The world's 'most famous' self-taught midwife spoke in Jerusalem recently and described how she came to advocate an unusual birthing procedure that has since been named after her.
By JUDY SIEGEL-ITZKOVICHbaby 88(photo credit: )
Ina May Gaskin - the woman widely described as the "most famous" and "most authentic" midwife in the world - never even took a formal midwifery course. Nevertheless, obstetricians, who in most of the developed world prefer to deliver all babies themselves, have given her the ultimate honor - naming an obstetric procedure that literally saves life and limb after this unusual woman.
Observing how uneducated, poor women deliver babies under primitive conditions in Guatemala, Gaskin formulated what she claims is the most effective way to deal with shoulder dystocia, in which the baby's head has already emerged but its shoulders are too broad to get out of the birth canal. Doctors try an incision on the perineum, pulling and twisting, but this can lead to fractures of the infant's bones, brachial plexus injuries and more. Instead, Gaskin suggested putting the mother on all fours - a position common in indigenous cultures - and in the vast majority of cases, the baby will pop out "within a maximum of six minutes."
SHE WAS brought to Israel earlier this month by Great Shape, a Jerusalem exercise studio based in the capital's majestic YMCA building and with expertise in workouts for pregnant and post-natal women. Hundreds of women from around the country, including midwives, dolas, nurses, pregnant women and new mothers packed the auditorium to hear the folksy Gaskin being introduced by Great Shape director and co-founder Rachelle Oseran. Most of the audience were either modern Orthodox or secular Jewish women - and some brought along their babies whom they breastfed in a nursing corner where the sound was piped in so they wouldn't miss out on Gaskin's lectures between 10 a.m. to 6 p.m. If there had been a large number of obstetricians guarding their territory, opposing home births and demanding that midwives get academic training, however, the reception would probably have been cooler.
Widely known only by her first and middle names, Ina (pronounced eye-na) May was born in 1940 to a Protestant farming family in Iowa. She recalled that she was a tomboy who delivered papers; because of the birthing of farm animals she witnessed from an early age, she was interested in how creatures enter the world. She had initially planned to become an engineer, but a turning point came at age 16, when she borrowed from a library the classic natural-childbirth guide by British obstetrician Dr. Grantly Dick-Read called Childbirth Without Fear.
"It made sense. If you're not afraid of childbirth, you breathe better and your muscles are more relaxed so you can have the baby more easily," she said from the YMCA stage.
AFTER GRADUATING from her hometown high school, she attended a community college, married charismatic "hippie guru" Stephen Gaskin at 19 and enrolled at the University of Iowa to study English. The idealistic Ina May and Stephen enlisted in the Peace Corps and lived for a time in Malaysia, where she taught English, but they returned to the heartland of America for her to earn her master's degree in English.
While still a graduate student in 1966, she first gave birth in a hospital, attended by an obstetrician, but found the experience nothing like what Dick-Read had described in his book.
Ina May - a grandmother of two with long gray hair and dressed in a calf-length peasant skirt and blouse - recalled that she had been left alone most of her time in the delivery room. When her contractions intensified, doctors came in armed with forceps to pull out the baby, even though she had wanted to have hers naturally. She wasn't permitted to see her daughter for a day and a half. "I wanted to have my next baby at home."
Many US obstetricians of that era who encountered shoulder dystocia performed the Zavanelli Maneuver, in which they rotated the baby's head and pushed it back into birth position before performing a Cesarean section.
"They decided to do this based on only 10 cases, and two of the women needed an immediate hysterectomy. I was surprised that it was even published in a medical journal. The Zavanelli Maneuver is sometimes still performed today!" said Ina May.
America's obstetricians then believed that "all women need a big episiotomy" (incision in the perineum, sometimes even to the anus) to avoid injury to babies and mothers during birth. "Every first baby had to arrive by a forceps delivery. As a farmer's daughter, I saw how animals were born - with no forceps. As I had read so many romantic 18th-century English novels, I thought I could escape my fate in the delivery room by being quiet, but it didn't help. I wasn't aware then that there were any midwives in the US. The profession had nearly been wiped out. There were 4.3 million births per year - almost all attended by obstetricians. Today," said Ina May, "fewer than 10 per cent of US births are performed by midwives, and home births constitute less than 1%. Even so, this situation is very threatening to the American Medical Association, which is always trying to push through laws to prevent all home births by preventing payment for it."
SHE WOULD probably envy Israel, where most babies are born with the help of midwives, and obstetricians are called in only if there is risk or if the couple pay privately. But there are few home births, as the Health Ministry says this is unnecessary and can endanger infants. Hospitals, which depend on per-baby payments from the National Insurance Institute, are not keen on losing the business, and women receive NII grants for delivering in a hospital.
After moving to San Francisco in 1970, the Gaskin family decided to start a commune in the center of the country. Some 250 people traveling in a bus caravan put down roots in Summertown, Tennessee and called the settlement near a forest The Farm. They grew their own food, but had no health insurance, ideologically refused to accept government help and had to manage without physicians.
"As lots of women were pregnant by the time we settled down in the commune" remembered Ina May, "they were having lots of babies." She helped bring children into the world - her first one on a bus in a parking lot - without any formal training. The Farm's population quadrupled in four years to 1,000 people.
Eventually, based on what she learned and recognized as a Certified Professional Midwife by a layman group as she lacked academic study, Gaskin wrote her best-selling books Spiritual Midwifery (1976) and Ina May's Guide To Childbirth (2003) - both of which promoted natural childbirth and the home birth movement. Via her midwife quarterly, theBirth Gazette, she has promoted a woman-centered, low-intervention method of delivery.
AFTER GETTING some pointers from a kindly physician, she was so calm and collected while delivering babies that her fellow residents at The Farm asked her to attend them, often in their own bedrooms. Ina May believes that midwives like her who have learned from experience ("direct entry") rather than from formal training should get a license like academically trained midwives, and pushed for this as a founder of the Midwives' Alliance of North America.
When a terrible earthquake hit Guatemala, the Gaskins went there to help the victims by building homes and outhouses, capping springs and other tasks. "The average life expectancy there was 44 years. I met a foreign midwife, from Belize in Africa, who was living there and working as the district midwife," Ina May recalled. "She supervised illiterate Mayan women, but found that when the baby's shoulders got stuck, the natives knew better what to do than she herself had been taught. The woman turned onto her hands and knees and was able to push the baby out easily."
Back at The Farm, there were 30 babies to deliver each month. "Shoulder dystocia had become America's most feared birth problem. Victims had useless, even permanently paralyzed arms. Doctors were afraid of being sued." Ina May was on hand to deliver the second child of her friend, Barbara. "His head was out, but she couldn't push because his big fat cheeks were against the perineum. I remembered what I had seen in Guatemala and turned her over. She thought I was crazy, but her 10-pound [five kilo] baby was born immediately."
INA MAY demonstrates on the YMCA stage why her maneuver is successful. Holding the front and back of her pelvis when standing straight, she instructs her audience to stand up and copy her. Bending forward, as if on all fours, they felt that the distance between the front and back of the pelvis expanded, leaving more room for the baby to get out.
"Another reason is when in the womb, the baby isn't glued in any particular position. When its mother rolls over, the inertia of the baby's weight can knock loose the wedged shoulder like a little ship inside a bottle."
Her most exciting achievement was when she collaborated with Prof. Joe Bruner of Vanderbilt University and published an article about the Gaskin Maneuver in the May 1998 issue of the Journal of Reproductive Medicine; obstetricians who read it were gradually persuaded that perhaps it could be of use when dealing with shoulder dystocia. Yet she knows of hospital departments where the chief of obstetrics forbids women to go on all fours "because they regard this as a sexual position that has no place in a hospital."
IN ANY delivery, Ina May advises, the midwife or obstetrician should "always take a very deep breath before saying anything. Then say it in a very quiet voice so you don't scare the mother. Understanding the ring-shaped sphincter muscles that surround the natural openings in the body and can open or close them is also a very important part of childbirth, she continued. In addition to sphincter muscles in the heart, gastroenterological system, urethra, anus and mouth, the cervix and vagina are also sphincters.
"There are many women so afraid of birth that without knowing it, they close these sphincters during labor. They can remain contracted when the mother is tired or shy," said Ina May. "When her mouth is open and smiling or laughing, you can feel the cervix and vagina soften and open. Fear can stop labor, and the baby can be drawn back into the uterus due to the adrenalin produced."
Many Aztec or Mayan birthing figures, she noted, show stylized women with their mouths and vaginas open that were used to promote quicker delivery. She told of cases in which women were so frightened by the arrival of obstetricians that their babies went back into the birth canal for minutes, hours and even weeks.
Some women are so afraid that they will defecate, urinate or release gas during their labor that they involuntarily hold the fetus in, said Ina May. Some of these fears originate in their toilet-training period when they were derided or punished for "accidents." Such women can have great difficulty delivering babies.
"If you suspect such trauma," she told her audience, "make jokes about pooping, peeing or farting. 'Shit' is a perfectly acceptable word; Shakespeare and Chaucer used it. If a midwife can't say these words during delivery, she's in deep shit!" said Ina May in her typical homespun manner. "Our bottom parts work better when our top parts - our minds - are either grateful or amused at the antics or activities of our bottoms. Humans are the only animals disgusted by their own poo."
This is not the style of most obstetricians, but it will be interesting to see whether women's growing demands for more natural childbirth will bring "direct-entry" and academically trained midwives and physicians closer in their outlooks, choice of procedures and language.
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