Congratulations, You're Pregnant!
Let the decision-making begin. Choosing a health care provider to care for you and your baby during your pregnancy is one of the biggest decisions you'll make.
In the United States, women's choices once were limited to an obstetrician or a knowledgeable family doctor. But in recent years midwives became another alternative for women with low-risk, uncomplicated pregnancies.
In Europe, midwives assist at more than 70% of normal vaginal births. Though midwives delivered only 7% of American babies in 2003, that percentage has been increasing since 1975. But most Americans aren't sure what midwives do, how they're trained, or if they're even available. Is a midwife a viable option for you?
The History of Midwives
The word "midwife" comes from Old English and means "with woman." Midwives have helped women deliver babies since the beginning of history. References to midwives are found in ancient Hindu records, in Greek and Roman manuscripts, and even in the Bible.
As early as 1560, Parisian midwives had to pass a licensing examination and abide by regulations to practice. Not all midwives had this level of education, however. English midwives received little formal training and weren't licensed until 1902. America inherited the English model of midwifery.
Early American midwives usually learned their craft through apprenticeship and tradition. They were not educated about scientific advances in fighting infection through hygiene and drugs such as penicillin. By the early 20th century, women and their babies were more likely to die under the care of midwives than under the care of doctors.
Around this time, American medical doctors began a campaign against midwifery in the press, the courts, and Congress. They cited the poor outcomes for mothers and babies under the care of midwives. Doctors might also have viewed midwives as competition.
The Foundation of Certification
Whatever the doctors' motivations, the rate of midwife-attended births dropped during and after the campaign. But the widespread criticism from the medical establishment prompted the foundation of the first certified American nurse-midwifery school in 1932. It aimed to incorporate the necessary medical training into midwifery's traditional approach to pregnancy and labor.
What Kind of Training Does a Midwife Have?
Midwives today come from a variety of backgrounds. The subtitle a midwife uses will indicate the level of education and training. Most American midwives are certified nurse-midwives (CNMs) who:
- have at least a bachelor's degree and may have a master's or doctoral degree
- have completed both nursing and midwifery training
- have passed national and state licensing exams to become certified
- are licensed in every state
- may work in conjunction with doctors
About 96% of births assisted by certified nurse-midwives occur in hospitals.
A certified midwife (CM) is not a registered nurse but otherwise meets the same qualifications as a certified nurse-midwife. Because this certification has only existed since 1996, there are few CMs. Currently, only some states recognize this certification as sufficient for licensing.
A lay or direct-entry midwife may or may not have a college degree or a certification. Direct-entry midwives may have trained through apprenticeship, workshops, formal instruction, or a combination of these. Not all states require them to work in conjunction with doctors, and they usually practice in homes or non-hospital birth centers. But not every state regulates direct-entry midwives or allows them to practice.
A certified professional midwife (CPM) is certified by the North American Registry of Midwives after passing written exams and hands-on skill evaluations. Direct-entry midwives and certified nurse-midwives can apply for this certification. They're required to have out-of-hospital birth experience, and usually practice in homes and birth centers. Their legal status varies according to state.
What's the Midwife's Philosophy?
A midwife's education stresses that pregnancy and birth are normal, healthy events until proven otherwise. Midwives view their role as supporting the pregnant woman while letting nature takes its course.
Midwives also focus on the psychological aspects of how the mother-to-be feels about her pregnancy and the actual birth experience. They encourage women to trust their own instincts and seek the information they need to make their own valuable decisions about pregnancy, birth, and parenthood.
Of course, many medical doctors (MDs) share these values. But an MD may be more likely to use preventive testing and medical technology — such as ultrasound, continuous fetal monitoring, and the option of pain medications during birth — as a standard part of care during pregnancy and labor.
High-risk pregnancies undoubtedly require this approach. But many midwives find it unnecessary for most uncomplicated pregnancies.
What Does a Midwife Do?
Midwives generally spend a lot of time during prenatal visits addressing a woman's individual concerns and needs, and will stay with her as much as possible throughout labor. They sometimes encourage physical positioning during labor such as walking around, showering, rocking, or leaning on birthing balls. Midwives also usually allow women to eat and drink during labor.
Certified nurse-midwives, like doctors, may use some medical interventions, such as electronic fetal monitoring, labor-inducing drugs, pain medications, epidurals, and episiotomies, if the need arises. However, a certified midwife, certified professional midwife, or direct-entry midwife may not legally be allowed to use these techniques without a doctor's supervision. And birthing centers may or may not be equipped for these procedures.
Cesarean Sections
Midwives of any licensing degree cannot perform cesarean sections (C-sections). If one were required, an obstetrician would have to perform your delivery. If any potentially life-threatening complications suddenly arose during delivery, midwives should also involve an obstetrician.
Certified midwives are trained in basic life support for newborns and, in the event of sudden complications with your baby after birth, can care for the baby until a pediatrician or neonatologist (an intensive-care specialist for newborns) is available.
Is a Midwife Right for You?
Several studies have shown that midwife-supervised births produce excellent outcomes with fewer medical interventions than average. Midwives' patients use electronic fetal monitoring less often and tend to have a reduced need for epidurals, episiotomies, and C-sections for successful deliveries. To some degree, this stems from the fact that midwives see only low-risk patients with uncomplicated pregnancies. But some researchers attribute the need for a minimum of medical intervention to the midwives' natural approach to the management of labor and delivery, which may reduce a woman's fear, pain, and anxiety during birth.
Midwifery is not advisable for women with higher-risk pregnancies. Those expecting twins or multiples and those with prior pregnancy complications, gestational diabetes, high-blood pressure, or chronic health problems of any kind before pregnancy should discuss their options with their primary health care provider or an obstetrician. Certified nurse-midwives who practice in major medical centers and work very closely with obstetricians and perinatologists (specialists in high-risk pregnancy) may take patients with risk factors. But midwives in solo practice or who practice in limited medical facilities generally do not.
Surgery and Anesthesia
A major difference between doctors and midwives is the doctors' ability to intervene surgically when necessary, and to deal with complications that arise. Midwives can't perform C-sections and some can't administer drugs or anesthesia. If you feel more comfortable having those options immediately available, a doctor may be the right choice for you.
What if Something Goes Wrong?
Midwives are trained to recognize the signs of trouble in pregnancy and labor. If a complication develops at any time, the midwife should consult a doctor. If your midwife doesn't already have a practice agreement with a doctor, be sure to find out what will be done in case of a complication.
If you plan to deliver at a non-hospital birth center or at home, an emergency back-up plan is especially critical. If you must go to the hospital, your midwife will go with you and will continue to support you throughout your labor.
But it's a good idea to get answers to these questions:
- What training or equipment does your midwife have to handle emergencies?
- How far will you be from the nearest hospital?
- Do they have fail-safe transportation?
Finding a Midwife
You can decide to use a midwife at any time during your pregnancy. Women often turn to midwifery a few months before their due dates, when they begin to seriously consider their birth plans.
To evaluate your medical needs, most midwives will request that you bring your prenatal care records to your first meeting. Few midwives will accept a patient well along in pregnancy unless she has had adequate prenatal care.
Interview a prospective midwife carefully. Investigate the midwife's background, certifications, experience, and emergency procedures. Because you'll be closely involved, make sure your personalities mesh. Do you feel comfortable with the midwife? Can you talk easily?
To locate a midwife, try asking your obstetrician-gynecologist (OB/GYN), family doctor, and friends for a referral.
Reviewed by: Larissa Hirsch, MD
Date reviewed: February 2008
Previously reviewed by: Serdar H. Ural, MD
