**I wrote this back when I was a student midwife. Someone mentioned the book again recently and I recalled that I had wrote this, and decided I should share it publicly so next time someone bring it up I can point them here! I am guessing Ina May has since revised her position on many of the things I bring up, but this is about the book, since it is still circulating and largely goes unquestioned.

Ina May Gaskin’s Spiritual Midwifery was first published in 1977 and is now in its fourth edition. Spiritual Midwifery reintroduced the US to midwifery care just as the culture shifts of the 1970’s were at their peak. It is one of the most widely known books on homebirth, and has become part of both the midwifery and home birthing lexicon. Ina May Gaskin has gone on to become one of the world’s most famous midwives, writing several more books, establishing the Farm as a internationally renowned birth center, having a new documentary released about her work, and influencing public health policy here and abroad (for better or worse).

The first half of Spiritual Midwifery chronicles how the Farm midwives came to be and the tales of a variety of the many Farm births. Included are stories about premature babies, breech babies, twins, stillbirth, c-sections, and of course plenty of the run of the mill Farm style homebirths with lots of hippies feeling “high” and “telepathic” with each other. She also has sections dedicated to nourishing a healthy pregnancy, and basic midwifery information. For the purposes of this critique I will be examining both the informational sections as well as the birth stories. I have used the third edition, which was released in 1990.

I first read through Spiritual Midwifery in the fall of 2010 before starting my homebirth apprenticeship. When it struck me that I wanted to be a midwife, I went to my university library and found the (very small) section on midwifery and natural birth. I had heard about Ina May Gaskin from the initial web searching I had done, and the cover stood out to me when looking through the book stacks. I read the book cover to cover within days despite having multiple books assigned that week for the graduate program I was in. I already had strong ideas about alternative medicine and health, so the book, rather than being a shock, felt more like a missing piece of the puzzle. I knew birth could be different than what I had learned about, but this book gave me more of the details. I liked that I got a sense of what homebirths can be like – the ambiance, the travails, the timing, the unpredictability. This was useful since I had never attended a birth and have no birth experiences of my own.

Upon rereading the book I can now see how far I’ve come in my own understanding of the art and science of midwifery. Rather than enjoying the book this time through, I was primarily disturbed by the lack of evidence based practice and the high rate of interventions found in the birth stories. Rather than being a hands off, spiritually oriented midwife as the title suggests, the stories highlight midwives poking, prodding, measuring, pulling, suctioning, rubbing and all other manner of physical interference.

Approach to Labor

While the Farm’s birth statistics are impressive for mother and baby health, I am amazing how good they are considering the way they approach the observation and “management” of labor. For example, in the story of Marilyn’s second birth, Ina May casually notes that she used a sterile glove to manually dilate Marilyn’s cervix during contractions because she noticed that it worked (Gaskin, 57). In order to notice that this worked, Ina May would first need to do a vaginal exam, and then think to try and manually dilate the cervix, which for a second time mom, progressing normally and with no reason for concern, is completely unreasonable. Manual dilation of the cervix is very clearly an intervention that even most hospital births do not include, and carries the risk of cervical trauma, introduction of infection, and emotional/sexual trauma for the mother. Less obvious to some, vaginal exam themselves are an intervention in the physiological labor process, and are not warranted unless the information gleaned will directly influence concrete decision making about the birth (which is really almost never) (Krista, 2012; Levine, 2012). Vaginal exams can be inaccurate, risk an accidental AROM, and obviously increase the risk of infection. Despite this, Ina May instructs midwives to perform routine pelvic exams to establish pelvimetry measurements at the beginning of pregnancy, to do routine vaginal exams in the last weeks of pregnancy to check when the baby is and and to assess cervical ripeness, and check periodically and do “more or less” vaginal exams in labor depending on the situation. Vaginal exams or “checks” are mentioned at least 40 times in the text, and are part of most of the Farm’s birth stories (Gaskin).

Beyond this amount of vaginal examination, there are also bizarre behaviors exhibited by both Ina May and Stephen Gaskin. If Ina May notices that the father doesn’t want to caress his wife’s breasts, she self reportedly and according to some of the mothers touches their breasts, squeezes them and “talks about how nice they are” (Gaskin, 441) to stimulate labor and get the energy flowing. While I am all for the mom or husband doing this if it feels right, I don’t feel this is an appropriate behavior for a midwife, particularly without explicit consent. That said, nipple and breast stimulation is also an intervention in the birth process since it is intended to “do something”. Farther down on the list of bizarre behaviors, in Cornelia’s birth story, Stephen Gaskin came to the birth with Ina May right before she started pushing. He grabbed her belly, squeezed and pushed down on it (176). Granted, the woman seemed to approve of this though, saying “I couldn’t let anyone else but him do that to me”. Ina May and Stephen seemed to be regarded as gurus who could do whatever they felt like as long as they were guided by their intuition, even when this meant exhibiting strange and non-evidence based care that in other contexts would be regarded as obvious examples of dangerous or inappropriate care.

That said, I did appreciate the general energetic and emotional information, specifically the parts about managing the energy at a birth, reducing the number of spectators, the midwife acting as an emotional anchor for the mother, and following the mother’s desire if she wants to transport to the hospital (286; 346; 349).

Management of the Second Stage

On the one hand, Gaskin recognizes that the urge to push will come at some point, and at that point and not before, the mother should listen to that urge (352); on the other hand, the book includes stories of the Farm midwives coaching pushing efforts including purple pushing (109; 110; 124). In the “management of the second stage” section, Gaskin writes, “[The midwife] should have the mother’s total confidence so that she can instruct hew how and when to push” (350). She also warns against early urges to push, the need to check for anterior lips before allowing pushing, and says mothers should “pant like a dog” to refrain from pushing before “full dilation” (352). Gaskin makes it all about the midwife, saying that the woman needs to wait to push until the midwife is ready which is a ludicrous holdover from obstetric care and insinuates that the midwife’s skills are necessary for the expulsion of the baby (353). Further, she suggests that standing or upright pushing is acceptable until crowning, at which point the woman needs to sit down so the midwife can facilitate the delivery of the baby (353). This is the opposite of woman led childbirth, and I continue to find it astounding that this text is touted as a revolutionary feminist text when it is all about the powers and abilities of the midwife, and almost never about the power and beauty of the woman and the elements of childbirth.

Additionally, Gaskin details the instructions for the delivery of the head, arguing that slow delivery, assisted by counter pressure from the midwife, is essential for minimizing trauma to the perineum and surrounding tissues (354). Again, this assumes that the midwife is an essential part of the process, and that the mother is not capable of doing this job instinctually and easily by herself. Midwife Rachel Reed instead argues based on anecdotal evidence (since there are no studies on undisturbed crowning):

“The intense sensations experienced during crowning usually result in the woman ‘holding
back’ while the uterus continues to push the baby out slowly and gently. Often women will
hold their baby’s head and/or their vulva. I have witnessed one mother attempt to push her
baby back in (you know who you are) – it was unsuccessful but gave us a giggle afterwards.
Telling a woman to stop pushing, pant or ‘give little pushes’ distracts her at a crucial moment
and suggests that you are the expert in her birth, which you are not. She is the one with a
baby’s head in her vagina – leave it to her (Reed 2010).

Since there is no data regarding the benefit of the intervention of coached crowning, the physiological approach (no instructions, no manipulation) seems to be the most conservative and efficacious approach. Reed goes on to say that research has found that “‘hands on’ approaches may or may not reduce the chance of minor tearing but increase the chance of episiotomy and major tearing  (Mayerhofer et al. 2002 McCandlish et al. 1998)” (Reed 2010).
Many of the birth stories also include the midwife suctioning the baby on the perineum, and she gives explicit instructions to do so in the section for midwives. She says to “[m]ake sure that you have removed all fluids from the baby’s mouth and nose before delivery of the body… [r]outine suctioning of the baby at his point greatly reduces the chance that the baby will inhale fluid into his lungs with his first breath” (Gaskin, 357). Again, this is simply a non-issue, is not based on evidence, and is a remnant of the technocratic culture of birth that they learned from.

While the baby is on the perineum, the midwife is also instructed to check for a nuchal cord, and to cut and clamp it if it is too tight, and this practice is also a feature of many of the birth stories in the text (Gaskin 356). There are multiple stories throughout the text where the cord is cut on the perineum (128; 135), which should really happen quite rarely if ever since even the baby with a tight nuchal cord is usually able to be somersaulted out or born without issue. Gaskin also says that 2% of babies have a nuchal cord, when the true statistic is really more like 33% (Reed 2010).

Immediate Newborn Care

After suctioning the baby on the perineum as well after birth, the baby is then typically taken away to be “cleaned up” before being given to the mother (80; 109; 168; 176). Sara Buckley best describes the potential damage that this sort of practice causes in her book Gentle Birth, Gentle Mothering. The mother needs the baby, and the baby needs the mother from the moment of birth on, and it is never physiologically acceptable for the baby to be taken away for any amount of time. The baby protects the mother from hemorrhage by massaging her breasts and eventually nursing at the breast. The mother keeps the baby perfectly warm through the delicate skin to skin contact and communication between the two beings. These first minutes should remain as undisturbed as possible while mother and baby are getting to know each other, smell each other, and develop the bond that mother nature provides so that they continue in their mutually beneficial relationship (Buckley, 2009).

Neonatal Resuscitation

The story of Roberta’s birth details one of the Farm’s neonatal resuscitation experiences (Gaskin 128-129). Willa May’s head was born with a nuchal cord, and Carol clamped and cut it on the perineum and then “heartily” pulled the baby out. The baby was cyanotic around the face and extremities, but pink at her core. She suctioned the baby’s mouth until she was breathing and then gave her oxygen to pink her up. It would appear that they never even gave the baby a chance to transition herself, and instead suctioned her and “made her pink” with oxygen to make themselves feel better about the situation. There is no mention of the babies heart rate, only that there was meconium (Gaskin 128-129). Later, in the section for midwives, Gaskin describes the process for dealing with a mildly asphyxiated baby, or a baby that doesn’t cry or breathe immediately, saying “He needs repeated suctioning with an ear syringe” (Gaskin 381). This is incorrect, as studies have shown than suctioning is not scientifically indicated in any circumstance (including with meconium), although suctioning a non-vigorous baby is still part of common practice (AHA, 4). It might make sense to suction a baby when they cannot establish breathing due to a large amount of matter that they have not already been able to clear on their own, although this should still be done by a parent rather than the midwife, and can easily be replaced with the mom sucking it out with her mouth, or swabbing it out with her finger. In fact, the mother or father can also provide mouth to mouth resuscitation if it is called for (Freeze, 2011).

Management of the Third Stage

Gaskin states that the third stage, defined as the time of the birth of the baby to the time the placenta is delivered, typically takes 10-20 minutes (234). That said, she does not advocate cord traction, and warns against being “impatient or uptight” during this phase of the birth which is wise. In slight contrast, Gloria Lemay suggests a “30 minutes third stage” in which the placenta is not even expected until 30 minutes, barring any dangerous bleeding (Lemay, 2009). Lemay suggests this to keep the mood in the room mellow, and to encourage undisturbed bonding between mama and baby, which is (as mentioned previously) a protective feature against postpartum hemorrhage. On page 363, Gaskin instructs midwives to check the fundus for tone after the birth of the baby and to have the partner or an assistant provide nipple stimulation (again, where is the baby in this scenario?!). Her preferred method of assessing placental separation is to push the uterus up towards the mother’s head and see if the cord follows up into the birth canal. All of these interventions and interferences have the potential to disturb the process of mother baby bonding and placental separation and expulsion. Lemay argue that the only observation that is important during the third stage is whether or not the mother looks healthy, bright eyed and beautiful, and if she present in her body and enjoying her baby (Lemay 2009). If she looks worried, pale, or nervous, it is a signal to investigate further. Obviously, subtly watching blood loss can be a part of the undisturbed birth picture as well.

In the case of postpartum hemorrhage, or “if there is a sudden gush of blood from the mother’s puss”, Gaskin says to get the mother lying down, massage the uterus into a contracted state, and adminster IM pitocin or methergine (433). I find it strange that she does not provide for the option of lying the mother down, doing fundal massage and choosing a wait and see approach (especially in the case of a single gush of blood, rather than a classically defined hemorhhage of 500 ccs!). She also does not mention trying other more traditional responses to portpartum hemorrhage such as herbs, a piece of placenta, acupuncture, relieving bladder fullness, etc. This is another example of the primarily medicalized nature of Spiritual Midwifery and Ina May’s approach to birth.

Conclusion

Ina May Gaskin should probably stick with what she is best at – telling stories, providing advice about the emotional and spiritual aspects of pregnancy, labor and birth, and giving basic advice on nourishing a healthy pregnancy. For the most part, this aspect of the text is well thought out and unique (particularly at the time of publishing). Spiritual Midwifery would be a stronger, more cohesive text if eliminated the technical elements. Of course, the spiritual and emotional information is not evidence based, but is simply an alternative perspective and approach that can be appreciated. I do respect Ina May’s contribution to the resurgence of homebirth midwifery in the US, and I am glad that she contributed this work in attempts to shift the culture of birth in the US.
The most difficult issue for me to reconcile is that this book is part 1970’s, counter culture hippy manifesto, and part medical and obstetrical garbage. Gaskin obviously bought into much of the technocratic model that she was taught by others and through her own self study, and for some reason she was not able to filter it out despite her alternative approaches to much of the rest of her life. Perhaps it is a context issue, and this is the best she could do with what she had at the time, but it is perplexing how these seemingly contradictory approaches can be held by the same person and be espoused in the same text.

The technical information provided by Spiritual Midwifery is outdated, basic, jumps quickly to medical intervention, and would be inadequate (and possibly misleading or dangerous) for the purposes of giving aspiring midwives any real foundation in the concepts of midwifery. I would not recommend this text as a starting place for new students, and would not recommend it to pregnant clients either. I hope that those who are introduced to natural birth and midwifery care because of Ina May Gaskin and Spiritual Midwifery will look beyond her and her work. I hope that they will seek out the many other incredible midwives and researchers that are truly revolutionizing the way we understand pregnancy and birth – a way that honors the body’s wisdom, and respects the needs for undisturbed, unhindered birth, especially when a midwife or doctor is present (no matter how “spiritual” they may be).

References

Buckley, Sarah J. Gentle birth, gentle mothering: A doctor’s guide to natural childbirth and
gentle early parenting choices. Berkeley [Calif.: Celestial Arts, 2009].

Freeze, Rixa. “Stand and Deliver: Final reflections.” Stand and Deliver: Final reflections. 10
Mar. 2011. 14 Jan. 2013 .

Gaskin, Ina May. Spiritual Midwifery. 3rd ed. Summertown, TN: Book Pub., 1990. Print.

Krista. “How Cervical Dilation Checks Undermine the Imaginal Power of Birthing Women.”
MamaMuse RSS. 28 May 2012. 14 Jan. 2013 .

Lemay, Gloria. “30 Minute Third Stage.” Gloria Lemay. 6 Aug. 2009. 14 Jan. 2013
.

Levine, Jackie. “Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed
Consent and Refusal.” Science and Sensibility. 2 Nov. 2012. 14 Jan. 2013
.

“Not All Infants Born to Women with Preeclampsia Are Low-Birth-Weight; Gestational Age Is a
Key Factor.” Perspectives on Reproductive and Sexual Health July/August 34 (2002). 13 Jan.
2013.

“Part 15: Neonatal Resuscitation.” Part 15: Neonatal Resuscitation. American Heart
Associations. 10 Jan. 2013 .

Reed, Rachel. “Nuchal Cords: The perfect scapegoat | Midwife Thinking.” Midwife Thinking. 29
July 2010. 10 Jan. 2013 .

Reed, Rachel. “Perineal Protectors?” Midwife Thinking. 7 Aug. 2010. 14 Jan. 2013
.

“When Latching.” Dr Jack Newman – nbci – Newman Breastfeeding Clinic & Institute. 13 Jan.
2013 .

Appendix A:

More Undocumented or Disputed Points
pg 240-241 recommended postpartum exercises
pg 247 cord care with honey or alcohol; signs of infection include 1) redness around the navel, oozing from the navel, a bad smell coming from the navel
pg 309 the EDD is 9 months and 7 days from the LNMP
pg 341 there is no harm in AROM if dilation is almost complete and the head is “down far enough”
pg 416 toxemia can lead to SGA babies. Disputed by article “Not all infants born….”
pg 354-355 a slow delivery of the head is better, and it is best to have the control the speed and massage the mother’s tissues
pg 376 recommends Kegel exercises. Disputed by Katy Bowman’s work
pg 248 recommends giving breastfeeding babies sterile water on hot days to prevent dehydration. Disputed by Jack Newman and other breastfeeding experts
pg 254-255 recommends positioning baby so that the nipple is centered in their mouth, equally above and below the nipple. Disputed by Jack Newman – he recommends more of the bottom than the top, and more of the areola towards the center of the body than the outside of the body.