INFORMATIVE ARTICLE

NRC 10-01-2010

Ex-hippie Ina May Gaskin began with scissors and a hemostat clamp. Now she researches birth-related mortality. This week the Ministry of Public Health issued a sobering warning about birth-related mortality. Pregnant women are getting much too little information and guidance from all of maternity care professionals. This must change, said the Pregnancy and Birth steering group.

The reason for the statement made by the steering group was the relatively slow decrease in the perinatal mortality in the Netherlands, which compares unfavorably with other European countries. And that lies thus on deficiencies in care and information. This situation has nothing to do with the many home births in the Netherlands, which is sometimes spoke about in critical terms. Dutch women have long been accustomed to giving birth without much technology at home or in the hospital. According to the steering group, this restrained use of technology in birth is not responsible for the perinatal mortality rate.

The U. S. embodies the other extreme: all women give birth with high-tech care (continuous monitoring of the baby and anesthesia) in the hospital. The c-section rate is twice as high as that of the Netherlands. But does this technology deliver better results? The question is a big one in the conversation with American self-made midwife Ina May Gaskin, recently in London. She is convinced by experience that more technology is not the solution.

The neonatal death rate in the U. S. is about as high as in Netherlands: 6.74/1000 (in 2003, after 28 weeks' gestation) versus 6.6/1000 in Netherlands in 2004. The maternal death rate in the U. S. in higher: 15/100,000 versus 12/100,000. That is double what it was in 1982, instead of halving it. More recent figures are still less than reliable, for according to the CDC, the true death count could be 3 times higher than those officially published.

The rising maternal death rate in the U. S. is Gaskin's greatest worry. She shows me a news report. It includes a photo of a young black woman with her prematurely born twins, who was sent home all on her own with the twins. A few days later she died from unknown causes. Her body was found weeks later, along with the two babies, who had fallen under the bed. The

babies were found under her bed—one alive and one who died just after being found. Another baby died from hunger after his single mother was sent home soon after birth with no postpartum visits nor help. She died of a postpartum hemorrhage, and her baby died of starvation before either was found. She also showed me a block for a nurse who died after a cesarean from an infection caused by a bowel nick.

Gaskin hammers frequently in the media on the U. K.’s system of Confidential Enquiries and its analysis into maternal deaths in England, through which it becomes clear if these deaths could have been prevented. She has quilts made, with blocks for every dead mother that she can trace whether the report came from a friend or family member or through the media. She makes contact with the family when possible and analyzes the cases. What was the cause of death? Was the death avoidable? So far, she has counted almost 300, and a lack of appropriate care is one cause of the excess maternal mortality. Obesity, a rising percentage of cesarean sections, and induction of labor account for the rest. Her scientific contribution to midwifery earned Gaskin an honorary doctorate from Thames Valley University in London last year. This is remarkable for a lay midwife, who in 1970 without any medical training began attending home births while traveling around in an old schoolbus in a hippy caravan in the U. S. A pair of boiled shoelaces, a clamp, and a pair of scissors were her only equipment in the beginning.

It is a leading theme in her life to make the profession of midwifery and descriptions of individual cases accepted science. This is how she learned the maneuver from illiterate Guatemalan midwives, that made her famous for its facility in solving the complication of shoulder dystocia (when the baby's little head is born and the shoulders remain stuck). She learned that it’s best to turn a woman onto hands and knees so that the baby can be born. The Gaskin maneuver is now mentioned in every midwifery textbook.

I can't ignore this kind of practical experience, says Gaskin.

The randomized controlled trial, research whereby the participants in the research group are chosen randomly and blindly has been put forward as the golden standard in science, but it has no value in the consideration of maternal death rates, because such groups are far too small to be helpful. For that reason, case reports remain important. However, private hospitals don't publish these. Since Reagan, almost all hospitals have been bought up by multinationals or supermarket chains. None of these has any incentive to publish their mortality rates.

Gaskin herself keeps meticulous track of all of her results. "I have always felt responsible in this way and wanted to know if our practice was up to standard, she remarked. The tally comes to about 2286 births with her and her colleagues' combined births. Of them, only 1.5% were cesareans; 1.5% instrumental births, and 1.3% requiring emergency transport to hospital. Unusually low percentages. Their population was not entirely low-risk, healthy women. For instance, hundreds of the women in the local Amish group, a very strong protestant religious community (that uses no birth control) are included in the statistic.

A little knowledge is nice, but has that cost any lives?

No, there was a local family doctor in the area near us, who taught us how to be ready for emergency situations: how to take blood pressures, stop a hemorrhage or resuscitate a baby. That was just right because I had to deal with these complications at the next birth after our seminar. The hospital we transferred people to is half an hour away. Still, no lives were lost because of my initial inexperience. Our perinatal death rate was low—0.36%, counting from pregnancies of 20 weeks gestation or more.

Without medical backup/ education, home birth is considered rather risky. What made you go in that direction?

During my first pregnancy in 1966, my doctor put me on a starvation diet and gave me diuretics—dangerous! When I was in labor and pushing, my hands and feet were tied to the bed. I was hungry and thirsty and found it a terrible experience, with a rather sadistic nurse and a doctor who did a forceps birth and gave me an caudal (a type of spinal anesthesia no longer given) against my will, even though I hadn't made a sound. Even worse, I still had to pay for it. I decided that wouldn't happen to me again.

Later I heard some stories of pleasant home births, with empowered mothers and midwives who stayed with the mothers. That made me want to have a home birth myself. Besides that, I knew that I wanted to become a midwife myself. I had studied literature at the university (had a master’s degree) and knew how to study, but there wasn't any midwifery training available. I later found that there was one track where you first had to become a nurse, then do midwifery training and after that you were not allowed or certified to attend births at home.

That is what made me ready to school myself in midwifery, if that could be possible.

Even in the Netherlands, where birth is less medicalized than in the U. S., the rate of transfers to obstetricians here is not so low as in your practice. What is your secret?

We did not have the usual fear of birth in our community. Fear is contagious. Fear is now defining everything for many women.

In our community, we realized that we were primates. Apes don't look at the clock and complain about how long it's taking. And we didn't have to worry about the clock; we could take all the time we needed.

The longest pushing phase we ever had lasted six hours; the baby was born in perfect condition, after we threatened to take the mother to the hospital. That gave her a better motivation to push that last little bit. We let the women push at their own pace and strength. Sometimes it can be good to let them go to sleep for a while.

This is better for mother and child than to make her push in a forced way, which can be exhausting.

Moreover, everyone was strongly motivated to stay at home; saving money was important. We didn't want to pay for a temporary stay in a hospital. Many Americans don’t have health insurance, so going to hospital can be bad for the purse.

Besides that, we believe in having the mother move throughout labor, instead of lying on the bed. It's important to keep up this movement as it helps to achieve the best presentation; moving helps the baby find the best way out.

When pushing isn't effective, two midwives can push on the upper edges of the hips so that the front-to-back diameter is increased. I learned that maneuver from illiterate Mexican midwives. Since we've been using it, we haven't needed any instruments for delivery.

Somewhat shyly, Ina May adds:

"And we used cannabis some of the time. Cannabis is a relaxant and helps women laugh. That helps enormously."

Is cannabis safe for use in a laboring woman?

Cannabis has been used for thousands of years to soften labor pain; we know this from archeological findings. We considered it safe, and when we were hippies, we were accustomed to using it. I haven't seen any negative effects from its use during labor and birth. It works in all kinds of forms, by the way. You can even put some tincture on your skin.

Is there scientific evidence that cannabis works against labor pain?

Not much research has been done on cannabis as an anesthetic, but the Netherlands is the country where such research could be done. I should perhaps say that there's a kind of cannabis that has more of a physical effect and another with a psychotropic effect. But that does not keep me from applying it. I don’t have much trust in the scientific validity of much of the research that underlies obstetrics. I had experience with an obstetrician who did a forceps delivery for every first child, as well as an episiotomy at every birth. That fashion was not exactly built upon scientific experiences. And just a few years ago the whole world has abolished the breech birth because of a worldwide research that purported to show that that breech birth was more risky than a caesarean. In the name of science. Later, it became known that the research wasn't well-designed. The outcome was a great forgetting. Still, returning to attending vaginal breech delivery isn't happening. The gynecologists have become afraid, not having seen the routine and learned how to do it. And now mothers are dying for c-sections.

Science must be approached with an open mind. There is an obvious connection between mind and body. Men know this; if you hold a pistol to their head and order them to, they can't get an erection. But when the conditions are right, they can't help but get an erection. In women, that phenomenon is less evident, but in them too, the body is much influenced through relaxation or by fear. The cervix is a shy organ that only opens when it is at ease, just like the anus and sometimes even like the urethra. Fear inhibits birth.

In the Netherlands, women are also more anxious. How do you respond to that?

The cultural fear of birth is something that is constantly manipulated here. It comes from outside. Women have to lose their fear of normal birth. In today's fear-based culture, a thorough preparation for birth is necessary.

The crazy thing is that women should be a little afraid of having a cesarean. As the cesarean rate continues to rise in the U. S., women think of it as a way to avoid being damaged. That is completely irrational. It's major abdominal surgery, just as much as an appendectomy is.

They think that with such a medical surgery that they are in control, but that is an illusory form of "control." Women much get that into perspective.

Besides, normal birth can give a chance to learn patience. I don't know how midwives can do their best work when they have to attend 105 births per year, as they do in the Netherlands. We do perhaps half of that. If we had so little time to be with the women in labor, our results wouldn't be so good.

An uncomplicated birth is the domain of the midwife. Is midwifery a known profession in the U. S.?

No, the U. S. was the first country to marginalize midwifery, which it did in the 20s. The doctors took over. Obstetrics was then the lowest ranked among the specialties. They were heads of the obstetrics departments but had only seen an average of 5 births each, according to the world-famous obstetrician, Williams, in 1905. That was why he wanted to destroy midwifery—so that obstetricians could have women as teaching material. The anti-midwife campaign was waged against immigrant midwives, many of them from Eastern Europe, who didn’t speak English. Another obstetrician, Dr. DeLee, wrote that Europeans were getting rid of midwifery as a “barbaric relic of the past.” Some of the immigrant midwives were imprisoned, even though their results were good.

Now that I have this honorary degree, it gives me some recognition from the scientific community. But it doesn't come from the U. S.; it comes from Great Britain.