Ina Mae in Zambia

A Zambian Midwife and the baby bundle in Chipata.

In my last week here I have been reading Donna’s (my host) copy of Ina Mae Gaskins Spiritual Midwifery from 1977.  This book is groovy in the true Simon and Garfunkle late1960’s sort of way.  Besides being an integral component of the midwifery cannon of literature, it is a fierce, if not dated, reminder of the potential pleasures of having a baby – and the essential role that trust, sensuality, surrender has in birthing [this is an Ina Mae term as is Puss, Rush, groovy, heavy, loving, tantric, psychedelic, telepathic, get high with each rush, smooching….]  

I have really been enjoying it. The first half of the book is birthing stories, each about 2-3 pages, written by women and their partners about their birth experience with the midwives on The Farm – and before the farm existed when they all lived and traveled in a caravan of school buses. (Yes, I’m telling you, those were the groovy days.)  While the stories are full of breech deliveries, premature births, tight cords around necks, and even a stillbirth, the excerpts by the women convey such a sense of satisfaction with their birth experience – even when there are episiotomies and hospital deliveries involved. They talk about loving the midwives, loving their partners, and feeling blessed no matter what the outcome.

The farm midwives placed a lot of importance on working through psychological blocks and interpersonal dynamics between partners on the ability of the woman to both safely and fulfilling deliver the baby.  They tell the women often that ‘tight lips equals a tight bottom’ and encourage the mothers to ‘smooch’ their partners, and get out all of the psychological crap between them.  The men play an integral role in the process – and many women write about how they relied heavily on the energy given to them by the presence of their partner.  They create an environment of love and trust and sensuality – as they say, “a baby should come out in the same way that it was created…”

And then I sit up. And I’m in Zambia. And birthing in the clinics here could not be any more different than the loving, groovy rooms of Ina Mae’s farm (indeed – they are all home births – the rooms designed and created by the mothers themselves).  And I wonder – should this privilege of a fulfilling birth experience come only after basic sets of safety standards have been met? Is this the equivalent of Maslow’s hierarchy of needs? That only after the basics have been met (shelter, food, safety) can one actualize one’s self and experience true fulfillment?  Or is birthing opposite? Is it especially important to create a kind, loving, mother-friendly environment in low resource settings? Or is the question a completely mute point? Is it important for ALL women, regardless of financial status or geographical location or health status to have that kind of experience? 

Yes. To both.

Here is why I think this kind of experience is especially important in a place like Zambia – besides the fact that (I believe) it is a human right to have a humanizing birth experience. 

1) One of the reasons that maternal mortality is thought to be so high here is the low rate of facility births.  Many women deliver at home – with traditional birth attendants – and not in the hospital.  The government has made a big push for facility births because the staff is trained to handle complications and there are more resources than at home.  However, after describing the birthing practices here – including the occasional hitting of women, yelling at them that they are ‘uncooperative’ – and leaving them virtually alone until they grunt and push – my mom said it best: “Why would the women come to the facilities to have their babies?” Even if it is ‘safer’ – it is less pleasant – more isolating- less fulfilling – and therefore less chosen.  If more emphasis was placed on creating a pleasant birthing experience for the women – perhaps that would reduce the maternal mortality just by getting the complicated cases near the interventions that could save lives.

 2) There is physiologic and anecdotal evidence that decreased stress leads to fewer complications in birth.  Separating a woman from her family, her partner, her loved ones, and placing her with a care provider who she perhaps less than trusts increases her adrenaline, which blocks the oxytocin (the contraction, orgasm and breastfeeding hormone), which slows down labor and increases risk of complications. So make her happy and decrease complications.  Sounds easy, no?

But the other parts of me thinks- do all these niceties really matter? Or are they just that? Is it basic skills in safety that are at the crux of decreasing the number of women who die in or after childbirth?  

During my presentation to HSSP to update them on the preliminary results of the project – I talked about the ubiquitous ‘baby bundle’ – as I call it. After the baby is born, it is whisked away and wrapped in a cloth diaper, then a towel, then a crocheted blanket, then a huge fuzzy adult size blanket – so it looks like an overstuffed burrito baby – which is so large in diameter that it is tough for two adult arms to completely wrap around it.  I talked about how that baby bundle reduces any skin-to-skin contact that the mother-baby pair gets, and I included in my list of recommendations that more emphasis be put on the importance of skin-to-skin contact in the hours following birth. 

After the presentation, the deputy director, an American woman, expressed her dismay in this reduced skin-to-skin time due to the baby-bundle, to which her Zambian colleague responded "everyone in this room was born into a baby bundle. We all survived."  Which is true.  It’s a good point.  And it calls into question that, which I think, from my midwifery background, is ‘essential.’

So what is the answer? Should each clinic around the world strive to create the groovy experiences as Ina Mae and her team does? Or should it be a strictly safely first approach? Or is it an obvious combination of the two that is important? 

It is this question of mother-friendly services that brought me into midwifery in the first place, back in 2002 in Tanzaniza, inspired by Mary Kroeger. I think it is this question that will keep me active and passionate about this profession.  I think one thing is clear – there is no harm in providing mother-friendly-fulfilling birth experiences. So why not include it?  We could all use a bit more Ina Mae. 

[There is an international effort to improve the friendliness of birthing practices. It came out of the work done by Mary Kroeger and her wonderful colleagues:  International MotherBaby Childbirth Initiative - www.imbci.org]