MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today sitting in for Diane Rehm. Diane is on vacation. One of America's leading midwives, Ina May Gaskin, believes giving birth can be one of the most empowering experiences a woman can have, yet she says the way birth is experienced by many women in the United States is too often disempowering. In a new book, she shares what she's learned in nearly four decades of delivering babies, and she offers her views on changes that would help mothers and their babies.

MS. SUSAN PAGEThe book is titled "Birth Matters: A Midwife's Manifesta." And author Ina May Gaskin joins me in the studio. Welcome to "The Diane Rehm Show."

MS. INA MAY GASKINThank you, Susan, it's great to be here.

PAGEWe're going to talk and later take some calls from our listeners. You can join our conversation, call us at 1-800-433-8850. You can always send us an email, our address, drshow@wamu.org, or find us on Facebook or Twitter. Well, I know that you are a hero in the midwife movement, but your college degrees are actually in English Literature, so how did you become a midwife?

GASKINI had my first baby in 1966 and I was just amazed by what I had expected to have a science-based kind of care, but when I found out a week before I actually went into labor from my obstetrician that I was going to have to have a forceps delivery, simply because it was my first baby, I knew that had nothing to do with science because I was a farmer's daughter, and I couldn't accept that the firstborn is a sacrificial -- a sacrifice to nature, so to speak. I just couldn't accept that because I knew better.

PAGESo you had your first child and then...

GASKINIn Illinois. Mm-hmm, mm-hmm.

PAGEIn Illinois, and then what did you do?

GASKINWell, having that first child, I -- it was very interesting because when I was 16, I read -- I was a big reader, and I went to the library and I read everything. So I read Dr. Grantly Dick-Read's "Childbirth Without Fear" and I said, oh, becoming a mother's kind of a test of courage because he said, and he was a doctor, so obviously I thought he knew what he was talking about, that much of the pain that people experienced in labor is due to their fear.

GASKINAnd I thought, well, OK. I'm afraid of the dentist and I want anesthesia when I get my wisdom teeth out, but childbirth is something different from getting a tooth out, you know, even if that involves major, you know, as it did in my case. And I knew that everything could be born on the farm and I thought, there's a lot of species of mammals and only the human doesn't work? I mean, that was just hard for me to accept.

GASKINSo in those days, in '66, you could labor a long time, and I was allowed to labor a long time without anesthesia, so I knew I could do that. But only when I was ready to push, that's when they came with the drugs, and now, as if I wasn't anybody, nobody talked to me. They were sinister. I'd been having a pretty good time before. In fact, there was this sort of plain wall and I'll never forget this. It became alive with color, and I wasn't thinking, oh my goodness, I'm having hallucination, that scares me, I was just seeing it like a stain glass window that was living and throbbing and it was beautiful.

GASKINIn fact, I would say today, I was in a trance, and I think that that's kind of what nature does, if you're not afraid and if you are left alone, the way any farmer knows that, you know, a mammal will do better, most of them, you know, especially the large ones, if they're left in peace. And if there's somebody nearby to help in the unlikely case, but sometimes it happens where they do need help. And I think that we forget that we're similar to that.

GASKINSo when the forceps part came, that's when it went really bad, and both my daughter and I survived, but we were separated and it was really quite disturbing how I was treated and then, of course, I didn't get to see her for a full day. And I was given a kind of spinal anesthesia that they don’t do anymore because it did kill enough people that they've sidelined that one and moved on to the epidural. This one was called a caudal.

GASKINAnd I was terrified that I would never walk again and there was some -- you know, although obviously I can and I was one of the lucky ones, some people weren't so lucky. So that put me on a course of, why -- why do they think that?

PAGESo you had your own difficult experience.

GASKINYeah.

PAGENow, tell us about the first time you delivered someone else's baby.

GASKINAll right. So now I was curious and I really wanted other women's stories. I'd always been trying to get other women's stories. And I knew a couple of people, for instance, before I ever had my baby, I lived next door to a woman who was a little bitty thing and she had a six foot five husband. And her belly was out to, I mean, it was just unbelievably big.

GASKINShe went to her -- what turned out to be her last prenatal visit and came home with a baby and I said, what happened? She said, well, he thought he should check my cervix because maybe I was ready to go into labor and he wanted to just sort of find out. Well, that examination actually put me in labor. Twenty minutes later, the baby was in my arms. She said, I couldn't even get my socks off. That was her first baby, so that taught me something. And I remember distinctly, I thought, she's as good as an animal. That's what animals do.

GASKINSo then after my baby, now I'm even more curious, so I talked to people and I start meeting some people who had had forceps deliveries like I had and questioned it in the same way I did, but they took it a step further. They found a woman who was a labor and delivery nurse, a friend, who would act as a midwife, which was to me a word that I didn't know such a creature existed in the United States in these times. And she had been with them as they had a home birth. And their -- they were empowered by this.

GASKINSo I thought, at that point, oh, I want to do that. And one of the stories just floored me because this woman, having baby number two, said, labor didn't hurt this time, as it had in hospital. She was sitting on the bed with her husband, cradling the baby in her arms. She's out in a rural area. And she looks at the window. The neighbor's cows have walked about 100 yard up the road and are now looking in the window at the baby. And just to hear that story made all the little, you know, goose bumps. It gives me goose bumps when I even tell the story.

PAGEBut now you were on a bus...

GASKINAll right, so then, yes...

PAGEYou were on a bus making one of these distinctly 1960s, 1970s kind of trips. Hippy, would you have called yourself a hippy?

GASKINI would. I was an adult hippy.

PAGEAn adult hippy. And there was a pregnant woman on the bus and she went into labor. What happened then?

GASKINWell, the trip was actually a lecture tour my husband Stephen was asked to make by a number of ministers in the country, and he was -- had been running something called The Monday Night Class in San Francisco for about four years, and 1500 people, by the -- you know, the year 1969, '70 were coming every week. So these ministers wanted him to go out and do something like that in about 42 different cities, and out of that class of 1500, about 250 or so people said, we want to come, too, and we'll get vehicles together and we'll follow you.

GASKINSo Stephen said, OK, nobody can be on welfare, no dealing of drugs and you can come. So everybody had to behave and they did. So we had maybe 50 vehicles at some times and there we were, parked in the parking lot of Northwestern, near an auditorium. The young man whose wife went into labor...

PAGENorthwestern University, mm-hmm.

GASKINThat's right, Northwestern University. And the young man wanted Stephen, who was a Marine Corp veteran, to come attend his wife because he was going to do it, but he's scared. I knew that Stephen had to go in and address the auditorium full and so at that point, I decided to go to volunteer. Now, I had never seen even a photo or a drawing of a birth, but I knew that birth could happen and I knew how I had wanted to be treated, so I volunteered.

PAGEYou volunteered. That was a successful birth? A healthy mother, healthy baby?

GASKINYeah, absolutely and it was the first -- being the first birth I ever saw, it was the most perfect birth I could've seen.

PAGEAnd it was on a bus?

GASKINIt was on a tiny school bus.

PAGEAnd how many babies have you delivered since then?

GASKINOh, I don't know, 12, 1300 when I was at...

PAGETwelve or 1300 babies, that's quite a few.

GASKINTwo births last week and I have six partners and we work together. My, when we settled in Tennessee, we were very lucky to get the help of a wonderful family practice doc who had a lot of experience with homebirth through the Old Order Amish community that's near us. And actually, while we were still on that lecture tour, I'd got the help of a obstetrician in Rhode Island, Dr. Louis Lapere, who gave me some very timely help and a little seminar one morning in emergency childbirth procedures, which equipped me with knowledge and equipment to deal with the next birth.

PAGEAnd so the farm in Tennessee that you settled in, how many years has it been operating?

GASKINSince 1971.

PAGESince 1971. And have you had additional training? I mean, what kind of training do you have to be a midwife?

GASKINWell, at that time, Tennessee, we had no idea, had only one law on the books and it was passed in 1896 and it said, the practice of midwifery is not the practice of medicine. So Tennessee, it was simply not mentioned because there had been no reason for it and the Southeastern states were different from the Northeastern states where in some states in the early part of the 20 century, midwifery was actually made illegal, Massachusetts being the first state.

GASKINOn the West coast, a little more liberal, out in the middle of the country, a mixed bag. So Tennessee, just by luck, didn't have any law against it and then this Dr. Williams, our GP, a family practice mentor, had 16 years of experience already in the Amish community and he said they actually do better than the people that go into the hospital. Fewer infections and now and then, of course, you have to go to the hospital, but they do very well.

PAGEWe're talking to Ina May Gaskin, she's got a new book out, it's called "Birth Matters: A Midwife's Manifesta." We already have some people lined up on our phones. We're going to go to the callers when we get back after a very short break. Stay with us.

PAGEWelcome back. I'm Susan Page with USA Today sitting in for Diane Rehm. And with me in the studio is Ina May Gaskin, she's the author of "Birth Matters: A Midwife's Manifesta:" We've got a lot of callers lined up. Let's talk to some of them. Amy has joined us from Birmingham, Ala. Amy, thank you for joining us on "The Diane Rehm Show." Amy?

AMYHi, yes.

PAGEHi, Amy, you're on the air.

AMYI have had two hospital births and two home births and I just wanted to say what a huge difference it was coming from a medical birth with my first child. I really wanted to have a natural birth, but I felt the only option was to go to the hospital, because in Alabama, there's sort of a legality situation with midwifery. And so I went through that and it was a 26-hour intervention -- (word?) intervention. Horrible experience.

AMYAnd then I had my second child and it was a little better, but still just medical. And I begged my husband to let me have the third child at home. And I said, sweetie, I love you, but I'm having this kid at home, I hope you can be there (laugh). And it was the most wonderful experience. It was -- I felt like I was made to do it and it was safe and I felt victorious and wonderful, where I felt like a subject of some medical mystery show the first time.

AMYThis is at home and I was safe and I was surrounded by people I loved. And my midwife was so competent and so knowledgeable. And it was just a wonderful experience, and I would really like for your guest to address the growing movement to get midwifery legalized in different states.

PAGENow, did -- was it actually illegal for the midwife to attend to you at these two homebirths?

AMYWell, in Alabama, it's sort of a-legal. They can be prosecuted, but what they're prosecuted for is practicing nursing without a license. Which, of course, if you talk to any midwife, it's obviously not what they're doing. They don't claim to be a nurse, they don't claim to be medical -- the medical practitioner. So they're sort of prosecuted for something they don't claim to be doing.

AMYYears ago, the OB Lobby in Alabama sort of convinced the legislature that it was unsafe for women to have home births. And in Alabama, 70 percent of our counties don't have access to OB-GYN care because there are a lot of people who live in rural areas. And so by making midwifery difficult or risky for the midwife, which it is -- it's not really risky for the patient and there's no way I could be prosecuted, but the midwife could be. By making that illegal, basically you're telling women in 70 percent of Alabama's counties, which includes a lot of very low income women, I'm sorry, but you can't have direct access to healthcare.

PAGEAnd did you have an obstetrician yourself?

AMYI did.

PAGEAnd what was the view of your obstetrician toward the home births that you had?

AMYMy obstetrician was actually pretty kind about the option of home birth. At first, I was with a nurse midwife with my first birth in the hospital. And she said, look, I support home birth and I would be doing it if it were legal in Alabama. But fortunately, she had a nursing degree and so she was able to practice legally within the context of the hospital. Now, the OB that I used for my other birth, he told me specifically, he said, I can give you care up until your sixth month, I can do blood work for you or whatever you need, but you can never mention to my staff that I'm doing it because if something goes wrong, I could get sued and lose my entire practice.

PAGESo you ran into some legal situations both with your doctor and with the midwife you used. Now, how common is this, Ina May Gaskin, with midwives? How many times do midwives face legal action for attending a home birth when it's not permitted in the state?

GASKINIt's -- the absolute number isn't horrendously high, but the fallout from it's huge. And of course, the consequences for that woman, her family, her clients are devastating, so it doesn’t take very many such cases to have a real inhibiting effect on everything. And -- but there -- if you counted up over four decades, the number is a lot.

PAGESo nurses who have become midwives, these certified nurse midwives, they're -- they can legally attend to births. Is that correct?

GASKINWell, there, too, they run into a lot of barriers. I'm just contacted by a friend who lived -- a nurse midwife, longstanding, going to move from one Carolina to another because she cannot have a home birth practice in North Carolina. She'll be able to get licensed the way I'm licensed. She has to get a different licensure and have to move to another state in order to work in a way that she isn't at risk.

GASKINSo nurse midwives have some constraints on them, that I believe they should not have, that keep them from doing home birth as easily as the certified professional midwife, the credential that I carry and that is licensed in, I believe, 27 states now, so we have several more states to go.

PAGEYou were talking -- we were talking before the break about the law in Tennessee, the state in which you work. Tell us about the law. What is the certification process now that you've gone through?

GASKINWell, it's based upon your ability to pass the examination, an assessment of your skills and your documentation of having assisted a certain number of prenatal visits, births, postpartum care. It's evidence based and it's been in place now since the mid '90s. So, you know, any way of -- it can deal with midwives who come up through multiple roots.

GASKINAnd there are some midwives, like me, who know how to learn, OK, and I was actually able to put together an education that was outstanding, I believe, because I was highly motivated, but I also recognize that nobody -- I can't advise other people to take the route that I did. That would be irresponsible. I know that I was extremely lucky that the first birth I saw was perfect and that I then was extremely careful and I got some timely help. That's not going to happen for everybody.

GASKINSo there are some midwifery schools, but they're all -- I think that the role of apprenticeship is also worth looking at because so much of birth is something that is not well recognized anymore, that you need actually role models of how to be calm in an emergency, how not to upset a laboring woman, how to be aware that your very mood when you enter the room can have a big effect on her labor.

GASKINBecause I believe that the busy schedule that midwives who work in hospitals, too many times -- or obstetricians who are actually taking care of more people simultaneously than they used to have to, and used to be considered safe, are pushing women. And you're right up against biology here because they're forced to do things now that weren't actually considered safe a generation or two ago.

GASKINLet's go back to the phones. We'll go to Atlanta, Ga. and talk to Sherry or Cherie. How do you say your name?

CHERIECherie.

PAGECherie, thank you so much for joining us. Go ahead.

CHERIEThanks for taking my call. I was wondering, I had a -- not a home birth, because that's illegal in Georgia, so I happened to be fortunate enough to live in Savannah at the time of my pregnancy and there was a rural birthing center, which I engaged for my prenatal care as well as the birth. However, things didn't go as planned and after 24 hours of labor, I had to be rushed to the hospital for an emergency C-section. And I was not well received at the hospital. I was wondering how often your speaker has had such a situation happen and what the experience is with the relationship of the hospital care providers?

PAGEAnd so you weren't received well because you were coming from this birthing center, do you think?

CHERIEExactly, exactly.

PAGEAnd how did things go? I hope everything went all right after that.

CHERIEIt was somewhat traumatic, as you can imagine. My daughter was perfectly healthy, which is all that matters in the long run, but, you know, coming from the perspective of homeopathy and wanting to have a natural labor and going through 24 hours of it and then to have, you know, not such a great feeling when you get to the hospital and basically be shunned, like, why would you do this? Why would you not come to a hospital? This is stupid.

CHERIEYou know, I have a master's degree, so to be treated in such a way is, you know, off-putting, to say the least. So it seems like there needs to be a bridge between, you know, that type of mentality and people who want to, you know, have a more natural childbirth.

PAGEAnd if you...

CHERIEI was just wondering if...

PAGEIf you...

CHERIE...in your area, does that happen very often and what your experience was?

PAGEAnd just one more question. If you were pregnant again, would you -- what would you choose to do? Would you choose to do the hospital birth or would you go back to a birthing center?

CHERIENo, I definitely wouldn't do a hospital birth. Absolutely not. I would probably find a home birth individual who was, you know, like the previous caller was mentioning, was doing it sort of under the table.

PAGERight. OK, Cherie, thank you so much for your call. We're glad your daughter turned out all right from that difficult delivery. So Ina May Gaskin, in your practice, does this happen sometimes where someone has to be taken to the hospital because of a problem, a complication with the birth?

GASKINOf course. Because that's going to happen in a small number of cases. And again, we had -- we were able to build sound relationships. We had the -- I think it helped us a great deal that this Amish community had been there and that this one physician noticed that they did very well. And he made sure, even though they were an odd group in some ways, I mean, you know, no birth control. You might bring in a woman who's on her 14th pregnancy. Uh-huh. I helped a woman with number 19 who was almost 50 years old. She had a beautiful time. She didn't have to go to the hospital.

GASKINBut because of him, and again, early experience, we educated the doctors at the two hospitals near us where we will transport now and then. Our transport rate is under five percent, so it's not so many, but we get a good reception when we go in. We were -- you have to have a team approach, you see, 'cause when you bring in a woman who doesn't want anesthesia and then typically, today, because those who are working in the hospital will have had little or no exposure to home birth or out of hospital birth, because let's include the birth centers, too, women who don't want intervention are not crazy.

GASKINAnd truth be told, obstetricians come to us to give birth sometimes. That was one of the births I did just a few weeks ago, was for an obstetrician that came out of state because she didn't think she could get the kind of care she wanted where she worked, in the state where she worked, so it speaks to a need for a kind of education of nurses, of doctors, so that they are no longer blaming out of hospital birth for what's wrong with birth in America. Get better information on that it's not irresponsible for women to want an out of hospital birth. They have very good reasons for it often and that there needs to be an integrative approach.

GASKINSo we actually had outreach from Vanderbilt Medical School from the neonatal staff early on in the '70s. They wanted to be sure that our training was up to snuff and we gladly accepted that. And we had members of our community that became some of the first ambulance drivers because they went -- they became paramedics and they actually rode ambulance. And then we had many members of our community also who went to nursing school and who went to medical school, so I tended to see it from both sides and I wanted that teamwork approach that I saw happening in other countries.

PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." Well, are there times when a pregnant woman would come to you and say, I want to be at your birthing center, not in a hospital, and you say, no, there are reasons why it's not appropriate for you to do so, you should be giving birth in a hospital. Are there cases like that?

GASKINAbsolutely. Let's say if we've got a diabetic woman who's insulin dependent, that would be one. I had a call from a woman who said, do you take women with twins? I said, yes. She said, what about assisted reproductive technologies? I said, well -- and she said, older mothers. I said, well, did you get pregnant the old way or the new way? I wanted to know if she was postmenopausal. When she said she was postmenopausal, I said, you're out of our league because that's just too experimental for me.

GASKINIf you've had two previous cesareans, we'll take you if you're -- if we've read your operative report and I can read that your uterus was stitched up in the old fashioned way, which turned out to be safer than a way that started to be used in the '90s that I don't quite trust as well. And now obstetricians have come to -- in their literature to agree with me on that, so we will do vaginal birth after cesarean. We're able to do some breeches, we're able to do twins. We're probably not going to accept you with triplets.

PAGEYou mentioned that attitudes in the United States toward midwives is different than the attitudes you might see elsewhere in the developed world. Compare that for us.

GASKINWell, my -- when my first book "Spiritual Midwifery" or midwifery, whichever way you like to say the word, I like both of them, was published in the mid '70s and the late '70s, it quickly brought me mail and visitors from Europe. I started getting midwifery tutors from, you know, UK mainly. Germans came, too, the Dutch came and they said, we're very interested in what you're doing here because this looks to us like authentic midwifery.

GASKINAnd they were starting to say -- I was amazed to find out that in Germany, for instance, there has to be a midwife at every single birth. Imagine how many midwives we would have in the U.S. if there was a midwife at every single one of the more than 4 million births we have every year?

PAGEAnd why does Germany do that?

GASKINWell, they have a law that was passed years ago that the midwives have been able to keep in place that said there has to be a midwife there not to perform the cesarean, but to be with the mother and attend to her needs during and just after a cesarean. So every country in Europe has more midwives than obstetricians or family doctors and they do this because they say this is a better allocation of their resources.

PAGEAnd why is that not the case in the United States? Why does the United States have a different attitude than that?

GASKINOK. That's a good question because we have a very different history here in the U.S. And I, you know, became very curious about this. Why hadn't I heard of a midwife, even though my great grandmother had been one? Because we were the first country in the world, first human society that we know of that decided to eliminate this age old profession entirely. And what I see happen from that is that we became terrified of birth rather quickly.

GASKINThe reason I had that forceps delivery that was obviously not called for in my case, because that baby of mine was two pounds smaller than her brother who came along. All my other children were bigger, so I wouldn't have had a problem. And also, you know, forceps can injure babies and can injure mothers, so it was not without negative outcomes, and the separation in itself was no fun and not helpful to my mothering. OK. So in other countries where people weren't so scared of birth, they saw better outcomes.

PAGEWe're going to take a short break. When we come back, we'll continue our conversation with Ina May Gaskin about her new book "Birth Matters: A Midwife's Manifesta." And we'll take your calls. Stay tuned.

PAGEWelcome back. I'm Susan Page of USA Today sitting in for Diane Rehm and we're talking this hour with Ina May Gaskin, who's a veteran midwife, author of several books about her profession. The latest is called "Birth Matters: A Midwife's Manifesta." We have an email here from an obstetrician in Utah who writes, "As an obstetrician, I take time to make sure childbirth is a wonderful experience and feel terribly that your guest's first birth experience influenced her view of all births, but that is not the case.

PAGEMost births are calm, positive experiences, but even in the most low-risk cases, emergencies happen. And when a mother chooses to attempt a birth at home and loses her child due to an unforeseen event, like a cord prolapsed or placental abruption, she has to live with that selfish mistake for the rest of her life. That is the unacceptable tragedy that would never occur in proper hands at a hospital." What would you say to this doctor, Ina May Gaskin?

GASKINWell, I can appreciate that this Utah obstetrician takes pains to make birth good for -- a good experience for the mothers and I know -- I don't condemn obstetrics as a, you know, as something bad. I depend upon obstetricians. I love -- I've had such wonderful help from obstetricians and support from them that I'm not that way. But a cord prolapse, unfortunately, can actually happen in a hospital, too, with bad results. Let me give you a story of a woman named Angela Wilburn.

PAGEWell, before -- but let's respond to the general point. That she's saying -- she's saying generally, even in a low-risk pregnancy, you can have an emergency and you need the resources that a hospital can offer you.

GASKINThe general point. She's right. OK. So let's take the cord -- what she suggested about the abruption. We had that in case number 324. This turned out to be our second C-section, OK, counting from that first birth I ever saw, and the midwife who had never seen such a case happen, but it was obviously something was wrong because the woman was experiencing pain that was continuous and it began rather suddenly.

GASKINSo she hurried the woman to the car, gave a phone call to the obstetrician at the hospital, rushed her to the hospital and they were getting the room ready while she was on the way. They got there, mother and baby were fine, OK. We've had that happen very few times because we -- with the woman that come to us -- that was incidentally our first cigarette smoker, and we thought, hey, it could've had something to do with her tobacco habit because that can raise the risk of it, OK.

GASKINAnother thing that can cause -- raise the risk of an abruption is induction of labor, which happens quite a lot in hospitals and, yes, they have the facilities nearby there, but still, it doesn't always happen right in hospitals, too. Some babies will lose their lives because of an abruption at a hospital. It's harder to hear about it because we focus on the out of hospital as the one that gets the blame and we know usually very little about nationwide statistics the other way.

GASKINLet me address the question of cord prolapse because this case that I was going to say that happened in a hospital, in Minnesota, happened to a woman who had had seven previous vaginal births and now she had twins. And she went to full-term, so her obstetrician, I think, rightly was going to give her a chance to have the babies vaginally.

GASKINThe woman was a Jehovah's Witness. Now, she had baby number one, no problem, a seven pound-something baby and then the feet came with a cord prolapse. Now, this is the one case where a cord prolapse isn't necessarily dangerous because the feet aren't pressing on it, and that's what you're worried about with a cord prolapse.

GASKINHowever, because of the role of insurance companies in obstetrics, that doctor had never seen a footling breech born and therefore was terrified by it and probably was also terrified and didn't know -- didn't think through that all they had to do was either grasp the feet or ask the mother to push. Instead they went to a C-section and the placenta must've been right under the incision site, the mother bled to death.

PAGEIn the hospital.

GASKINAnd that's terrible. So it can happen both ways. You...

PAGETragedy. Now, there was -- I was reading -- of course, you're much more the expert on this than I am, and we've had callers who've talked about how powerful the experience of a home birth has been, but I was reading about this subject last night in preparation for this hour and I read about a study published a year ago by the American Journal of Obstetrics and Gynecology.

PAGEA meta-analysis, that is that they combine 12 previous studies of home births, and it found some significant benefits associated with home births, but it also found that home births -- concluded that home births led to two to three times higher risk of neonatal death than planned hospital deliveries when you're talking about healthy low-risk women. This seemed to be the biggest study on the horizon that looked at home births and how safe they are. So what do you think of that study?

GASKINWell, I thought that that study got immediate attention and that it didn't deserve it, because it wasn't a well put together study. Let me take it apart a little bit and this I address in some detail in "Birth Matters" because this was really important for us. It wasn't that that one was a such big study in itself. It took 12 different studies of varying -- it said they were just going to deal with planned home birth and yet they included studies that were unplanned and that were controversial by scientists in -- when they were published in part. So I think that that study really was just swallowed whole because people were blown by the fact that used that word meta-analysis and that sounds so scientific.

GASKINThere is such a good thing as -- there is such a thing as a good meta-analysis, but one that was done somewhat earlier and it was far better, was ignored. So I think that we don't have sort of -- people don't take the time to read more than the abstract sometimes. When I read that study, I think, scientific writing should be clear.

GASKINThe -- we call it the wax paper, and internationally it's been criticized, so I dispute the finding because what they did was they inflated the numbers by including a Dutch study, which they then limited and didn't even look at that study in the final result of looking at the neonatal mortality and, in fact, all of those studies that they did include, the 12, on every other measure of birth outcome, agreed that the home birth figure outcomes were better than the hospital, so it was a way of fooling you with phony science.

PAGESo you think this was phony science and why would this journal publish phony science?

GASKINWell, that's a good question. It certainly -- several of the articles of those 12, their authors complained and they wrote to the American Journal of OBGYN, insisting that their numbers had been misused and this included the very large Dutch study that inflated the numbers.

GASKINAnd it made it sound like, oh, they looked at half a million births, but for this outcome of neonatal mortality, they actually only looked at 50,000. So this subject -- let me just say that home birth has been the scapegoat for everything that's wrong with birth outcomes in the United States for a century, and what happens is we just demonize out of hospital birth without looking at the science.

GASKINHere we are with one percent of all the births. We are in a time now when maternal death rates are rising sharply in the United States, where they actually tripled in California, one of our most populous states, between 1996 and 2006. These are solid statistics with much of the problem by -- the researchers are saying because of the rise in C-section.

GASKINC-section has -- is performed so easily now that we even have women who aren't pregnant who've had C-sections. I mean, that's -- when I tell people that, they can't believe how could that happen. Well, I don't think it probably could've happened in the '70s or the '80s, but now that one in three U.S. women will expect almost to have a C-section and we don't have the opportunity anymore in many medical schools and nursing school educations for people to see un-medicated women giving -- even laboring.

GASKINSo when a woman comes in and they've never seen this before, they're clueless about how to help her, and they're not going to be calm because they're going to want to get her on that epidural as soon as possible. Epidurals then will confine the woman to one position. They'll put her in a position that's rather painful for her. Now, she'll be in a position where her labor often won't progress as quickly.

GASKINObviously, it won't be as painful because she's on the epidural, but now you've made labor longer for a large percentage of women and you've lost the chance for your incoming nursing or midwifery or medical students to know how much a little compassion, the telling of the story, the getting into a different position could help this very same woman.

PAGENow, what about efforts by many hospitals to strike some middle ground. So you'd have a hospital birth, but it would a birthing center that would try to make sure to be more nurturing, less medical. What do you think about those efforts?

GASKINWell, it's very interesting because birthing centers, I think, are a really good idea and they didn't have any in Germany in 1980 and now they have more than we have. We had more birth centers in 1980 than we have today. There's something in the U.S. that doesn't like a birth center and people can just put all kinds of effort and money and good planning into making a beautiful birth center, but now they come under state rules.

GASKINWe in Tennessee have to have such wide corridors for a birth center that there are hardly any. You have to have wider corridors for birth centers than you have to have in some hospitals I've been in recently. I've been in some hospitals in the Northeast where there are so many computers and just stuff in the corridors that I don't know how they can function because maternity units are no longer the cash cow.

GASKINAnd this is hospital slang that they used to be, OK. Now, it's the cardiology unit, now it's the neurosurgery unit and big cities are now closing the maternity units in many hospitals. That means that all that maternity care population is going to the few that are remaining and now they're overloading and they're not subject to the same laws that the birth centers are.

GASKINSo we could do better with that. I think we need to really stop and go, how can we get better use of our resources? How do we get better outcomes? How do we move up so that we're not 50th -- the 50th country in the world, according to the UN, in how high our maternal death rate is.

PAGEI'm Susan Page and you're listening to "The Diane Rehm Show." We've been taking your calls and reading your emails. Here's an email from Matt, who writes from Durham, N.C. He says, "Is there a precedent for men as midwives or doulas? I've had an interest in assisting with births, but feel as a male that I would be barred from most programs." Now, first of all, what's a -- explain the difference between a midwife and a doula.

GASKINOK. A midwife provides prenatal care, a doula does not. Although, a doula may provide childbirth education, all right. A midwife can prescribe -- not in all states, you know, but in most, midwives can prescribe, a doula cannot. Midwives in hospitals more often have to take care of more than one woman at a time. That's where the doula comes in, because a woman actually needs continuous care. Now, those of us who work in the home will give that continuous care and we can do that in the home. A midwife provides postpartum care.

GASKINNow, there are certain doulas that do postpartum care, additionally or exclusively, but -- so a doula is not a medically trained person, but she's a labor companion, she's knowledgeable about birth and she can help a mom stay calm. She's also there to help the dad relax.

PAGEAnd so what about Matt's question, about men filling these roles?

GASKINThere are some male midwives, usually they're nurse midwives. Sometimes they're working in administration, sometimes they're teachers, sometimes they're practitioners and I think that they work very well. You know, it depends on the man's personality. I know a guy in Belgium who's just fabulous because he's -- he doesn't afraid to -- he was telling us how his name was Jo, OK, Jo. And he got in because his name sounded like he was a woman.

GASKINSo he sort of sneaked in and he's also kind of a small guy and he has a lot of respect for women, so I saw no problem at all with the women midwives accepting him and he told us the story of a -- this woman where she needed to be, sort of be up on her kitchen counter and he was sort of below. That's not something that you would see a male obstetrician particularly putting himself in that almost subservient position, but that's what worked for that woman and that's what got that baby out, so...

PAGESo Matt, maybe you should give it a try. You know, one of the interesting things in your book is it turns out there is an actual birth maneuver that's named after you, the Gaskin maneuver. What is that?

GASKINOh, well, this is something that I've learned from midwives. Hold your breath now, who are illiterate, OK? Now, how can somebody illiterate know more than people know in hospitals? Because people -- there's age-old knowledge that's just common sense, OK. So the complication is called shoulder dystocia, it's when the baby's head is born and then the shoulders are wedged in such way in the woman's pelvis that on the mother's efforts alone, she can't get that baby born. And so the outcome's not going to be good unless we do something.

GASKINSo I was taught that you're supposed to snap the baby's collarbone. I thought, that sounds, like, drastic. Couldn't there be a better way? Traveled to Guatemala, there I met a midwife who had been taught, you know, the formal training maneuvers, which are rotate the baby in some way, but that can be kind of rough for the mother sometimes.

GASKINAnd she said she learned from those illiterate midwives that lived up in the mountains something much simple. She said, turn the mother over. I remembered that, so I came back, had such a case, turned the mother over, the baby fell out, 10 pounder, no episiotomy, no tear. Then we had quite a -- we counted up our instances of that. It was published and ultimately came to be called the Gaskin maneuver.

PAGEWell, congratulations to that. Ina May Gaskin, thank you so much for joining us this hour on "The Diane Rehm Show" and talking about your new book "Birth Matters: A Midwife's Manifesta."

GASKINThank you, Susan.

PAGEI'm Susan Page of USA Today sitting in for Diane Rehm while she's on vacation. Thanks for listening.

ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth, Sarah Ashworth, Lisa Dunn and Nikki Jecks. The engineer is Tobey Shreiner. A.C. Valdez answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information.