Teaching Respect for Hands-On Care
by Ina May Gaskin

[Editor’s note: This article first appeared in Midwifery Today Issue 70, Summer 2004.]

Caring Hands

[Photo by Caroline E. Brown]

One of the greatest challenges before US midwives is teaching the value of hands-on care to birthing women, the midwives who come after us, the medical profession, the nursing profession and the overall culture. Our culture’s love affair with machines, contraptions and gadgets has, unfortunately, blinded literally hundreds of millions of people to the importance of human contact, feeling, experience and judgment in maternity care. Part of what makes our task a challenge is that hands-on care can be difficult to describe, to record in a few short words, to evaluate—even to recognize, especially to people who have never been present continuously through a labor and birth. We midwives have to learn how to excel at this kind of description, and we need to re-legitimize the art and importance of storytelling if our profession is to thrive once again.

If we don’t tell our stories, how are we to teach women that cervical dilatation can reverse itself simply because they go to a hospital or because the wrong person enters the room? How can women re-learn confidence in their bodies unless they hear how well women’s bodies work, given the right atmosphere? How else can we give the woman who has always had pain medication while giving birth the confidence to labor without medication?

When midwifery was “on a roll” during the 1970s and 1980s, many in our movement thought insurance companies and health maintenance organizations (HMOs) would recognize the savings that would follow adoption of the high-touch, low-tech version of midwifery care we wanted for ourselves and those close to us. That was because few understood the intricacies of how services are billed in hospitals, the extent to which women’s health insurance plans would limit their choices of care provider, the medical-legal requirements of hospitals, the close links between insurance companies and hospital corporations or the ease with which judges and juries could be convinced that a yard-long electronic fetal monitor (EFM) strip is equivalent to or better than the notations made by a midwife or nurse providing intermittent auscultation (along with kind words, comfort measures, encouraging stories and loving touch). EFM strips have incredible illusory power; to the uninitiated they make it look as if someone is in the room with the laboring mother and give the impression that knowing the fetal heart rate during contractions is more important than it actually is. (No one has been able to count the unnecessary cesarean sections that have been performed because of low fetal heart rates recorded during contractions simply because of EFM.)

It seems to me the only reason the assessment of cervical dilatation is still done by hand in hospitals is that no one has yet invented a set of indwelling calipers that can be installed to do the job mechanically—although some inventors in the early 20th century did try. We may be able to land a spaceship on Mars, but human flesh still doesn’t lend itself to easy measurement as it changes form, consistency and position during the process of labor.

But there are signs that some within the medical profession are paying attention to the loss of knowledge and skills that accompanies excessive dependence on machines, devices and quasi-mathematical formulas. Take the assessment of the baby’s weight before birth, for instance. I have long believed that manual weight assessment is far more accurate than anything modern obstetricians have come up with. A recent article published in the Journal of Reproductive Medicine corroborates this. Gerard Nahum, from Department of Obstetrics and Gynecology, Duke University Medical Center, studied 44 women between 37 and 42 weeks of gestation.(1) Each woman was asked to estimate her baby’s weight at the point that she went into labor. Then a medical student performed Leopold’s maneuvers to manually assess the baby’s weight. These two figures were then compared with the best ultrasonographic estimates and the estimates gained using a birth-weight prediction equation based on maternal and pregnancy-specific characteristics (mother’s height, weight, obesity, parity, baby’s sex and the length of gestation, with adjustments for smokers).

Nahum found that an experienced person’s hands were definitely superior to the mathematical formulas and just as good as the most modern ultrasonic techniques. Given that we still don’t know what subtle or long-term effects ultrasound exposure can have on the baby, this study can be cited as an argument for foregoing routine ultrasound near the end of pregnancy merely to estimate the baby’s weight. Nahum concluded that Leopold’s maneuvers are extremely useful and should still be taught, even though manual assessment is perceived by some obstetrician educators as “a methodology that is intrinsically subjective and operator dependent.”

Another type of hands-on care that I’m involved in now is the Safe Motherhood Quilt. The Quilt commemorates women who have died in the US since 1982 (the last year that our maternal death rate declined) from causes directly related to pregnancy or birth. Volunteers, surviving family members, midwives, doulas and doctors have all taken part in creating quilt blocks for women who have died. At present, the Quilt exists in two 5-yard-long panels, a yard high, each consisting of twenty blocks. A third panel is almost ready to be assembled, and I am in the process of assigning blocks to be made for the next 20 mothers that we have identified.

In late February, I took the Quilt to Washington, DC, in search of lawmakers to sponsor legislation that will enable the Centers for Disease Control to accurately determine how many US women die from pregnancy-related causes every year. (The CDC estimated in 1998 that the actual number of maternal deaths may be as high as three times the officially reported number.) Such a high degree of inaccuracy keeps us from carrying out the kind of careful analysis of maternal deaths that is reducing such deaths in other wealthy countries.

You may wonder how this second kind of hands-on care impacts the other kind of hands-on midwifery care that I continue to give. Do I work on the Quilt when I’m attending a birth? Of course not. Do I hide the Quilt from pregnant women? No, I don’t find this necessary. Any time I talk about the Quilt I point out how few of the deaths were not preventable (four out of 70). I also point out the number of deaths associated with Cytotec-induced labors (five), so women understand that labor induction is less benign than most realize.

And so we go on, attending one birth at a time, taking one stitch at a time or telling one story at a time, knowing that we have more influence than we realize. This is how we bring back a living, breathing, surviving midwifery that will be there for our granddaughters and grandsons and their grandchildren.

Ina May Gaskin is director of The Farm Midwifery Center in Summertown, Tennessee, and author of Ina May’s Guide to Childbirth.

References:

  1. Nahum, Gerard G. 2002. Predicting fetal weight: Are Leopold’s maneuvers still worth teaching to medical students and house staff? J Reprod Med 47: 271–78.

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