If you’re pregnant, you have quite a few decisions to make prior to the arrival of your bundle of joy. Chief among these choices is who will care for you during your pregnancy and immediately after giving birth. Although the most common answer to this question is an obstetrician, for an increasing number of women, midwives are fitting the bill of preferred care provider during this special time.
A midwife is a specially trained health care professional who assists women during pregnancy and childbirth. These care providers can work in a range of settings, facilitating at-home births as well as births in hospitals or birthing centers.
Midwife involvement in births is on the rise.
The American College of Nurse-Midwives reports that in 2014 (the most recent year for which data have been finalized), certified nurse-midwives and certified midwives attended 332,107 births. That represented 12.1 percent of all vaginal births and 8.3 percent of total U.S. births that year. The organization also reports that since the commencement of data collection about midwife-attended births in 1989, “the percentage of CNM/CM-attended births has risen nearly every year. In 2014, CNMs/CMs attended 8 percent of all hospital births, an 11.1 percent increase [in the rate] since 2005. The percentage of out-of-hospital births attended by CNMs also increased 9.1 percent over this period, from 28.6 percent in 2005 to 31.4 percent in 2014.”
[See: 10 Ways to Make Your Childbirth Easier.]
One compelling reason for this increase in use of midwives is recent research that has indicated midwives generally have comparable birth outcomes with fewer medical interventions. Midwives “tend to be more low intervention,” says Laurie MacLeod, a certified nurse-midwife at The Ohio State University Wexner Medical Center. “We don’t schedule inductions just because of our schedule. We only do it when it’s medically indicated. We have lower C-section rates and lower episiotomy rates.” (A C-section, short for cesarean section, is a medical procedure in which the baby is delivered via surgery. These operations are usually reserved for cases when a vaginal delivery would put the health of the mother or baby at risk. An episiotomy is a surgical cut made to the vagina to ease a difficult delivery.)
It seems that less really can be more when it comes to healthy delivery for women who are at low-risk of complications, says Laura Attanasio, an assistant professor of health policy and management at the University of Massachusetts Amherst’s School of Public Health and Health Sciences. “There’s been a growing recognition in culture, more generally, but also specifically in births that at some point, more medical intervention when it’s not necessary can actually have unintended negative consequences.”
Attanasio studies the impact of midwifery practices on birth outcomes and was the lead author on a recent study that examined birth data at the hospital level. That study found women who worked with midwives had fewer medical interventions. “There’s been a number of studies that have looked at the individual level, comparing women who were cared for during pregnancy and birth by midwives to women cared for by doctors or other health care providers. These studies have found that women cared for by midwives have comparable outcomes [in terms of healthy births] to women cared for by physicians. But at the same time, they are less likely to have use of certain obstetrics procedures,” such as C-sections, episiotomies and labor induction. “Our study was adding” to this discussion by looking at the share of births at specific hospitals attended by physicians or midwives and how that related to the number of medical procedures.
Attanasio says the number of births attended by midwives varies greatly by hospital. “Some hospitals have no midwives attending births, while others have a large proportion of births attended by midwives.” But the hospitals with a higher proportion of midwife-attended births had lower rates of medical interventions.
Midwives approach births as ‘a normal physiological process.’
Although the reason why midwife-attended births tended to have fewer medical interventions isn’t entirely clear, Attanasio says it’s likely related to how midwives are trained and how they approach pregnancy and birth. “There’s a difference at the philosophical level of care. Doctors are trained to identify and treat pathology, and midwives are trained to think of birth as a normal physiological process.” She says midwives are there to “facilitate that normal process running its course. They certainly can identify pathology and treat it or refer to a care provider that can, but I think that they’re also trying more to support the normal process. Their whole philosophy is rooted in pregnancy and birth not potentially being pathological conditions, but being thought of more on the fundamental level as being normal processes and normal life stages.”
And in hospitals where midwives are more common, Attanasio says that low-intervention philosophy may sway how physicians practice, too. “We weren’t able to directly test this, but it’s possible that having the culture of midwifery might influence the type of care everyone is providing,” in a particular hospital.
[See: What’s the Healthiest Month to Be Born In?]
MacLeod says that this difference in philosophy shows up in the patient-provider interaction. “Appointment times are longer, so we have more time to spend building that relationship and educating women about the normal changes of pregnancy. The biggest difference is during delivery — we’re with women during their entire labor process, whereas the physicians tend to come in at the time of delivery, deliver the baby and they’re focused on ER consults, surgeries, those sorts of things. They don’t have as much time to spend with women in labor.”
Midwives can work independently and often do, but they also frequently work in collaboration with physicians, particularly if the pregnant woman has a complication or is at higher risk of developing one, MacLeod says. “Patients who have diabetes or preeclampsia [high blood pressure during pregnancy and delivery] and other complications — sometimes during [pregnancy], we’ll alternate visits” with an obstetrician. During labor and delivery, midwives work closely with the physician if the woman is experiencing complications. “If a woman has preeclampsia, [the physician] will be medically managing the patient, whereas we manage the labor. We’re still able to support them regardless of the birth outcome,” MacLeod says.
Doulas are another option that some pregnant women seek to include in their prenatal and post-partum care team. Doulas act as a sort of health coach to pregnant women, but have a limited role, Attanasio says. “The key distinction to understand between doulas and midwives is that midwives are health care providers who are taking on the responsibility for the medical safety of the birthing person and the baby during pregnancy and birth, whereas doulas are there as an adjunct role to provide physical and emotional support to the birthing person. The doulas aren’t doing medical tests. They’re not trained to do so.”
Attanasio has completed doula training, which she says typically lasts about four days and is sometimes followed by an apprenticeship, “or just jumping in and supporting some births.” She says the training is not higher-education based, but focuses on “relaxation techniques, positions you can be in” and other techniques that can make for an easier delivery. In addition, Attanasio says doulas can be a helpful resource to women looking for the right obstetrician or midwife to deliver their baby. “If they’ve been practicing a long time, [doulas] often have a lot of knowledge about what different providers’ practices might be like,” and what options are available to women giving birth in that area.
MacLeod explains that “doulas provide labor support, but they’re not medical professionals. So, they do not provide any of the prenatal care, they are not managing the labor, they are strictly there just to support.” Certified nurse-midwives, on the other hand, MacLeod says, are practicing nurses who have completed a two- to three-year master’s degree in midwifery. A certified midwife has also completed a master’s degree in midwifery, but is not necessarily a nurse as well. The Accreditation Commission for Midwifery Education is the official accrediting body for CNM/CM education programs. There are 39 such programs in the United States.
When it comes to deciding whether you want an obstetrician or a midwife to deliver your baby, MacLeod says “I don’t think there’s a wrong choice to make. It really just depends on what the woman is hoping to get out of her care. The biggest difference is that continuous support during labor. And it’s really evidence-based — the research shows that midwives have better outcomes and it is directly related to the relationship that we build with women and the support that they get during their pregnancy and beyond.”
Organizations back the involvement of midwives.
For its part, the American College of Obstetricians and Gynecologists supports the use of midwives. In a joint statement issued in 2011 and reissued in 2014 by the ACOG and the American College of Nurse-Midwives, the two organizations highlighted their preference for collaboration, noting that the two organizations “affirm our shared goal of safe women’s health care in the United States through the promotion of evidence-based models provided by obstetricians-gynecologists, certified nurse-midwives, and certified midwives. ACOG and ACNM believe health care is most effective when it occurs in a system that facilitates communication across care settings and among providers.” In some areas of the country where OB-GYNs may be harder to come by, midwives can and often do pick up the slack, offering better access to quality health care for some women who might otherwise not be able to access appropriate care.
MacLeod does urge women considering working with a midwife to seek a partnership with a board-certified nurse-midwife. The American College of Nurse-Midwives offers a search feature for certified nurse-midwives. MacLeod cautions against seeking the services of a lay midwife, an unlicensed and sometimes self-trained individual who may have a lot of experience but hasn’t met the stringent certification requirements to carry the title certified nurse-midwife or certified midwife. “In Ohio, there are lay midwives who are not regulated or licensed through the state who do home births and sometimes that can be really confusing for patients because they don’t realize [these providers] do not have a master’s degree. They don’t have that training, so looking for a CNM is an important thing.” To become certified, a nurse-midwife must pass a certification exam administered by the American Midwifery Certification Board. You can verify a midwife’s certification on the group’s website. Individual states have varying licensure requirements for practicing midwives.
[See: 10 Weird Mind and Body Changes That Are Totally Normal During Pregnancy.]
MacLeod says it’s also a good idea to meet with the midwife early on to see if your personalities mesh. She also recommends asking about the midwife’s transfer arrangements — which hospital facility the midwife works with and which obstetrician would take your referral in case a complication arises. “Oftentimes that can have a huge role in terms of birth outcomes. Look at the hospital itself and its C-section rates, because there can be policies in place” that could influence the outcome of the birth “even if you have a great midwife.”
Lastly, Attanasio notes that just because you opt to work with a midwife doesn’t mean you’ll be forgoing all modern medical support or conveniences. There’s a common misconception that midwives only offer natural birth experiences, but that’s not the case, she says. “Especially in a hospital setting, for example, the pain relief options that would be available to women during labor would be the same with a midwife as with an obstetrician. It’s not only for unmedicated birth,” so you’ll still be able to opt for an epidural (a powerful pain blocker) during birth if you decide you need relief.
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Should I Call the Midwife? originally appeared on usnews.com
