Ina May’s Guide to Childbirth – book review

Ina May’s Guide to Childbirth by Ina May Gaskin.

NY; Bantam, 2003.

The physiology of birth is complicated and still not well understood. Our subjective experiences of birth are richly textured. Personal accounts spill over with combinations of intense sensations, strong emotions, vague impressions and fine details. What is astonishing about Ina May’s Guide to Childbirth is how exquisitely she traffics in the language of an internal landscape to describe and explain this complex process. She truly captures the uniqueness and universality of birth. I am adding this book to the list of recommendations I give my clients, as well as suggesting it to other teachers.

Devoting nearly the first third of the book to positive first-hand birth stories provides a substantial grounding. Many times I found myself thinking: Yes! That woman is describing this or that essential bit of wisdom I want to impart to my clients. Let me point out one example.

On pages 24 and 25, one of narrators describes 3 slices of her experience. First, she got advice not to read or learn too much and not to make a plan because the more details she had in mind, the less likely she would get what she wanted. Too much reading would interfere with her ability to go with her body, she was told.

Second, she describes her experience of being in a tub and how she needed a lot of reassurance because she was both scared and aware of the great power in her body. The physiological phenomena occurring in her brain and motor systems indeed would be described as these subjective states of being. She definitely perceived what was happening.

Third, she describes turning from looking at things during a contraction to listening because looking made her think, while listening allowed her to feel and be instinctive, which felt better than thinking and was not so overwhelming. Thus, she was going with her body. We see her process in this narrative.

The stories all got me thinking about whether I am telling my clients too much or too little! One of my teaching goals is to insure that clients distinguish between strategy and tactics. Example:  In the case of the story above, the strategy was to go with her body. The tactics she used were to not get too much information so she did not have too many expectations and to use sound rather than vision as her way of connecting inner and outer reality.

As a teacher, I see my job as insuring that my clients who might hear this story do not think that they must use sound rather than vision in order to go with their bodies, but rather that this was a piece of the process for this woman to reach her objective. It might work, but it might not. To get this across to clients, I tell stories about births in which I have been present when opposite tactics accomplished the same strategy or where the same tactic led to different outcomes.

The multitude of stories she presents in part I allow part II – the textbook part – to come to life. Whether she is discussing stages of labor, pain or release, she calls up stories and because the reader is already receptive to the notion of examples, the illustrations help the reader grasp whatever point she is making about the process.

However, the complex physiologic sequence of birth, including its variation from woman to woman, is less well served – in part because there is still so much to be learned about how birth happens, and in part because the birth community in general (whether having had professional or academic training) is not as well versed in normal physiology as it could be.

Let me focus on two issues: One is pain/pleasure and the other is hormones/behavior. Regarding pain/pleasure, Ina May makes a lot of important points, among them that how we experience an intensely sensational experience depends to a great degree on our preparation and that different women have different pain/pleasure experiences during birth. What she doesn’t tell us, though (and I suspect because it’s not common knowledge), is that some of the factors that control how we experience sensations are beyond our control. We experience pain/pleasure through a series of sensations, mental foci and behaviors such as breathing and muscle release. These nerve impulses are forwarded throughout the brain, some sensations taking on emotional content – some terrifying and others ecstatic – depending on the neural pattern. This is the basis of both the fear/tension/pain syndrome and the orgasmic pattern. But the precise pattern is dependent on genetics, as well as environment and behavioral training.

Some individuals become aware of sensations at a very low neurological threshold; others do not. Some individuals quickly find sensation of which they are aware to be uncomfortable or emotionally intolerable; others do not. Some people need comfort measures for their discomfort soon; some later, or not at all. Tolerance of what finally becomes pain or pleasure (or just a sense of stretching or motion through space) is also variable from person to person. Thus, the point at which we start has both biological and psychosocial determinants within this already variable process. In describing the variation in how women experience pain and pleasure in labor, Ina May is great at giving us examples and identifying psychosocial or cultural variations identified in research, but not so enlightening on the biology of why and how. This may or may not matter to the reader.

The issue of hormones that govern the vicious cycle we call labor is much less well understood. We have a pretty good concept of how prostaglandins, oxytocin and endorphins are stimulated and affect the process, and Ina May describes these in accessible ways. But while adrenaline is thought to inhibit early release of oxytocin, there has been little discussion of its importance in the pushing or ejection phase (she does cite Michel Odent’s notion that adrenaline might play a part in the ejection reflex when a labor is slowing down). But, there is little recognition outside of the physiology field that what happens in transition is our energy system shifting to a sympathetic [adrenal] source to give us more power to push. That’s why contractions change, why some women have a rest period between, and why – back in the day – we used to say to a woman having difficulty culling up her resources to push that she could get mad! Going through the effort and discomfort is key to inducing the rush of beta-endorphins. We know this, in a scientific way, from research that tells us runners who listen to music (relaxing and dissociative) experience lower rates of beta-endorphins at the end of the run than runners who do not listen to music, but work through the effort and discomfort they experience (stress inducing).

One of the things that makes Ina May’s book so valuable, in my mind, is the discussion near the end about midwifery, statistical support for natural birth and enumeration of the risks associated with surgical birth that are often glossed over when a family experiences dystocia. There are many elements within the birthing community striving to create an accessible spectrum of choices for birth. Let’s face it, birthing at home for low risk women, seamless transport alternatives, birthing centers attached to medical facilities, and readily available medical options when emergencies arise, would be a wonderful future. Birth attendants with universal acceptance, variable but rigorous training, and delineated scopes of practice would be ideal. Whether we get there remains to be seen, but I am glad Ina May exists, has her track record and is being listened to in this effort.

The 51% Factor: Pregnancy, Power & Health

Recently I came across this posting and thought it worth posting again. On one hand I see signs of continuing progress, and on another hand it seems to me there are fundamentalist influences popping up everywhere (including among U.S. evangelists) that threaten women’s right to reproductive freedom and health. There is no end to the need to be vigilant.

In the U.S. and most of the developed world, approximately 51% of the population is female. Most females give birth at some point in their lives, although, in any year, only about 2% of the population gives birth.

No one living on earth got here any other way than gestation, so there ought to be some power attached to being part of that 51%. Historically, it might be said that the power has been merely for survival…the good breeders survived long enough to produce heirs and those who lived on knew where the roots and fruit grew.

Only women can make more people with their bodies.

Here are some things to consider:

  • Women make people
  • Women’s health and fitness before pregnancy affects whether the pregnancy is healthy
  • Women’s health and fitness during pregnancy affects her lifetime health and that of her offspring
  • Maternal survival is important to offspring well-being
  • Maternal health and fitness affects maternal adaptation and thereby offspring well-being

Thus, is it not a sanguine notion that the health and survival of women is critical to the health of everyone? After all, the health of nations is associated with this slight majority of females, and the wealth of nations is associated with its health.

The good news is that people working from this understanding are making some headway around the globe. Recently, the World Health Organization noted that maternal death among pregnant and birthing women world-wide has been dramatically reduced from the 1980’s to recently. This is very good news!

Here is the interesting footnote:  Maternal death in the U.S. has risen 42% in the same period. While the absolute numbers remain small, this is a disturbing picture. What could be causing this?

Time will tell if we can figure it out and fix it. I venture to suggest some directions for consideration:

  • The elevated cesarean birth rate with its sequellae of cardiovascular and immune system disorders
  • Obesity
  • Metabolic syndromes
  • Diabetes
  • Heart disease

Why am I hopeful, then? I see among our current educated generation of new moms and moms-to-be a willingness to exert their influence – as breeders – over the health care scene. They want less technological birth. They want support. They want more information. They want to be healthy. These are wonderful things. I salute these young women…they also make my job easier in the process.

In addition, I see among young health care practitioners an understanding of the value of these things. Among practitioners working in public health clinics there is a sense of desperation on the one hand that the poor and indigent have no capacity or will to take care of themselves. On the other hand, the first step is always education and there are a lot of people working on this issue.

Which brings me to the closing point:  How do we bring more resources and intelligence to helping women be healthy, prepare for pregnancy, have healthy babies, reduce pregnancy complications, and improve infant and maternal death rates? I, for one, will keep blogging on this issue. You, I hope, will vote for people who understand this issue. The political power and will is in our hands.

51% of us are women…some day 51% of us can set priorities

Mother’s Day for the Compassionate

Mother’s Day is an important day!  It is set aside because – let’s face it – without our mothers, none of us would be here. Not only do moms carry us inside their own bodies for those critical nine months, but once we are here our mom, or someone who can sub for our mom, is essential to our early survival.

For moms, moms-to-be and those with moms, here is something else to consider: Many presents celebrate motherhood. We can also give gifts that save mother’s lives, help them nurture their children, and improve the lives of families in our own countries and the developing world.

Here are a few groups to which you might want to consider giving this year. By donating to these organizations you can help improve the lives of mothers and children. Most will send a card or email message to the mom in whose honor you give the gift.

UNICEF Inspired Gifts.  You can choose gifts that improve education, water, health, nutrition, emergency care and other factors that affect the well-being of women and children.

White Ribbon Alliance for Safe Motherhood. You can advocate for every mother and every child in 152 nations when you give to this organization.

International Confederation of Midwives. This group exists to raise awareness of the global role of midwives in reducing maternal and newborn child mortality.

The Fistula Foundation. This group exists to raise awareness of and funding for fistula treatment, prevention and educational programs worldwide. Fistula is the devastating injury cause by untreated obstructed labor.

The Preeclampsia Foundation. This organization supports research to prevent and treat one of the most dangerous disorders of pregnancy, one that accounts for a large percentage of premature births and low birth weight infants. Having preeclampsia is also a risk factor for later heart disease for the mother.

March of Dimes. The “mother” of all charities for helping prevent and treat disorders and diseases that affect children.

Happy Mother’s Day to you and – hopefully – to all mothers everywhere!

Sex, Pregnancy, Birth Control, Viagra & War

For some time, the connections among these things have been stewing in my mind. Hoping to avoid an outright rant, I put off writing until my amygdala was calmed down sufficiently to make my key points briefly and reasonably. Global events and U.S. politics motivates me to write this blog now.

Item #1: Sex

For whatever reasons (God’s grand design, nature’s instinct for survival, your favorite theory inserted here…) sex has immediate rewards if done properly. Both men and women experience orgasm, which affects pleasure centers in the brain and encourages us to do it again.

Women’s orgasm is less tangible that men’s. It’s also more controlled in cultures where men’s pleasure is valued over women’s. In fact, in some settings – those that allow female mutilation – it is prevented as a means of controlling women and preventing infidelity or even sex for any reason other than the male’s pleasure or impregnation. Western religious and political cults are slightly more civilized in that rather than cutting women, they merely frighten them into submission.

Keep these thoughts in mind, for when we get to the end of this discussion (war), we will bring the ideas full circle and return to this point.

Item #2: Pregnancy

It’s easy to make the connection between sex and pregnancy. Unless, of course, something has prevented you from hooking up these phenomena conceptually, like being too young to understand or being prevented from figuring it out by others with social or political motives.

What makes pregnancy of interest here is that it can make even the strongest women vulnerable. Two people using one body (or three, if the male thinks the woman’s body belongs to him) places big demands on the woman’s body and depletes her physiologic resources. Even in a setting where food and shelter are abundant, it puts her internal organs under stress.

It is in the best interest of cultures to support and provide a safe environment for pregnant women. And, most importantly, to allow a woman to make decisions about when and with whom she will bear a child. Yet, we do so rarely.

Item #3: Birth Control

The great leap forward for women in the 20th Century is clearly the advancement in birth control. For the first time, by mid-Century, women could reliably prevent unwanted pregnancy before it happened. It was the 1960s (!!!) when women were finally able to gain legal control to obtain their own birth control in the U.S.

Yet, clearly, preventing pregnancy is preferable to aborting an unwanted pregnancy, which until the 20th Century really was the only reliable way to prevent carrying DNA that a woman did not wish to carry.

Why would a woman not want to carry certain DNA? To answer this, we have to look at men’s biological make-up. To oversimplify, but make a point:  When there were very few people on earth, it was understandable that the males who could impregnate many women were able to develop loyal clans. Follow this out through the centuries and you get genetically homogeneous civilizations. When conquering, rape was an important part of the process because it enabled this genetic loyalty.

The method by which women could level the playing field was abortion. The combination of maternal/fetal mortality and abortion worked to provide some balance in the civilizing forces at work as the population grew.

Item #4: Viagra

I love this:  Most insurance will pay for medications that improve erectile dysfunction, but many will not pay for birth control. There is a glut of propositions for laws prohibiting women from protecting themselves…and seven billion people later, we really do need to protect ourselves at least until we can get some colonies in space underway.

So, by now you have read enough to see the incredible irony of this situation. Despite a need to limit populations growth, there is currently such a beating-of-the-chests attitude clobbering world events, one which includes the notion of ownership of women’s bodies by men. You can get free Viagra, but the same people using the Viagra are telling women they can’t protect themselves!!

Item #5: War

This leads us to the final item…war. Right now, war is everywhere. Thanks to people who shall remain unnamed here, the notion that if you don’t like someone, it is okay to go to their country and kill them and/or takeover their way of life, has led to this “okay-ness” of waging war. Unfortunately, this bully pulpit has infiltrated civilization, which – until recently – was making pretty good progress on commonality of human existence and the need for peaceful solutions.

So, what do we see? A return to the “ethics” of war, including rape and control of women’s bodies (go back to item #1). It is interesting to me that in the U.S. there is a growing awareness among young, childbearing women that there are a lot of unnatural processes going on in birth. I am duly impressed by the extent to which young women have pressed the discussion of whether or not the way in which we birth as a nation produces the best outcomes for baby and mother.

We don’t need as much abortion as we used to. We have much more effective ways to prevent unwanted pregnancies. Our teenagers are finally getting the message in some demographics that prevention is best. If we continue as a warring nation, will we threaten this progress? This worries me. I hope we can steer our culture in a more productive direction. Women’s bodies should not be a battleground.

One World Birth, Video Trailer

This is a must see…

Healthy Moms Having Healthy Babies – the Challenge in 2011

Welcome to 2011! We want to take this opportunity to say, once again, that our main goal here is to provide credible, evidence-based information on how to prepare for a healthy pregnancy and birth, recover quickly and begin your mothering experience in good health. Why? Because that is what you can do to help get your baby off to a healthy start in life.

Helping women be healthy during the childbearing period is our primary goal. Not everything is within your control, especially genetic factors. But your baby’s life is determined – in part – by your behavior before pregnancy, during pregnancy, during birth and in the early mothering stages. More and more, we are coming to understand that the environment within the uterus is largely affected by the mother’s behavior (exercise, nutrition, stress, breastfeeding and avoidance of risky behaviors such as smoking) and environmental exposures (toxins in chemicals, the air we breathe and food products).

We are recommitting to making up-to-date and well-documented information available through this blog. Now and then you will get a rant, but for the most part, we want to help people have terrific experiences during the childbearing period. Of course, since we are part of Dancing Thru Pregnancy and its Total Pregnancy Fitness and Mom-Baby Fitness programs, you will hear a lot about being fit before, during and after pregnancy BECAUSE fitness has more benefits for mom and baby than any other single factor!

Here are some of the well-documented findings about being fit during the childbearing period:

  • assists in healthy implantation and improves placental function
  • reduces the risk or severity of gestational diabetes
  • reduces the risk of preeclampsia
  • reduces the risk of prematurity and low birth weight
  • reduces the risk for childhood obesity
  • may reduce the risk of surgical (cesarean) birth
  • improves long term maternal heart health
  • reduces the risk of postpartum depression
  • increases the likelihood that a woman will be fit in mid life

You can find references for these findings on this blog, on our website ( or through the American College of Sports Medicine and other organizations listed in our blogroll.

Our secondary goal is adding to the effort to assure Safe Motherhood around the globe. We do this, in part, by supporting the White Ribbon Alliance for Safe Motherhood and helping sponsor projects that improve mother’s lives locally. We are also committed to spreading the word that improving the lives of women and children involves a reality change…namely that helping women plan their families, have healthy pregnancies and give birth in safety are more important human goals than wars and violence.

Please join us this year in this important endeavor.

Thank you.

Ann Cowlin, founder/director,, twitter@anncowlin

Labor Pain…or Labor Sensations?

There is no sensation known as pain. Sensations are nerve impulses that travel from the body toward the brain. Touch, sight, hearing, taste and smell are the major physical sense categories. Pain is a combination of sensations and emotional content supplied when the brain notices sensations and routes them through parts of the brain that determine emotion, or feeling.

Sensations include touch subcategories such as pressure, temperature, stretch, speed and acceleration, spatial orientation and movement direction, texture and so on.

There are nociceptors – receptors of touch perception that tell us when the body is being damaged, as when we are burned or struck. If you have ever had these things happen to you, you will recall that any pain associated with these experiences is not immediate, but develops as we create our response to the sensations AND feelings involved.

I have written more extensively on this phenomenon in my textbook, Women’s Fitness Program Development (Cowlin, AF. Human Kinetics Publishers, 2002, pages 192-3). But, my point here is that as we embark on the discussion of how to bring birth back to a mother & baby centered experience, we must examine the evidence concerning the physiology of birth. Solid knowledge about the nature of sensation and how it becomes something we call pain is key in our ability to educate and train women to be fully present – that is, to control – their experience of labor and birth.

Our perception of pain is partly genetic, partly training and partly culture. Birth educators work hard to help women understand they have choice within their experience of the sensations of labor. But, changing women’s experience of labor to a more positive and purposive set of sensations requires a large contribution from the culture. Why is sensation sometimes NOT to be avoided so that it gives us information about what is happening to our bodies?

Most of us spend large portions of our day disconnected from our bodily sensations. When we sense our bodies, we take pain-killers. One of the most common things new dance students say when learning to dance is: “That hurts.” Often, I find when I query them further, what they are actually saying is: “I have never had a sensation of that part of my body and it is strange.” Getting in touch with our bodies these days often requires breaking the digital connection, the altered virtual reality in which we now so often live.

How will we do this? If you have suggestions, please post them. Thank you!!

Birth and Human Survival

Ever wonder if humanity will become extinct sooner rather than later?

Animal Planet program on sea turtles…hatchlings crawl across the sand to the ocean and the commentator remarks that only one in a hundred will survive to adulthood. Those who escape the pelican beaks or salt water crocodiles waiting for them on the sand may meet with sharks or other swimming predators. Not good odds. Conclusion:  No wonder they lay huge numbers of eggs in the sand.

But, what would the result be if the turtles figured out some way to destroy all these predators so that most of each hundred survived?

New Jersey has just completed a brief bear hunting season in which about 500 bears were killed by hunters because another species that competes with them for space and food has over-populated that space. The close interface of bears and humans resulted in a situation in which the natural predator (bear) was overcome by the competing creature (human) who figured out how to destroy the predator.

Human beings have been party to a number of species’ extinctions or near etinctions because of our capacity to use technology to overwhelm the natural process of competing for resources. Nature has a way of balancing out the advantages that one species gains over another, but the use of advanced technology – everything from guns to in vitro fertilization – oversets this natural order. Essentially, we are working on having more and more surviving members. Check it out:

What questions does this thinking raise for those of us concerned about the safety of birth?

How do we make birth safer throughout the world while at the same time address the issue of over-population? There was a time when the capacity to overset nature worked to human advantage. The notion of “go forth and multiply” worked for us much as it currently does for the sea turtles. But that balance has changed. Essentially, the difficulties of establishing family planning as accessible and acceptable behavior for women goes hand in hand with aiding women in having safe pregnancy and birth, as well as supporting infant survival. For directly working on this issue, a thank you    is due the Bill and Melinda Gates Foundation.

How do we balance women’s need to work, the trend in developed nations to delay childbearing, the dangers of childbearing too young, and the need to reduce population? A hard question we need to ask is whether it is a “good” thing to have a child at 55 or 60. We know it is not safe for 12 year olds bear children. Yet, we go to extreme, expensive lengths to permit older women to have this experience while we spend very little on projects to prevent the atrocity of coerced reproduction in young women and girls.

So, the turtles and bears got me thinking scary thoughts:

  • What are the odds that the human population is growing so fast we cannot sustain safe water and prevent or quarantine infection sufficiently to avoid major epidemics that kill most of us?
  • What if engineered food products turn out to be not so good for us?
  • What if we so disturb the food chain by causing extinctions that we upset our food supply and end in chaos?
  • And, how does climate change fit in to all this?

Why would we allow this? Oh, right, greed. Growth is how economies are sustained. Have to work on that, folks.

Okay. I’ll stick to writing about enabling healthy pregnancy for now. But, let’s all work on raising awareness of the need for family planning.

Safe Birth – Who’s in Charge?

Who Controls Birth? Defining the Argument.

Periodically, arguments arise in the birthing field over who controls the way we give birth. Often this happens at times when birthing women change their behavior trends, putting financial pressure on professionals working in this field. The major players in this argument are medical doctors (obstetricians), certified nurse midwives and professional home birth midwives.

Currently we are seeing women leave the traditional hospital setting for birth in larger and larger numbers…and taking their dollars with them in the process. While the question of home birth safety arises every time this control argument comes around, the question of whether it is safe to intervene in a labor that is progressing normally is a new component of the discussion. This time the argument is: The safety of home birth vs. the safety of using hospital technology to intervene in normal birth.

How Money Affects this Issue

As with all commercial ventures, controlling access to safe birth requires controlling the information in the market place. This information needs to address the perceived wants of the target audience. For a long time the main message has been:  Safe birth is only available in a hospital.

The financial pressure of giving women (consumers) what they want – a normal experience of birth in a safe setting where medical help can be quickly available – has powered the birth-center industry. Free-standing and in-hospital birth centers have grown in numbers, and are largely enabled by certified nurse-midwives. Meanwhile, professional home birth midwives have increased both their credentials and practice standards, as well as their visibility.

Both of these options, birth centers and home birth, threaten the livelihood of traditional obstetrical practices. Low risk births (about 70% of births) have the potential to be normal births, requiring little or no intervention. But, giving birth in the hospital means participating in measurement procedures that intervene in the labor process.

So, to convince women they need to be in a hospital to be safe, medicine has maintained the argument that home birth or out of hospital birth is not safe.  However, research does not indicate this is true. The nature of this ongoing argument is discussed in a 2002 article from Midwifery Today.

What’s New? The Counter Argument.

The physiology of normal labor is dominated by parasympathetic, meditative, gonadal energy systems. Measurement is a sympathetic, rational, adrenal energy dynamic. Only when it is time to expel the baby does the underlying energy system make a transition (transition, get it?) to an adrenal impetus for the strength activity of pushing. Immediately following normal birth, maternal physiology is again dominated by gonad-driven energy along with a rush of endorphins.

“Intervene enough and things will go awry. You can easily end up being cut and/or separated from your baby at birth.” These ideas have gone viral. With the arrival of the internet, women have found a very quick way to do what we have always done:  Share information.

Thus, in my exercise program and in my childbirth preparation classes, I have more and more frequently been fielding the following question from women who want a normal birth and want to be safe: “How can I avoid interventions while I am in the hospital?”

So, I ask them what leads them to ask this question.  And, they say:  “I read on the internet and/or heard from my friends that interventions make birth less normal and less safe. I want to protect myself.”

Women themselves are entering the argument in a much more conscious way than in the past. Some professionals would like to keep women out of the argument. But, like with many things in our 21st century world, we have already past the point of no return. As they say, the horse has already left the barn!

Word has gotten around. More and more, as a prenatal fitness expert who strives to listen to my clients, my job has become educating and physically training women to cope with a strenuous and primitive process in a technological world.

Hopefully, we can all keep our eye on the ball here. Preventing trauma should be one key goal. Just as we have learned to hold our newborns skin to skin so they can smell and taste us, listen to our heart beat and voice, and maintain their core temperature, let us learn to comfort and nurture our new mothers, while we steel them for the rigors of birth.

World-wide Maternal Mortality Rate Down, but U.S. Up!

Maternal mortality rates are down; however, U.S. rates are rising! What’s with the U.S.? We have asked this question before on this blog, but now a lot of others are asking, too!

Must read:

Hogan MC, Foreman KJ, Naghavi M, et al.  Maternal Mortality for 181 Countries, 1980-2008: A Systematic Analysis of Progress Towards Millennium Development Goal 5. Lancet. 2010;375:1609-1623.