*
*
My first introduction in book-form to the idea of homebirth came via Spiritual Midwifery by Ina May Gaskin. I chanced upon a copy of the book before I was pregnant, and fell in love with the emotive and very real photographs of women giving birth with their partners, wearing their own clothes, in their own homes. I also felt a strong connection to these women who all looked a bit like my mother in 1973. Or did my mum actually give me my first copy of the book? The book felt nostalgic to me at the time, but also inspiring. The overall message was that I could do this radical thing–give birth at home, in ecstasy. Ina May Gaskin and her work was certainly a catalyst for a way of looking at birth that diverged from the technocratic model. But over the years, and throughout my own education and experience with pregnancy and birth, I have looked back at Spiritual Midwifery with a much more critical eye. I disagree entirely with Gaskin’s more recent position on the regulation of midwifery, and I have worried that Spiritual Midwifery may still be read by mothers and midwives, not as the historical document that it is, but as an actual working manual, its value for which is, I believe, outdated, and to some degree dangerous.
*
But I really wanted to share with everyone what I think is a brilliant analysis of the book, by a brilliant birth attendant with whom I have the privilege of working and talking and hanging out. Sarah Hendricks is currently studying midwifery at the Ancient Art Midwifery School, which provides a superlative online, holistic training in Midwifery. Sarah is a genius writer, and she also has a blog at www.primalmotherhood.blogspot.com. Thanks so much for giving me permission to publish this piece Sarah!
*
**************************************
*
Spiritual Midwifery by Ina May Gaskin–A Critique by Sarah Hendricks
*
‘Spiritual Midwifery’, now in its fourth edition, is a fairly comprehensive and legible book that conveys Gaskin’s experience with and understanding of midwifery. The book presents us with textbook-style information, complete with intermittent stories, essays, and pictures. This approach to the creation of the book blends together elements of emotion and spirituality with clinical advice in what has come to be widely regarded as an important guide to being with-woman.
*
As much discrepancy as I found between Ina May’s and my own personal approach to midwifery (which I will later discuss in more depth), I could not help but identify with her as she described her own early, personally-shaping experiences: an interpersonal exchange with a female monkey that showed her the importance of compassionate touch (Page 11), and the affective birth of her own first son, who was born prematurely and died shortly thereafter, the tenth birth that took place on the caravan. (Page 19).
*
Following a bit of background information which introduces the farm midwives (and their admittedly obstetrically-rooted education), the book launches into a fairly extensive collection of birth stories (“Amazing Birth Tales”, Page 33). The birth stories, told mostly by the birthing women themselves- but sometimes from the perspective of father or attending midwife- are told simply, humorously, and emotionally. The women of the farm evocatively describe their often awe-inspiring, visionary, or ‘psychedelic’, experiences giving birth. While reading the stories, I found it easy to feel affection for the mothers in the telling of their birth stories, honestly and unselfconsciously.
*
One such story, Ernest’s birth (Page 59), is an interesting example of a story in which the paradox between physiological birth and interference is made potently clear. Mary, the birthing mother, is clearly experiencing the full expression of her hormones, is in all-out-psychedelic-birth mode, and her uterus is doing a fine job of ejecting her baby. The midwife notices a nuchal cord after the head emerges and proceeds to pull on the already tense cord, hoisting it from around the baby’s neck and over his head. The baby comes out, born blue, and then quickly turns pink and robust; a healthy boy. The manoeuvring of the cord seemed meddlesome and risky, and involved the pulling on and tightening of the already tense cord. I found myself marvelling at the birth, which proceeded well, regardless, or perhaps in spite of, this hasty manoeuvring on the part of the midwife. I am inspired by the resiliency and adaptability of the baby, and of the birth process, despite regularly inflicted interference upon its design. Even given the fairly regular intervention the births on the farm were subjected to overall, outcomes were still spectacular. ‘Appendix A’, (Page 468), details the outcomes of 2, 028 pregnancies from 1970-2000, with astonishingly low rates of caesarean section and neonatal mortality. Notably, initiation of breastfeeding rates and continued breastfeeding rates were 99% and 100%, respectively- an important outcome that entirely escapes the radar of the western birth machine, which deals strictly is terms of morbidity and perinatal death. We are then able to realize, overwhelmingly, that it is only when birth is subjected to the most extreme conditions of duress and interference that it becomes unsafe.
*
It was during the reading of these stories where I first found Ina May`s practice of midwifery to conflict with her idealized notion of “spiritual midwifery”. Her level of interference with the births in these stories seems to defy rationality, compromises safety, all while giving birth the illusory appearance of being a risky medical event requiring supervision. It quickly becomes evident in the reading of the book that Ina May is coming from a pseudo-medical standpoint, where the basic emphasis is placed on the importance of knowledge about and employment of obstetrical skills in the context of normal birth.
*
I felt put-off as I read a passage describing an event where a woman was giving birth surrounded by a large group of people. One of the people in the crowd was a woman who thought that “no one person should be in charge of the birth”. This apparently anti-authoritarian spectator injected into the situation what Pamela refers to as “superstition about any conventional medical information” (Page 24). I actually cringed when the paragraph ended with, “Ina May backed off, even though she was the most qualified person in our group to help the mother” (Page 24). The book proceeded to tell us that this particular event led to Ina May becoming established as “the main midwife in charge.” (Page 24) This event illustrated to me the midwives’ subtle association with the medical paradigm, in which the questioning of routine procedure is regarded as “superstitious” (when one could argue that the use of routine procedures is, in fact, actually superstitious.) This event also seemed to be a power struggle in which Ina May’s social status and image as “the most qualified person to help the mother” won out over emphasizing the mother’s authority in choosing who she wanted to be present and helping her at her birth. The truth is that the only true qualifier when it comes to serving a mother is her choosing a person to be there, and that freedom for birth means that she needs to be able to make that choice freely without restriction or threat of litigation. This last point brings up issues of power, responsibility, autonomy, and the way our society assumes legitimacy while punishing those who fall outside of its constructs. Indeed, there is much social control surrounding who may be considered a “skilled birth attendant.” With so much emphasis in our society being placed on position, title, and rigid guidelines which directly create the potential for conflict of interest between the midwife and mother, the midwife’s fear of a bad outcome and ensuring litigation become the motivating factors behind the diagnostic procedures and interventions performed; thus “covering all the bases”, regardless of the outcome or the mother’s informed consent. This is a coercive and imbalanced system. While this issue certainly deserves much more detailed exploration and attention than I will discuss here, I can only say that my ideas about the restrictive nature of licensure- which assume dominion over women’s bodily functions- are in sharp contrast to Ina May and the farm midwives’ apparent clamouring for one more way to identify with the medical paradigm.
*
Another very concerning practice I noticed was the cutting of nuchal cords on the perineum, which happened several times throughout the different birth stories in the book. Common seen throughout these stories is the need for newborn resuscitation- the obvious result of having their lifelines- their umbilical cords- cut off too soon. We know that the cord is a tough and resilient structure, filled with a protective and flexible substance that cushions the vessels within, which, even when compressed to some degree while around the baby’s neck, are still doing the job of exchanging oxygen for carbon dioxide in the baby’s blood even while the baby is in the process of being born. The risk that the midwives took by cutting the cord on the perineum far exceeded the risk of leaving it intact, and represents a dangerous level of interference. These were births that the midwives attended in the 70’s, but the seeming legitimacy of this practice seems to have hung on in the newest edition of the book, published in 2004. Later in the book, during the reading of “Tristan’s Story” (Page 380), the story of the farm’s first severely asphyxiated baby, this danger becomes clearer. Dangerous and highly unnecessary intervention during his birth involved the cutting of the nuchal cord on the perineum. The midwife, Kay Marie, coaches the mother’s pushing. The father remarks that “The cord was wrapped tight around the neck and they had to cut it, and then he came out all luminous and glowing, but he wasn’t breathing.” (Page 382). The midwife frantically suctions the baby’s mouth, performs mouth to mouth, and administers oxygen. The baby breathes after some time, and spends time in the hospital recovering following the difficult transition he went through. Time stands still as you read this story. The fact that this baby had to go through so much iatrogenic injury occurred to me as truly horrifying. The obvious connection between the midwife’s interference with the birth and the complications experienced by the newborn is never made. The parents, unfortunately, seemed to accept that what happened to their baby at his birth was justified. They lovingly recall that, “no one ever touched [Tristan, the newborn] that did not love him.”- I agree, and believe this wholeheartedly. That is precisely why it so heartbreaking that such a disservice was done to this family; that those who touched and loved him, unwittingly did so much harm to this little one. I am convinced that is an outcome that could have been avoided if the midwife had better understood the safety of, and the normal variations of, birth.
*
Throughout the writing, it is clear that the midwife-mother relationship is marked by the mother’s pervasive dependence on the midwife. During “Jody’s birth” (Page 102), the mother, Deborah, recalls that she “told Cara [the midwife] I thought I could push. She told me to wait because they weren’t ready. That was okay with me.” In this instance, the mother’s needs are clearly secondary to the midwife’s procedure and readiness. The fact that Deborah was “okay” denotes acceptance of, and submission to, this arrangement. I would argue that this is an unreasonable and inappropriate request to make when in service to a woman on the brink of giving birth- who is herself the only essential variable to the birth. In another instance, during “Sally Kate’s Birthing” (Page 66), Mary Louise, the midwife, dictates to the mother where she is in her birth process following a vaginal exam, and the mother expresses her fear and dependence on the midwife when she makes this statement: “I was almost completely dilated. I tightened up some then because Ina May wasn’t there and neither were the sterile packs. The rushes kept coming but I was holding back.” We are able to see clearly the nature of the midwife’s relationship to the mother: a necessary supervisor, a savior, one who assumes responsibility over the bodily function of another woman. In my own practice, I cannot see myself working with a woman without ensuring that she knows and owns her full capacity for power and autonomy as the sole-birth-giver, with myself in service to her and a witness of her and her baby’s process, their miraculous hormonal synchrony. Ina May seems to place herself in, and maintain, the position of ‘essential deliverer’ throughout Spiritual Midwifery- a notion that removes emphasis in the book from where it had ought to be: on the mother, the only one capable of giving birth to her child, a whole person, a sacred being channelling new life through her body.
*
The pictures throughout the book are, for the most part, poignant and moving. Women with wild hair are passionately captured in black and white stills, in movement, at birth, pausing, sighing, and breastfeeding their gorgeous babies. Certain pictures, however, such as the depiction of a baby being suctioned , literally 5 seconds after the birth, or the midwife performing vaginal exams, or the midwife’s hands all over the opening perineum (Pages 341, 348, 396), did not have the same effect. I found that these pictures conveyed all too glaringly their own obvious lack of function or purpose. Mothers do not need to be massaged “sensually” or internally examined in order to give birth. Vaginal exams to assess dilation are not necessary, nor are they benign, introducing and increasing the risk of infection. Likewise, babies do not need to be poked and intruded upon with a plunger-action-device in order to breathe and clear out their throats and nasal passages. It is simply ludicrous to think that this is a good idea, particularly in the presence of meconium staining, when the driving down of the suctioning device actually creates the potential for the pushing of pathogenic fluids deeper towards the respiratory tract. Suctioning appears in several of the births in Spiritual Midwifery and its routine use prior to the birth of the body is actually encouraged and explained without any meaningful reasoning, and without the provision of any research that could justify the application of this intrusive procedure (Page 353).
*
The clinical/textbook style information provided in the book, ‘Instructions to midwives’ (Page 269), while somewhat agreeable, is mostly wrought with inaccuracy, fear, and procedures I would not consider essential or necessary to good midwifery. “Essential Measurements” (Page 278), on pelvimetry, is not a skill I would include in my personal midwifery repertoire, other than to know what it is, and why it is mostly useless. Ina May details in this section how to internally examine the mother to determine pelvic diameter. This accomplishes nothing and does not glean any meaningful information when you consider the reality of birth: stretching, relaxing, moving, molding, and flexing that is biologically normal, fluid, and evolutionarily designed to work. Cephalopelvic disproportion is, I am convinced, a bogus diagnosis, or a very questionable one at the very least, and the idea of imposing on a mother how I feel about her particular pelvic outlets ability to open based on my pathetically inadequate measurements, is at the very least irrelevant, and at worst, distressing and inhibiting.
*
On page 318, Ina May discourages induction for postdates, and I agree that 42 or 43 weeks gestation may be optimal for some women. Paradoxically, she then goes on to list and describe “natural” methods of induction. She claims that castor oil, enemas, and membrane sweeping are “safe for women who have had a previous low transverse ceserean”. I do not agree. I think that all methods of induction alter the chemistry of birth and that any nudging needs to be weighed against the risk of prematurity, failed induction turned ceserean, and the spiritual significance of forcibly removing a baby who still wants and needs to be inside the womb. Because of these risks and because induction is a deviation from normal physiology, it falls outside the scope of midwifery and should take place in the hospital.
*
As pseudo-medical, and therefore as off-base, as the book frequently is, I enjoyed some of the observations that were made. One mother Jan, expressed her transformation following her birth by saying, “In the end, the opportunity to draw on strength I wasn’t aware I had became a door through which I rose into my own power.”- a quote that makes my throat waver, at the truth of how birth truly is a gateway to growth, a portal, an opportunity to know ourselves as truly powerful, surrendered, and aware. This is a pivotal event that, to a great degree, influences who we will become as mothers, and inevitably imprints our baby’s nervous systems. It is this passage that, in essence, midwifery strives to preserve, witness, respect, and serve. That is precisely why Spiritual Midwifery is such a conflicting and actually harmful book. Throughout, service to women is muddled in issues of power and pervasive distrust of physiology on the part of midwives. Truthfully, the message that is effectively conveyed is that birth is a dangerous event, midwives are essential saviors, and that obstetrical skills are, in fact, midwifery skills. I am glad to have read this work, because the distinctions between medicine and midwifery, to me, have never been more clear. It is easy to see the cause and effect relationship demonstrated again and again between interference, poor outcomes, and then the necessary illusory heroism of the pseudo-medical-midwife. Rather than feeling defeated by the rampant misrepresentations in the book, I feel relieved to know that there is another way, an easier way, and a much safer way to practice midwifery. Delving through these stories and Ina May’s thoughts has proven itself to be truly educationally valuable- provoking much thought, research, openness, and questioning. I am not satisfied with Gaskin’s take on spiritual midwifery, and my mad desire for knowledge and truth persists, as my awareness of what mothers today are up against in their search for unhindered physiology increases. I believe that in our education, we are free to question everything, and questioning everything has never been more crucial to changing our current dominant and broken maternal care system. This book has offered an opportunity to once again reject a way of thinking and a system which is not in true service to women.