Monday, March 24, 2008 - Page updated at 01:26 PM
Looking to nature, doula Penny Simkin practices the art of delivery
By Paula Bock
Penny Simkin's cheerfully cluttered basement office looks nothing like a sterile hospital.
It's graced by maternity tchotchkes collected from around the world, piled with books and scientific journal articles about birth (many penned by her), thumbtacked with whimsical reunion snapshots of babies leaning precariously against each other on the couch.
Simkin's pug, Hugo, wheezes while Simkin putters, wadding a doll baby and crimson "placenta" pillow into a hand-knit argyle "uterus" sack. She cinches a rubberband around the opening. There. That's the "cervix" — ready to dilate. Class starts in half an hour.
Nearly 70 years old, Simkin is an internationally revered childbirth educator who, with nurse co-authors Janet Whalley and Ann Keppler, literally wrote the book on giving birth: "Pregnancy, Childbirth and the Newborn." It's been translated into Russian and Italian, among other languages; more than a million copies sold.
Known as the mother of the doula movement, Simkin has trained thousands of these caregivers to provide physical and emotional support for women during birth — the only intervention scientifically shown to decrease time in labor (by 25 percent) as well as to reduce Cesarean-section rates by a third.
"Birth never changes," Simkin says. "But the way we manage it and the way we think of it has. Right now, we're in a culture of fear around birth." Pain, medical mishaps, lawsuits.
"In our fear that we might have a bad outcome, we decide Cesarean is the answer for everything, and so we're losing the skill and art" of delivering babies, Simkin says. "For six years, nobody's done a breech birth. Some don't even know how to turn a baby who's posterior!"
Cesarean rates have climbed to 32 percent in Seattle, an all-time high on par with the rest of the nation, and an increase of more than 50 percent in a decade. While a direct link has not been proven, infant and maternal deaths are rising, too.
"Things are not so marvelous in birth these days," says Dr. Michael Klein, who studies worldwide Cesarean trends as an emeritus professor of family practice and pediatrics at the University of British Columbia. "To say it's medicalized is an understatement. It's industrialized. Somehow, Penny remains optimistic."
With earthy humor and a steadfast belief in evidence-based medicine rooted in scientific study (rather than hospital fashion), Simkin preaches a radical notion: Birth is normal. Birth is natural. Women deserve the support they need to have the kind of birth they want.
Birth is also political — mired in insurance regulation, hospital protocols, legal anxiety and hectic lives. Insurance doesn't reimburse as much for midwives as for doctors; learning how to give birth takes time; Cesarean births are convenient for schedules; high-tech births fuel a big business in drugs and medical equipment.
Experts may differ on whether to offer massage or drugs during hard labor, but they all acknowledge Simkin as a "living treasure" for her knowledge about birth, compassion for women, and ability to teach skills developed during 40 years in the field.
"How Will She Remember It?" Simkin's mantra. She's printed the phrase on doula T-shirts to remind hospital staff to be sensitive to laboring moms. "When you start focusing on a woman's experience of birth and not just the issue of natural childbirth," Simkin says, "it opens up a whole new world."
Simkin is not a die-hard natural-birth proponent, but she does wonder why women have become so timid about birth when they're so powerful in other aspects of life.
"I'm so sad that women think birth is impossible," Simkin says. "They're also very busy and don't have time for classes. There are very few sources where they can get confidence in themselves . . . Women are so fit and athletic and run marathons, and yet think they can't do birth.
"I want people to appreciate how well their bodies are designed to give birth. Every cell in your body knows how."
PENELOPE PAYSON was born in 1938 in Maine, the third of six children. Her father owned a hardware store and served on the school board and water commission. Her stay-at-home mom led a Girl Scout troop and victory projects for the war. They expected their children to do chores and community service and to stay out of trouble.
In a small town where many youngsters drank and a third of the girls got pregnant before graduation, Penny was different, a swimming champion good enough to try out for the Olympics. "She was feisty," recalls sister Helen Seager. "She could do things girls weren't expected to do. . . . Even though I was the older one, she was my idol." Penny, herself, recalls being so sensitive that when punished for misbehaving at 9, she vowed to never forget what it was to be a kid. That vow, Simkin says, has helped her be aware of other people's feelings ever since. Growing up, Penny knew nothing about birth. Her mother, like many American women at that time, had been drugged during births and couldn't remember.
Penny chose Swarthmore College for its undefeated swim team; she graduated as swim captain with a degree in English literature. During her junior year, she married Peter Simkin, a medical student, and after graduation studied physical therapy at the University of Pennsylvania.
At 23, they moved to North Carolina and she became pregnant with their first child. It was 1961, the start of a movement toward natural childbirth, and her doctor told her she'd be an excellent candidate. But her son was 22 days post due-date, 10 pounds 4 ounces, and facing the wrong way. She ended up being induced, laboring unsuccessfully, then having general anesthesia and a forceps delivery.
"I felt awful because the doctor told me I would have a natural birth, and I wanted to please the doctor," Simkin says. "Then he grabbed my ankle, looked in my eyes and said: 'What a trouper.' He made me feel I didn't have to be ashamed." For Penny, the doctor's compassionate treatment was pivotal; it became the philosophical seed of her life's work.
Within five years, she had three more children (two natural births, one with epidural anesthesia to block the pain), and after most of the kids were in school, she started teaching childbirth classes, figuring it would be a good use of physical-therapy skills.
She was a born teacher, delved into research, spoke at conferences, and attended many students' births as a doula before the role had that name. She invented a "birth bar" and birth sling to help women squat and lean during labor; codified birth plans to give women more control over the process; co-authored several books; edited a journal of current scientific literature about birth; pioneered pregnancy-care techniques and counseling for survivors of sexual abuse.
After 20 years, career crisis. Cesarean rates were climbing in the late-'80s, and the trend was to focus on parenting rather than on birth. After all, birth was only one day.
Does childbirth really matter? Simkin wondered.
Over the years, she'd had students write their birth stories and fill out questionnaires, and she'd saved them all. She tracked down 24 students from her first classes, and asked them to recall their birth experiences — 20 years later. Simkin compared original versions with new.
"It was uncanny how clear their memories were and how powerful," Simkin says. She interviewed 20 women in person. Nine wept as they talked, some out of joy and pride, others from anger and remorse. The women who were satisfied with their births didn't necessarily have an easy time or a natural birth, Simkin says. What mattered was how they were cared for by medical staff.
"We can't control labor, whether it's hard; that's a leap of faith," Simkin says. "But we can always control how we care for her." Even though it's only one day, women are more vulnerable, Simkin says. There's pain, exposure, dependence on others, possibility of physical harm, authority figures who may, or may not, be sensitive. One in four women today describes birth as having been traumatic. What women really need, she decided, was an experienced, caring advocate who would not only coach them through the physical part of labor but also tend to their emotional needs. So Simkin helped start regional and international doula associations, PALS and DONA, and trained doulas at a rapid pace. She taught the senior doulas to train new doulas for ripple effect. Within a few years, there were thousands of doulas, and the concept was on the map.
"If a woman is empowered by birth, she thinks: 'If I can do that, I can do anything' — for the rest of her life," Simkin says. "If she was humiliated or shamed, what she learns is: 'I'm a wimp. I can't handle pain.' How does that affect how she deals with other things?"
WOMEN, OF course, have been giving birth since the start of humanity. Yet until fairly recently, birth was likely the most dangerous event of their lives.
A century ago, one in 100 women died during childbirth. In the United States, that number is now one in 4,800. (In sub-Saharan Africa, the current risk of maternal death is one in 22; in Afghanistan, one in eight — a reflection of malnutrition, disease, poor health care.)
In the U.S. through the 1800s, most women gave birth at home, assisted by midwives, relatives, their husbands. Hospital births began in the 1900s, mostly in cities. Doctors began using anesthetics ether and chloroform; narcotics such as Demerol; "forgetting drugs."
Simkin calls the ether-soaked 1940s and '50s the dark age of obstetrics. She roots around filing cabinets in her basement and pulls out a startling investigative series, "Cruelty in Maternity Wards," by the Ladies Home Journal.
The exposé started in 1957 with publication of an anonymous letter from a Chicago nurse asking the magazine to investigate "tortures" in delivery rooms. The nurse described mothers "strapped down with cuffs around her arms and legs and steel clamps over her shoulders and chest" for more than eight hours; doctors suturing without anesthetic; an obstetrician who ordered nurses to "slow things up" by tying a laboring woman's legs together while he went to dinner.
The nurse's letter triggered hundreds more from readers who described other horrors, including children who'd suffered brain damage from lack of oxygen because delivery had been forcibly delayed.
The series helped spark a countermovement toward natural childbirth. Husbands demanded to stay with their wives during labor; expecting parents Clifford and Audrey Stone in Seattle sued to do so in 1958. The judge ruled against them, saying he had no authority to regulate obstetrical practice. Simkin recalls another Seattle father who handcuffed himself to his wife during the labor.
Enter Grantly Dick-Read, a British physician who taught relaxation and controlled breathing to reduce fear and pain. In the late '50s, his worldwide teaching tour touched down in four North American cities, including Seattle, leaving pockets of natural-childbirth advocates. Among them was family doctor Virginia Larson, founder of the Seattle Association of Childbirth Education. She became Simkin's mentor.
Simkin's career grew with the natural-childbirth movement in the 1960s and '70s. Urban middle-class moms were clamoring for midwives so much that some midwives left Appalachia and the migrant communities they'd originally trained to serve.
By the 1980s, hospitals tried to lure back middle-class moms — and their health insurance — by building comfy home-like birthing suites. Advertisements touted flowered curtains, straw hats decorating the doors and epidurals.
Home-birth midwifery dwindled in other parts of the country, but it's still thriving here, fueled by the Seattle Midwifery School. Simkin calls Seattle the best place in the country to have a baby because of the many options: midwives, home births, birthing centers, high-tech hospitals.
The problem with hospitals, she says, is that when it comes to birth, they often don't practice evidence-based medicine. They induce labor unnecessarily, she says, and that feeds C-sections. They use continuous electronic fetal monitoring that has not been found to improve outcomes. "Yet it's a big industry and nurses are terrified if the monitor isn't on," Simkin says. Even worse, slight blips in the baby's heart rate often make docs scurry to do a C-section. "If doctors would just listen to their own literature!"
In 2003, the American College of Obstetricians and Gynecologists gave a nod to elective C-sections requested by healthy moms who want only one or two children. Aghast, other birth professionals cite studies about C-section's hazards, including greater risk of infection, blood clots, death; surgical injuries; increased infertility and a chance the next baby's placenta could get stuck to the old scar and hemorrhage.
Much of the rise in C-section rates is patient-driven, says Dr. Nancy O'Neil, a respected Seattle obstetrician/gynecologist. "The U.S. is such a trendy country. . . In the late '70s, early '80s, people would do anything to have a vaginal birth. Seattle was natural . . . Now, the city has become more of a city. Educated older patients are used to having a lot more control over their lives, and the idea of scheduling something and having it be controlled is very appealing. That's why it's really important to have people like Penny who say, 'Stop! Look at the advantages of vaginal birth.' . . . Some people feel vaginal birth will become archaic."
O'Neil calls Simkin a bridge. "Her book on childbirth is the bible we all use . . . She also helps patients realize, yeah, natural childbirth is great but y'know what? There's a lot that's great about medicine, too."
Simkin, who's attended more than 750 births as a doula and still takes cases, says she's not done. Her goal is to leave vast knowledge about supporting women in natural childbirth "so when we finally hit 50 percent C-sections or 80 percent and people say we have to find a better way, it's time to swing back with the pendulum, (we won't) have to reinvent the wheel."
TEACHING IS what Simkin loves best. With a calm voice, plump lap and Mr. Rogers-like gentleness, Simkin combines common sense with facts-you-can-use science.
Eat almonds, leafy greens and dark chocolate in the last few weeks of pregnancy to stave off anemia as the baby drains mom's iron; touch your tongue to the roof or your mouth so you won't hyperventilate during heavy contractions.
She teaches birth partners how to squeeze a laboring woman's hips to take the edge off back ache; how to rock through contractions in a slow dance; how to manage pain through rhythm, relaxation and ritual.
Simkin's childbirth classes are so popular that Scott and Debbie Fynn stayed up until 2 a.m. while vacationing in Tokyo last fall just to call her office at 9 a.m., Seattle time, on the first day of registration for the three-month class.
"She's so enthusiastic and easy to listen to," Debbie says, "even though you'd think when you're huge and waddling, you wouldn't want to sit in a chair for two hours."
On Monday night, a wiggly class of small children surrounds Simkin; she's preparing them for the births of siblings — "your babies. Can we all say umbilical cord? Um-bil-i-cal! I love that word!"
The Wednesday-night class, the series' last, , has a certain urgency. The couples practice double hip squeezes, slow dancing, then Simkin falls to her knees in hard labor. OOOhh, she moans, face contorted. She shakes, writhes, hyperventilates.
"OK," says Russell Grandinetti, a 36-year-old father-to-be who volunteers to play the role of birth partner. "I know. It's coming."
"HELP me!" Simkin yells. Get your head down close, she stage whispers. Grandinetti kneels, nose to nose with Simkin.
"You're doing great. Look at me, Penny." He breathes loud, rhythmically, flaps his hand, like a conductor. She moans in sync.
"I HATE THIS!"
"You're making good progress. Doing great!"
Gasp! Gasp!! "I'm going to vomit!"
"OK. That's good! Don't worry about it, we got the doula helping!"
Everyone laughs. Simkin commends Grandinetti for helping her cope and keep a rhythm. "He didn't have panic on his face. That's important. You have to look like you have confidence in the woman."
There's a pause as couples realize labor will soon be for real.
"When you get to complete dilation," after the hardest contractions but before spontaneous pushing, Simkin tells them, "your spirits will rise. I love that rise. "
Then it's over. Three months. Videos, role-plays, hundreds of tips. Simkin sips some water, unplugs the projector.
Grandinetti's wife, Hanouf, wanders over to thank Simkin. Hanouf says her blind optimism turned into true confidence as she learned about birth and how to cope with pain. "I'm so excited," she says. "I can't wait!"
Paula Bock is a Pacific Northwest magazine staff writer. E-mail:firstname.lastname@example.org. Benjamin Benschneider is a Pacific Northwest magazine staff photographer.
Copyright © 2008 The Seattle Times Company