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Midwifery: the Revival an Old Profession

On April 22, 2005 at 12:02am House Bill 36 managed to pass with just enough votes. Now it goes on to the Senate. House Bill 36 seeks to legalize direct-entry midwives (non–state licensed) in the state of Missouri. Missouri is one of eight states where the practice of midwifery without a state license is illegal. The language of the law makes the practice of medicine without a license illegal, and midwifery it is argued falls under the practice of medicine. But is assisting a woman in the completion of a natural physiological process really the practice of medicine? For thousands of years, the birth of a child was considered to be a natural, normal physiological function of the woman's body. What has changed? Attitudes concerning birth and not much else. These days giving birth is almost considered to be hazardous to a woman's health. The idea of giving birth without some kind of medical intervention such as narcotics or an epidural is met with skepticism. The thought of giving birth naturally outside of the hospital, in one's home, is met with disapproval and fear. Truly ignorance is the mode of the day. Ignorance of how a woman's body works, the birth process, how to cope with labor naturally, and the reality of the safety of giving birth when it's done with a true understanding of all of the above. With overall U.S. c-section rates as high as one fourth of all births (Gaskin pg.207) it's not difficult to see why so many of us have been scared into choosing hospital births. The possibility of something going wrong, of losing the baby or the mother, and of being overwhelmed by pain are in the front of our minds. How is the use of a midwife going to make a difference if this is the reality of giving birth? Ina May Gaskin, whose recent book The Guide to Childbirth documents more than 30 years experience as a midwife, addresses all of these concerns and much more.

The Woman's Body and the Birth Process

It seems silly to have to state the obvious – that women were made to give birth to babies – but this is precisely the mantra we need to keep repeating to each other and ourselves. One of the big difficulties in accepting this truth is the cultural mythology in the United States surrounding the birth experience. Birth is one of the necessary hardships women must go through to have children, the discomfort of which should be avoided if at all possible. Gaskin points out that this negative attitude concerning labor and birth has much to do with the influence of the Techno-Medical Model on our thinking. The Techno-Medical Model looks at the woman from the perspective of the three P's says Gaskin: The Passenger (the baby), The Passage (the pelvis and vagina), The Powers (the strength of uterine contractions). According to the three P's, if a woman's body doesn't deliver the baby in the time prescribed then either her body grew too big a baby, her vagina is too small, or her uterus is too weak, thus interventions are needed. The main problem with this way of thinking is it doesn't allow for individual differences in the way each woman's body progresses through labor. While we each have the same basic design, our body's ways of working within that design differ from woman to woman. The Midwifery Model of care respects and honors these differences. One way it does this is with something Gaskin refers to as the Sphincter Law. The Sphincter Law recognizes the cervix as a sphincter along with the other excretory sphincters. These sphincters function best, Gaskin points out, in an atmosphere of privacy and familiarity. Obtaining privacy in the hospital is nearly impossible. If you are having a normal, healthy pregnancy and yet chose to birth your baby in a hospital you will be surrounded by at least a half a dozen people during and after the birth – most of whom you have never before met. In addition, these sphincters do not respond to commands such as "relax!" or "push!", and can close up at any time if the person becomes frightened, or humiliated. Perhaps the best example of this from Gaskin's book is of a woman who while attempting to give birth was frightened by the expression of the young resident delivering the baby when he saw what he thought was a horrible birth defect as the child was emerging. What he in fact saw was a baby who was presenting face first, an unusual occurrence that he had not yet experienced. When the woman saw his expression she became so frightened that her cervix tightened sucking the child back up into her uterus at such a force that one of her ribs cracked!

The Midwifery Model of care arms us with an understanding of what is needed for optimum functioning of the woman's reproductive processes; therefore, labor and birth need not be such a huge mystery, and certainly not something we should fear.

"The Pain/Pleasure Riddle"

When I was pregnant with our first child, women who had been through a pregnancy and delivery felt it their duty to warn me of the horrendous pain I would be going through. Everyone from relatives to complete strangers would share how terrible the experience was for them. "Thank God for drugs!", some would exclaim. It was all very discouraging and made it difficult to approach the impending conclusion of the pregnancy with excitement and joy. Gaskin's insights concerning what she refers to as the "Pain/Pleasure Riddle" are truly a revelation for those of us in this predicament. The tendency here in the United States is to focus solely on how painful childbirth will be, and subsequently is. For many women, childbirth is indeed painful; however, what may surprise you is that some women have virtually painless births. Still others experience what can only be described as an orgasmic birth. To try and understand these differences Gaskin compares birth to another act that involves the exact same reproductive organs: sex. Sex as experienced by a woman can be either painful or pleasurable mostly depending on her level of comfort with her partner, and her level of willingness. "A lot depends on how ready she is for the experience," Gaskin states. "Looked at from this perspective, it should be less surprising that there is such a wide variation in the way different women describe the sensations of labor and birth…. Labor pain is a far more subtle, changeable set of sensations than our cultural mythology admits. When I say u2018subtle' I am not talking about the feeling of labor pain so much as the change in attitude that can alter our perception of it."

For those women fortunate enough to be the "painless birth" category, contractions seem like something of an afterthought. One woman I spoke to when I was pregnant with my daughter fit into this category. She confided that all of her labors were very short, and she only felt a sensation similar to having to go the bathroom before her baby's head was crowning! Yet another woman friend of mine had a similar experience in that labor lasted a mere twenty minutes from the first contraction to the delivery of the baby – and this was her first baby! (First labors tend to be longer overall for most mothers.)

But what about "orgasmic birth"? Gaskin conducted a small survey of 151 women out of which she found 32 who had experienced at least one orgasmic birth. Here are two such accounts from the book:

First account: "I had an orgasm when I had my fourth child. It happened while I was pushing… I orgasmed as she was being born. "

Second account: "I have always felt that labor and birth were like one big orgasm… I only found the last few centimeters of dilation as extremely strong and slightly less pleasurable. But I felt like labor and birth were and are a continuous orgasm."

Granted, the majority of women will not fall into either of these two categories, and will experience pain and discomfort during labor and birth. If you choose a hospital birth you will be under the thumb of the Techno-Medical approach, which does not cater to the woman in labor. Hospital policies like not being allowed to eat during labor, not being able to be submerged in water to cope with contractions, putting a time limit on labor, being made to lie on your back during pushing, and being surrounded by strangers, will all greatly add to the discomfort and pain.

If you choose a homebirth with a midwife, you will be in familiar surroundings with privacy. You will be allowed to move around and get in the bath if that helps you. You can eat, sleep, and go to the bathroom without having to roll around an IV hookup. You can let gravity work for you and give birth the way women have for centuries: squatting or on your hands and knees. All of these things add up, alleviating labor pain and speeding up the process since it is easier to stay relaxed when you are not on the doctor's clock or hindered from letting your body be your guide.

The Safety of Birth with a Midwife

Is birth safe outside of a hospital with a midwife? Perhaps the best argument for the overall safety of giving birth with a midwife is to simply site a few of Gaskin's and her associate's statistics. Gaskin and her husband are the co-founders of The Farm Midwifery Center started in 1971. Here Gaskin has attended, with her associates, more than 2,000 births in a home-like setting.

The Farm Outcomes of 2,028 Pregnancies: 1970–2000

  • Births completed at home (not in the hospital) – 95.1%
  • Emergency transports (to the hospital) – 1.3%
  • C-sections – 1.4% (61% were first-time mothers)
  • Forceps deliveries – .05%
  • Inductions – 5.4% (No synthetic drugs used for these)
  • Twins – 15 sets; all vaginally born
  • Maternal mortality – 0%
  • Neonatal mortalities – 8 out of 2028 (4 occurred during the first week of life)

These statistics for The Farm are not an anomaly. Midwives in general have better overall statistics and less medical interventions. Gaskin sights a few: Mrs. Margaret Charles Smith, author of Listen To Me Good, attended over 3,000 births from 1943 to 1981 and boasts a zero maternal death rate. Another example is a home-birth midwifery practice in Australia whose c-section rate was only 1.6% for 1,190 births recorded from 1976–1983. Yet another example is a midwifery service in Vienna where more than 44,500 births took place between 1965 and 1985 and the c-section rate was only a little more than 1%. These are just a few examples from Gaskin's book.

By comparison the U.S overall c-section rate for 1998 alone was 26.3%, and the labor induction rate doubled from 1989 to 1998 from 9% to 19.2% (Gaskin pg 207). Also noteworthy with regard to induction – women who tend to receive prenatal care earlier on in their pregnancies were more likely to be induced (Journal of Reproductive Medicine 2002 Feb;47(2):120–4). Gaskin questions why this phenomenon exists since there has been no change in the sizes of babies, or any increase in maternal illnesses requiring induction. Is it that doctors just like to have the control of how and when women give birth? Gaskin has a theory: Obstetricians are trained primarily in pathology – in how to recognize when something is going wrong. While in med-school they are exposed to the worst of what can happen during pregnancy and delivery. After such exposure it's hard to trust in the body's natural abilities – even though these horrors occur in only a very small percentage of births. I know of one family doctor, who upon attending med-school changed her pro-home birth attitude to a pro-hospital birth attitude. Another obstetrician, whose home birth testimony is included in Gaskin's book, tells a story of similar fears even though she went ahead courageously, and safely gave birth at The Farm Midwifery Center.

If midwifery is so safe and so woman-centered then why aren't more people using this valuable resource? Obstetricians have their place certainly when necessary, but why not use a midwife for a normal pregnancy? Midwives are trained to recognize when to refer to an obstetrician if something does go wrong anyway so in this day and age we truly can have the best of both!

There are only eight states where midwifery is illegal, and yet it is still not the most common choice mothers make for themselves and their babies. I think the only explanation is just plain ignorance. If women really knew the risk at which they put themselves and their babies by allowing themselves to be subjected to the Medical Model of care where unnecessary interventions are the norm, often with terrible side effects for the mother and baby, they certainly wouldn't do it. Gaskin's book is a valuable resource for educating oneself about one of the most wonderfully satisfying experiences those of us with children can claim to have had.

May 31, 2005

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