called "the midwife of modern midwifery" by Salon, INA MAY GASKIN has practiced midwifery for nearly forty years at the internationally lauded Farm Midwifery Center. She is the only midwife for whom an obstetric maneuver has been named (Gaskin maneuver). Known around the world for her birthing practice’s exemplary low rates of intervention, morbidity and mortality, she has gained an international reputation in obstetrics for demonstrating the magic key to safe birth: respect for the natural process. She is the author of Spiritual Midwifery, Ina May's Guide to Childbirth, Ina May's Guide to Breastfeeding, and Birth Matters: A Midwife's Manifesta.
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This is an excerpt from Ina May Gaskin's new book Birth Matters: A Midwife's Manifesta with the kind permission of Seven Stories Press.
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