Ina May Gaskin

(2011, USA)

for her whole-life's work teaching and advocating safe, woman-centred childbirth methods that best promote the physical and mental health of mother and child.

About

Ina May Gaskin has been called "the most famous midwife in the world". A pioneer in a millennium-old profession on the brink of extinction in her country, she combines scientific evidence and analysis with her own broad experience in exercising natural medicine. Ina May Gaskin is a role model for midwives who still dare to think in different paths, trying to implement more humane obstetrics in their countries, and providing women with the chance to choose the way of giving birth that seems right for them.

Contact Details

Ina May Gaskin
149 Apple Orchard Lane
Summertown
TN 38483
USA
Website

Biography

Ina May Gaskin was born on 8 March, 1940. She is the wife of the first Right Livelihood Award Laureate Stephen Gaskin, who received the Prize with his organisation PLENTY International in 1980. 

Ina May Gaskin's first midwifery experience was in 1970, when she assisted at a birth in a schoolbus on Stephen's speaking tour of universities and churches prior to the establishment of The Farm, an intentional community in Tennessee, and the subsequent development of Plenty International. This experience inspired her to study midwifery as a way of providing birth choices for women in her country, where the profession of midwifery had been eliminated early in the 20th century, because obstetrical leaders at the time saw no reason for its continued existence, and because of the benefits medicated birth and caesarean sections provide to for-profit hospitals, insurance companies and the drug industry, though often not to the women.

The Farm Midwifery Center

With a strong motivation to become a midwife in a country that lacked opportunities for such an educational path, Gaskin founded The Farm Midwifery Center in 1971. The Center became well known during the 1970s as a place where authentic midwifery was practiced and taught. 

Achievements in teaching & campaigning

Over all these years, Gaskin has assisted some 1200 unmedicated births and together with her partners, more than 3000. Her work and expertise have pioneered midwifery education for decades, preserving knowledge mostly forgotten in technically dominated births. Her 'Gaskin Maneuver', an obstetrical procedure she learned from traditional Guatemalan midwives, is now taught internationally. Birth videos have helped promote her techniques for the prevention of protracted labours, routine episiotomies, and for successful breech and twin births.

For more than a decade, Gaskin has led a campaign to promote awareness of the dangers of the use of Cytotec (generic name: misoprostol) to induce labour for reasons of convenience. Her 2000 article published by the online journal Salon.com has been credited with prompting the drug's manufacturer, G.D. Searle, to issue a letter to all U.S. maternity care providers warning against its use in pregnant women. 

Setting standards for midwifery and maternity care

In 1982, recognising the need for high standards for midwifery practice and education, Gaskin became one of the founding members of the Midwives Alliance of North America (MANA). She served on the MANA Board of Directors from 1982 to 2002, and as its President for six years.

MANA later gave rise to the Midwifery Education and Accreditation Council (MEAC), and to the North American Registry of Midwives (NARM), an organisation which created a national competency-based certification credential for U.S. midwives. These developments have led to the passage of laws recognising the NARM midwifery credential in more than half of the states so far. Gaskin and her colleagues have been deeply involved in this process for more than 25 years.

Analysing maternal death rates

In the late 90s, in order to build a valid case for policy recommendations, Gaskin began her study of maternal mortality rates. While anecdotal evidence suggests that rising death rates are at least partly - if not even to a significant degree - due to the rise in caesarean sections and the use of misoprostol to induce labour, autopsies after maternal deaths are rare even in the U.S. In addition, the lack of any mandatory federal standard death certificate makes collecting data difficult and incomplete. 

In April 2011, the Maternal Accountability Act got introduced into Congress, which would make mandatory the use of a standard Death Certificate allowing the extent of birth-related deaths to be recorded. Ina May Gaskin has been a fierce supporter of this Act. 

Current main fields of activity

In 2011, Ina May Gaskin's main mission was:

The Safe Motherhood Quilt Project, in which a quilt is made of patches, each with the name of a woman who died in childbirth in the US since 1982. The Project aims at summoning the national will to take the first step toward lowering the currently rising maternal death rate by creating a consistent, mandatory system for reporting, classifying, and counting the maternal deaths in the US and reviewing and analysing their causes.

An information campaign, aiming at women, midwives, nurses and physicians, about the potential 'side effects' (maternal and fetal death) of using misoprostol to induce labour.

Teaching. Gaskin has lectured to physicians and midwives throughout the U.S., in Argentina, Canada, Mexico, Brazil, Costa Rica, Sweden, Norway, Denmark, Iceland, Germany, Switzerland, Israel, Italy, Austria, France, the Netherlands, Slovenia, Russia, Hungary, the Czech Republic, Spain, Australia, New Zealand, and Japan.

She also promotes breastfeeding and fights against hospital routines which unnecessarily separate newborns from their mothers, as well as puritanical attitudes which discourage many women from breastfeeding. In some U.S. states it is still unusual for breastfeeding mothers to be seen in public, and some mothers have been threatened with arrest for doing so.

Books & Publications

In 1975, Gaskin's Spiritual Midwifery was an immediate bestseller and soon became regarded as the bible of home birth and woman-centred midwifery. Having been translated into Dutch, German, Danish, Russian, and Spanish, the book has convinced countless women that labour and birth can be approached without fear, and with confidence that most women's bodies are still perfectly capable of giving birth. Recent books include Ina May's Guide to Childbirth (2003), Ina May's Guide to Breastfeeding (2009), and Birth Matters: A Midwife's Manifesta (2011). Ina May Gaskin also contributed to an anthology of U.S. midwifes that pioneered the return of that profession in the USA called Into These Hands. Wisdom from Midwives (2011).

In 2009, Gaskin received an Honorary Doctorate from West London University, and in 2013 she received an Honorary Doctor of Science from Shenandoah University, Winchester, Virginia.

Speeches

Acceptance Speech by Ina May Gaskin

5 December 2011

It is a great honor to have been chosen as the first midwife to receive the Right Livelihood Award. In accepting this award, I feel a deep sense of responsibility to my fellow midwives throughout the world.  Most of us necessarily share an awareness of powerful forces that now threaten the continued existence of the profession of midwifery in many parts of the world. Rates of cesarean section are rising rapidly in most countries, far beyond the upper limits recommended by the World Health Organization. As cesarean rates increase, rates of maternal death and serious injury rise as well, and women's fears of birth increase. At the same time, time-honored knowledge and skills begin to vanish. I have visited private hospitals in Brazil where the cesarean rate was 95%, because women (and their doctors) had become so afraid of the normal process of birth that the cesarean became the default.

When surgical and technological interventions in birth become the norm rather than the exception, the profession of midwifery loses its basis for existence, and obstetrics itself no longer encompasses the skills and knowledge that were once considered essential competencies of the profession. I'm speaking of the skills and knowledge necessary for assisting vaginal breech birth, the birth of a second twin, the ability to manually assess fetal weight, to distinguish between normal labor pain and pain that warns of complication, to determine the position of the baby in the womb, to change it when it is unfavorable, and even to accurately diagnose pregnancy. To explain what I mean by this last-mentioned skill, we in the U.S. have already come to the point of discovering several cases of false pregnancies diagnosed only after a woman's abdomen was opened for a cesarean, an order of mistake that could hardly have been imagined two or three decades ago, when physicians' education in manual skills was still considered important. The shrugging off of traditional knowledge in the U.S. had progressed to the point that by the 1990s, the two major obstetrics textbooks no longer included any reference to the phenomenon of false pregnancy (pseudocyesis), even though it has always been known to exist in humans, as well as other mammals. Only a country which has become superstitious in its use of technology could imagine that the use of imaging technologies could eliminate the need for teaching traditional manual diagnostic skills and all of the phenomena that occur in women's reproductive lives.

The history of birth in the U.S. during the 20th century illustrates well how essential a strong midwifery profession is if women are not to be held within a web of fear concerning their bodies' supposed defects when it comes to giving birth. The elimination of the profession of midwifery in the U.S. in the early 20th century paved the way for a factory model of hospital-based maternity care that by the mid-century had two-thirds of all babies pulled from their mothers' bodies with forceps. Such a radical overuse of forceps did not happen in countries in which the value of a strong midwifery profession was recognized. With no midwives present in hospitals to instruct medical students in the wise ways of nature, men with the least understanding of the conditions necessary for women to give birth in a humane way soon came to believe that birth was necessarily a brutal and bloody affair and that human females actually represented a serious failure on the part of nature - one that could only be remedied by routine use of technology and medication. Now the profit motive really began to emerge vis-à-vis birth, and fear, greed, and ignorance have combined to make a nasty brew, as well as a witch-hunt against midwives who work according to the rhythms of nature.

The belief soon grew that babies would be most safely born when the mother's body was intentionally injured in order to free the baby, with the further rationale that such an injury would prevent worse injuries that would otherwise occur. Such myths, unfortunately, are perpetuated through Hollywood films, which usually focus on birth complications for dramatic value, while physiological birth is not depicted because of taboos against showing the relevant portions of the female body.

As one of the mothers who knew there was nothing wrong with my body and that the birth of my first child by forceps had been unnecessary - risky for me and my baby, with no discernible benefit, and psychologically harmful as well - I was left to find an escape route for myself for my next pregnancies. This dilemma prompted me to arrange for my own midwifery education (as I was unaware of that any other way was available), an arrangement that I was able to accomplish with the timely help of four physicians who also saw the need for midwives in our country. Free to learn from any sources I considered relevant, I learned from non-literate traditional midwives, from old books, and animals, as well as from kind physicians.

From the beginning of the Farm Midwifery Center, my colleagues and I placed women's needs at the center of our policy-making and found that this way of organizing care yielded huge benefits for our babies as well as their mothers. We learned how to prevent complications by providing good antenatal care and we developed practical methods for preventing unnecessary cesareans and inductions of labor.

Looking around, I found some other midwifery services backed by supportive physicians in other parts of the world with outcomes that were nearly identical to ours. The midwives who worked with the late Dr. John Stevenson in south Australia, those who worked with Dr. Alfred Rockenschaub in Vienna between the mid-60s and the mid-80s, and those still working with Dr. Tadashi Yoshimura in Okazaki City, Japan, all reported cesarean rates well under 5% with good newborn outcomes - just like ours. This was especially interesting, since we hadn't previously been aware of each other's existence. Unfortunately, in each case, these physicians - instead of being saluted by their peers - were treated as if they were hopelessly out of tune with the times and therefore irrelevant. We need to honor these men, who are still writing and teaching anyone willing to listen.

Now that many industrialized countries are reporting cesarean rates of 30% or more, despite the fact that midwives have always been accepted members of maternity care staff, it's important to recognize other factors that drive up rates of intervention in birth. Popular culture, the profit motive, fear, prudery, and ignorance all play a role and should be addressed. 

What is often missed is that excessive cesarean rates have other negative consequences than the loss of midwifery and obstetrical knowledge and skills. Simply put, as rates rise beyond 15-20%, more women die from complications such as pulmonary embolism, infection, hemorrhage, and a sharp increase in placental complications in subsequent pregnancies. None of the countries with the highest cesarean rates can report on low maternal death rates. This is especially true of the U.S., where women now face at least twice the chance of dying from pregnancy-related causes as their mothers did. In California, between 1996 and 2006, the maternal death rate tripled, with much of the increase being attributed to an excess of cesareans. Don't expect the U.S. to report these telling facts with any accuracy, though, because the current lack of an infrastructure that requires and produces accurate and consistent reporting, and analysis of maternal deaths, means that the official maternal mortality figures represent possibly only a third to a half of the actual numbers.

To avoid facing the problems that we are now experiencing in my country, I have some recommendations to propose:

Countries with increasing cesarean rates should consider taking positive steps to reverse this trend, including stepped up efforts if rates rise about established limits. Midwives should be placed at the gateway to maternity care, instead of being introduced to women late in pregnancy and grudgingly if at all. This model of care recognizes that a woman's confidence and ability to give birth, care for, and breastfeed her baby and the baby's ability to feed effectively can be enhanced or diminished by every person who gives them care and by the birth environment. Because of this, all care given during the time surrounding birth should give the needs of the mother-baby pair precedence over the needs of caregivers, institutions, and the medical and insurance industries. Individual hospitals should consider implementing the 10 Steps to Optimal MotherBaby* Maternity Services (www.imbci.org).

Midwives must have an important say in the formation of maternity care policy. Care should be individualized and founded upon consideration and respect for every woman. When not under threat of a dominant medical profession, which is itself dominated by a powerful insurance industry or a powerful hospital industry, midwives can provide care that is organized around the principle that women?s and children's rights are human rights and that access to humane and effective health care is a basic human right. Independent midwives must be able to make a living from their work, which means that insurance companies should not be permitted to charge such high premiums that it becomes impossible for them to make a living. 

We must wake up to the fact that it is easy to scare women about their bodies, especially in countries in which midwives have little or no power in policy-making, relative to physicians and the influence of large corporate entities. This takes no real talent. Given such imbalance, fear, ignorance, and greed begin to reinforce each other, and rates of unnecessary intervention soar, with women and the babies suffering the consequences. Birth care must not be profit-driven. This makes incentives to cause problems, not prevent them.

For this reason, there should be no more fee-for-service payment - for instance, financial reward for the unnecessary use of a vacuum extractor.

If all countries put the welfare of mothers and babies at the center of maternity care policy, midwifery would have to grow strong again. In some countries, such as my own, it will be necessary to greatly increase the number of midwives as just one of the ways to prevent complications and to reduce rates of medical intervention in birth. We'll need lots of doulas as we make this transition. Midwives need to have a say in the major issues surrounding birth. In countries where they currently work under the intense domination of obstetricians, the work will be to bring the relationship back to one of balance. Midwives cannot allow obstetricians to bully them, because doing so is almost certain to mean that laboring women will be the next ones to be bullied. 

Attempts to make home birth illegal in any country will only distract from the real problems and exacerbate them, since planned home birth for healthy women provides a necessary safety valve for women who want a wider range of choice than their hospital might offer and a learning opportunity for midwives to learn about women in their natural state. Home birth midwives must be able to make a living from their work, and insurance companies should not be permitted to keep home birth midwives from being compensated for their work. Home birth midwives are being persecuted in almost every country, even in The Netherlands, where home birth services have a long and honorable tradition. I believe the development of a country can be measured by the degree to which it respects the right of a birthing mother to receive a woman centered birthing experience, whether the birth occurs in a home or hospital setting. In this regard the current situation in Hungary greatly disturbs me. There, the failure to fully provide and protect this important right is highlighted by the prolonged discrimination and mistreatment of the independent midwife Dr. Agnes Gereb. Agnes has spent more than 20 years trying to defend the fundamental rights of mother and child and in doing this she has been imprisoned, recently received a further 2-year prison sentence and has been held under house arrest for the past year. I now ask the Hungarian government to intervene to stop the abuse and unjust treatment of this internationally respected homebirth expert.

Birth shouldn't be thought of as money-making commodity or condition in which large institutions or governments control and dictate how women will give birth, ignoring individual mother's wishes and needs. Inevitably, this too often puts bullies in charge of women's bodies, something no other mammalian species allows. Some countries have midwives who are totally subordinate to physicians. In these countries, it's typical for very harsh methods of birth care to be applied, and outcomes show this. It's time to stop this sort of behavior. Traditional peoples, indigenous people don't permit such behavior. We need to learn from them.

  Pictures
 Videos

Ina May at Democracy Now!

Ina May Gaskin on her book Birth Matters: A Midwife's Manifesto

Interviews

Three questions to Ina May Gaskin

Interview conducted by Lyndsey Unwin in September 2011

In your view, how dangerous is it for a woman to have a caesarian?

It's probably safe to say that a large proportion of women do not know that death from caesarean surgery is three times greater than for vaginal birth. In the case of emergency caesarean, this figure rises to four times greater. 

Most maternal deaths from pulmonary embolism follow caesareans. That's a well known fact. According to figures published by the UK's Confidential Enquiries into Maternal Deaths, it's possible to see how the number of pulmonary embolisms has risen with the increase in caesareans: 32 maternal deaths were recorded in the period of 1985-87, 48 were recorded in 1994-96, and 41 were recorded in 2003-05. 

Most women are probably unaware of problems in subsequent pregnancies, with complications such as placenta previa, placenta accreta, and abruption. 

Are natural births on the increase in the US or is it still seen as an alternative experience?

The US caesarean rate reached 34 percent in 2008 (the last year for which we have national data). I'm sure that natural births would be on the increase here if most women had choices in regard to how they will give birth, but we have such a small number of midwives, (10,000 at the most - consider that 4.3 million births take place every year) that choices for most women don't exist. Keep in mind that those midwives working in hospitals are usually responsible for caring for several women at a time - far from an ideal situation. As for home birth, even after a 20 percent increase in home birth between 2004 and 2008, still only 1 percent of women can have a planned home birth. This means that a larger number of women every year are having home births that are not assisted by a qualified midwife.

Are things getting worse for women in terms of information about the benefits of natural birth?

Actually, I think that US women are beginning to get a little more information of this kind from films such as Ricki Lake and Abby Epstein's The Business of Being Born and their new More Business of Being Born and Debra Pascali-Bonaro's Orgasmic Birth. More and more women are wanting to become doulas and more and more are hiring doulas. But if we look at the mainstream media and how it reports on birth, I see no improvement yet in that sphere.

Are you still delivering babies?

Yes. I'm waiting on a woman in early labor as I write. Although I still travel quite a bit, I schedule in blocks of time to be spent at home, and during these times, I continue to attend births (usually being a co-midwife with one of my partners). I get most of my writing done while I'm at home.

Your husband was the first recipient of the Right Livelihood Award in 1980. What does becoming a Laureate in 2011 mean to you and how will it help your work?

I can't express how grateful I am to become a Laureate. The previous recipients of the award are some of the bravest, most visionary, selfless, and most effective people in the world. To be in their company is quite an honor. 

(...)

This award will give me a chance to warn people in the UK and in many European countries that it is a great mistake for countries with lower maternal and newborn death rates to imitate maternity care practices that had their origin in the US. The US maternal death rate is underreported to a large but unknown degree, and it is currently rising rather sharply. At least 49 other countries reported lower maternal death rates than we do in the US (despite our underreporting). Our newborn death rates also do not compare favorably with innumerable countries, all of which spend less on maternity care than is spent here.

According to the Centers for Disease Control (CDC), US women today face more than twice the chance of dying from causes directly related to pregnancy and birth than their mothers did. The myth that we have the greatest maternity care system in the world pervades most media coverage of birth issues in the US. Yet, in some states the maternal death rate has more than doubled what it was years earlier. In 2010, California, for instance, reported a tripling of the death rate between 1996 and 2006, attributing a significant part of the sudden rise to an excess of caesareans. I have been writing about these issues for more than a decade, but the mainstream media has not yet seen fit to report anything on this shocking situation, despite my attempts to spoonfeed it. Perhaps the award will bring these important issues before the US public. I certainly hope so

Further interviews with Ina May available on the web

Interview in Time Magazine, 2011
Interview on babble.com, 2010
Article in The Guardian, 2009

Links

Contact

Right Livelihood Award Foundation

Head office:
Stockholmsvägen 23
122 62 Enskede
Sweden

Phone: +46 (0)8 70 20 340
Fax: +46 (0)8 70 20 338

Geneva office:
Maison de la Paix
Chemin Eugène-Rigot 2, Building 5
1202 Geneva
Switzerland

Phone: +41 (0)22 555 09 55

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