100 years ago, one doctor was very much like the next, at least in their base of knowledge. Medicine had not yet branched out into the specialities which are common today. Accordingly, a midwife was almost always a layperson with some experience in assisting women giving birth in the home. Today there seems to be a specialist physician for every part of the body, and there are now several distinct categories of midwives.
Doctors Who Deliver Babies
Across most of the U.S., there are now 2 types of MDs (medical doctors) who deliver babies. One is the obstetrician/gynecologist (Ob/Gyn), and the other is the Family Practitioner (FP). The Ob/Gyn is a person who has completed 4 years of college, 4 years of medical school, and 4 years of “residency” in obstetrics and gynecology. Almost all of the experience an Ob/Gyn has is obtained in large hospitals. The Family Practitioner is the modern day version of the old General Practitioner, but the specialty is much more formalized today than ever before. Like the Ob/Gyn, the FP graduated from college and medical school, but the FP’s residency is usually a 3-year training which includes “ob” as only a small part. Ob/Gyn MDs have been educated to care for normal and high-risk pregnancies, and are able to perform surgeries, including cesarean section. Most FPs only take care of normal and moderate risk pregnant woman, and do not perform cesarean sections without the help of a surgeon or ob/gyn.
An osteopath, a “D.O.” or Doctor of Osteopathy, is very similar to a medical doctor. Osteopaths use D.O. after their names instead of M.D. An osteopath may attend a four-year residency in obstetrics and gynecology, and become an Ob/Gyn.
Other types of “Doctors” Delivering Babies
Some chiropractors (D.C.) and naturopaths (N.D.) also deliver babies. Their training, however, is only a fraction of that of a MD, and must be considered, as far as formal training goes, on a level with a formally trained, “direct-entry” midwife. Very little to none of the training that a chiropractor or naturopath obtains occurs in a traditional hospital. Obstetrics is not a formal part of a DC or ND’s training. Most of the births they attend occur in homes and birthing centers. Generally speaking, they are not trained or qualified to handle medical problems or problems which will require prescription medicines or surgical solutions. If you select a naturopath or chiropractor to attend your labor and birth, it is very important to inquire closely about their experience and their consultation/referral relationship with an obstetrician.
Naturopaths may be well versed in the use of herbal medicine, accupuncture, accupressure and other “alternative” therapies. Many herbal remedies are unsafe if used improperly. A naturopath will know which herbs to use when, and in what dosages and formulations. Don’t use an herbal treatment unless it is recommended by a clinician who is experienced in its use.
Midwives
The word, midwife, is derived from two Old German words, “mitt” (with), and “wif” (woman). Thus, the word, midwife, means “with woman”. Like doctors, there are also different types of midwives. Most people still believe that a midwife is an apprentice-trained person who attends births in the home. But since World War II, and the emergence of the Certified Nurse-Midwife (CNM), the large majority of midwife-attended births in the U.S. occur in hospitals attended by a CNM working in collaboration with a medical doctor.
Certified Nurse-Midwives are registered nurses with specialty training and education in the science and art of midwifery. The majority of CNMs now earn their midwifery certification in Masters Degree programs at established universities and colleges (after obtaining a college degree in nursing). With recent changes in the profession, there is now an avenue by which a person with a college degree may attend a school of nurse-midwifery and obtain certification without first becoming a nurse (though these individuals receive an education that assures an adequate base of knowledge in the general health sciences*). By the standards set by the American College of Nurse-Midwives, CNMs practice in collaboration with a physician. CNMs are registered or licensed in all 50 states.
CNMs attend about 6-7% of the births in the U.S. In some states (Oregon, New Hampshire, Georgia, Arkansas), the percentage is over 10%. In New Mexico, almost 20% of births were attended by CNMs. Of the 240,000 births attend by CNMs in 1996, only 9,000 occurred outside a hospital.
Midwives who are not CNMs attend about 1% of the births in the U.S. Many of these midwives use the the term, “direct-entry”, to describe their training process. Almost all of the births attended by this group of midwives occur in the home. This group of midwives may be called by one of several terms- lay midwives, direct-entry midwives, or granny midwives. These midwives may or may not have formal training or education. The “apprenticeship” is usually an important part of the training and education of these midwives. The Midwives Alliance of North America, or MANA, has taken great strides in the last decade to assure that midwives associated with the alliance meet certain minimal standards and qualifications. But not all direct-entry midwives subscribe to MANA’s authority or standards. There is now a certification test for midwives who wish to meet these standards, and a few states now recognize this and license and regulate direct-entry midwives. Midwives certified by MANA, use the credential, CPM, or Certified Professional Midwife. Some states still do not recognize non-CNM midwives, and to varying degrees, limit their ability to practice.
If you are totally confused about midwives, and still interested in finding one to attend your baby’s birth, inquire about three things:
- Education
- Examination
- Experience
Doulas
Regardless of whether you chose to have your baby in the hospital or at home, with a doctor or a midwife, having a doula is an excellent idea….especially, if you want to birth “naturally”. The term, doula, comes from ancient Greece, where the doula was the primary attendant to the female head of the household. The doula served “the mistress of the house” in a domestic role, but was often her primary support person during childbirth and childrearing.
The Fine Print
To the degree that is practical, make sure that the person who cares for you is experienced, qualified and backed up by a system of health care that can handle the rare, but potentially devastating, complications of pregnancy, labor, delivery and the postpartum period. Although most pregnancies result in healthy mothers and babies, it was not so long ago that 1 in 10 mothers and babies died as a result of complications of childbirth. Bad things do happen to good people. Pregnancy is a very serious part of life……you need the guidance of a competent, caring, and experienced professional.
Other Professionals Who Care
In addition to the clinician who meets your primary needs during pregnancy you may be introduced to any number of professionals who can also play a significant role in your care.
The Registered Nurse, or RN, is an important part of most hospital-based childbirth experiences. In different settings, the RN may serve as part physician, part midwife, and part doula. However, the professional nurse is quite proud of the nursing role s/he provides…….described as both the art and science of caring. RNs work in physicians’ offices, health departments and hospitals. Most RNs now have college degrees in nursing.
A Perinatologist is an obstetrician/gynecologist who has an additional 3-year “fellowship” in perinatology. Perinatology is the branch of medicine that deals with the highest-risk pregnancies. If you have serious medical problems, or a serious problem which develops during your pregnancy, you may need the attention of a perinatologist.
Geneticists, and Genetic Counselors, assist women with problems related to chromosomal disorders or problems with fetal development. Many women will talk to a Genetic Counselor to find out if their babies are “at risk” for genetic, chromosomal or developmental problems. In the 21st century, genetic science will blossom. As this is being written, several high-speed computers are working round-the-clock to map the 3 billion “base pairs” on a strand of human DNA. When this map is completed and analyzed, a new frontier of medicine will emerge based on manipulation of human genetic material. This effort will greatly complicate the science of Genetics and Genetic Counseling.
Nutritionists and Dieticians are professionals specializing in human nutrition. Pregnancy is such a special time, it would not be unwise for any pregnant woman to consult with a nutritionist. Women who are overweight, underweight, diabetic or have malabsorption problems should consult a nutritionist early in pregnancy, or even before, if possible.
Social workers, are professionals trained in the discipline of social support and counseling services. A social worker knows the assets of the community, and evaluates an individual’s needs for those services. Many social workers have additional training as mental health therapists and counselors. A social worker may help a family acquire assistance with housing, food, substance abuse programs, and domestic violence situations. They can also assist in providing resources for adoption and resolving grief after a pregnancy loss.
Hospital, Birthing Center or Home
At the beginning of this century almost all births occurred in the home. As this century comes to an end, almost all births occur in hospitals. One might assume that our current “standard” is all good, but there are some problems with this assumption.
Although many argue that “hospitalizing” pregnancy has accounted for most of the improvement in maternal/child health outcomes, this may not be the case. Since the turn of the century, major improvements in public health and the introduction of antibiotics have probably attributed more to good mother/baby outcomes that simply taking birth out of the home. There are credible scientific studies which now show that outcomes in home and birthing centers, when attended by qualified, competent providers with appropriate emergency back-up, are equally safe for the low-risk mother and baby when compared to hospitals.
One of the more significant criticisms regarding the “hospitalization” of birth was the alarming increase in unnecessary medical intervention during the 1970’s and 80’s. But this is also the major benefit of the medical/hospital model of care- the ability to handle emergencies and deliver high-level medical services in high-risk situations. Many mothers and babies owe their lives to this system of care. However, unnecessary medical intervention in the normal labor and birth process increases the risk of “iatrogenic” complications. “Iatrogenic” means “caused by the therapy”. Thus, an iatrogenic complication is a complication that is caused by the treatment of the original problem. For example, if the colon is damaged by a surgical instrument during an operation to remove an appendix, the colon damage is “iatrogenic”.
Many feel that the “medicalization” of the normal process of pregnancy, labor and birth has produced unacceptably high levels of iatrogenic complications. Unnecessary cesarean sections are a frequent target of concern.
Hospitals and the physicians (and Certified Nurse-Midwives) who practice in them are regulated by several governmental and professional oversight agencies. Standards of care have been established which should guarantee a high level of competence and care. This standard is one of the highest in the world and certainly the highest in U.S. history. However, this standard is not without a price……both financially and psychosocially. Although most hospitals and physicians provide fantastic physical care, their services often fall far short on the emotional, social, and spiritual aspects of human health which many new parents need.
Direct-entry midwives, home-birth, and birthing centers offer care at the other end of the spectrum. The care is usually very personalized, with an emphasis on the emotional, social and spiritual aspects of health. However, in some cases the standards of care are not as clearly defined or adhered to……there is frequently little regulatory oversight. It could be argued that birth outside of a hospital or not directly under the care of a physician carries risks which are associated with the inability to provide for the rare emergencies.
Midwives and physicians who offer “out-of-hospital” birth options argue that women can be selected for their risk of having a complication. They further argue that the decrease in iatrogenic risks offsets any risks imposed by not being in a hospital……especially if the woman is healthy and has had a normal pregnancy.
There are studies which show that birth outside of a hospital can be a safe option for many women. What is most important is that there is a system in place to handle the contingencies associated with labor and birth. In Holland, 30-40% of births still occur in the home. These births are attended by midwives working within a system which mandates “meticulous selection of women at low risk” and provides for easy referral to a obstetrician and hospital when problems arise. The statistics on Holland’s home-birth outcomes are admirable. In the U.S., a study of almost 12,000 home-births attended by CNMs demonstrated the safety of home-birth for women at low-risk and attended by an qualified midwife. When women are properly screened for risk factors, attended to by an experienced and competent midwife, and have a back-up physician/hospital sytem in place, home-birth outcomes are at least as safe as hospital births.
The dilemna is this…….the majority of pregnant women do not need the services of doctors and hospitals to have a healthy pregnancy and birth; but those that do, need those services very much, and it is sometimes difficult to predict who will need such services and who will not. Only hindsight is 20/20. If you are healthy (and especially if you have a history of normal pregnancy and birth) and can find a midwife who adheres to the standards of care established by ACNM or MANA, birth at home or in a birthing center can be a safe option for you.
If you are shopping for an alternative to a doctor-assisted, hospital birth, consider these alternatives:
- A Certified Nurse-Midwife.
- A direct-entry midwife certified by MANA/NARM who has a reliable, formal relationship with an obstetrician.
- A Birthing Center certified by the National Association of Childbearing Centers.
Modern doulas are people who provide tender, physical and emotional support and encouragement during pregnancy, labor, birth and the postpartum period. There is an emerging number of doulas who are professional or semi-professional, selling their support services to women who feel they may need an experienced support person during labor and delivery. Most doulas also offer support in the home after delivery, assisting with infant care, household chores, and comfort of the new family.