By Trina Hampton

Midwife. When the word midwife is said, one usually imagines an elderly tribal woman using herbs and chants. Or perhaps one thinks of a sandal clad, hippie lady from a few decades back. These may be good for laugh, but this demeaning stereotype has no reflection on the midwives who are medical professionals today. Unfortunately, the perpetuation of these images may be keeping American women from receiving the best possible pre-natal and birth care available. There are many reasons why women should consider hiring a midwife for their care.

At the heart of midwifery is the philosophy that childbirth is natural and normal. Respecting that birth is an emotional and psycho-social event, not just a physical process. The word midwife means with woman and indicates in name that a midwife provides a very personal level of care. Midwives refer to their moms as clients rather than patients. The word patient infers illness and inferiority. Client indicates that they are hired by mothers to provide a service. Removing the implication of ownership over the mother-to-be, this opens up the relationship to include the mother as a partner in her care. As demonstrated by midwives' use of the phrase 'catching the baby' to describe their role, rather than 'delivering the baby'. Let's not forget who is doing the real work here, mother is given credit where credit is due.

Most people know that historically midwives cared for women during childbirth, but they also believe that childbirth was deadly and that doctors, obstetricians, took over maternity care because it was safer. It may be surprising to many, but this assumption is completely false. The trend of moving childbirth into hospitals during the first part of the 20th century, managed by male doctors, was driven purely by sexual discrimination and 'class warfare'. It was a time when women were thought to be inferior to men and therefore midwives were dismissed as incapable of their task. Having little understanding of the physiology of birth, doctor and parents alike felt it was peril that women needed to be rescued from. Statistics of the time did indicate that birth in hospitals had better outcomes. We now see that these statistics were flawed in that they didn't take into account that midwives still cared for poor, immigrant, who were unhealthy and the most at risk. Hospital births composed mostly of middle and upper class white women who received some measure of pre-natal care. The introduction of interventions, drugs and hospital policies actually made the maternal and infant death rate go up. Today, midwives still care for a large majority of 'at risk' women, and yet study after study has shown that women cared for by midwives have better birth outcomes, and are just plain more satisfied with their experience.

How could this be true? First, a focus is placed on pre-natal nutrition, education, and locating community assistance when necessary. Clearly this is the first step in avoiding complications in the first place. Secondly, midwives spend more time with their clients. On average, midwives spend 30-45 minutes with a client during a prenatal visit, allowing for more communication and observation. This is much longer than the average 5-10 minutes doctors spend with their patients, when they don't hand off prenatal visits to their staff. Midwives also spend more time with their clients during their labor and birth. It's common practice for doctors to only see their patients momentarily during labor , if at all, and join them only once they have started pushing, leaving the majority of maternity care up to the nurses and hospital residents. Many doctors are likely to have never even seen a normal labor from onset to birth. Midwives however, spend the majority of labor with their clients. In doing such, they are better able to honor the mother's preferences, be on time for the birth and diagnose any complications as soon as they arise.

Industrialized nations around the globe with the best maternal and infant outcomes employ midwives as their principal maternity care providers. The US currently ranks 34th in the world, despite increasing use of interventions and physician dominance. This means mothers and babies in 33 other countries fare better during and after childbirth than here in the U.S. American women intending to choose the best practitioner usually pick an obstetrician, a surgeon, assuming they are safer. A study published in 1998, looked at more than four million births in the United States. Removing the high risk cases and examining only the low risk births attended by obstetricians and those by midwives, found the newborn death rate to be 33% less in the midwife group. There has never been any verifiable data to prove that obstetricians are safer for healthy low risk pregnancies than midwives.

Utilizing midwives has also show reduce the cost of prenatal and maternity healthcare. A study of two California medical centers showed a 13% and 7% decrease in payroll expense when midwives were added to the maternity staff. In short, midwives cost less. Salaries are competitive, midwives provide more hands on care, so nurses can be used more effectively, and unnecessary (and expensive) procedures are more likely to be avoided. Another survey suggests that if 50% of births took place in birth centers attended by midwives there could be a saving of $4 billion annually. The cost effectiveness and improved birth outcomes resulting from midwifery is too significant to ignore.

There are two different types of midwives. One is the C.N.M. (Certified Nurse-Midwife). This generally requires becoming an RN (Registered Nurse) first, and then on to one of 47 schools in the U.S. that offer a nurse-midwifery program. A nurse-midwife usually practices in a hospital or birth center, and works with a back up physician. They have been shown to have a lower cesarean rate, low episiotomy rate, and better infant outcomes, such as higher birth weights and APGAR scores. Women can receive their non-pregnant well-woman care from their nurse-midwife and in most states they have the authority to prescribe medications, assist in cesarean sections. Although nurse-midwives value un-medicated birth, women can receive an epidural or pain medication during a hospital birth if they request it.

A second type is the Direct Entry Midwife. This category includes credentials that vary on state laws, such as C.M. (Certified Midwife), C.P.M. (Certified Professional Midwife) or L.M. (Licensed Midwife). They are not nurses, though they still receive comprehensive evidence based education, and hands on experience through internship or apprentice programs. They usually only attend home births and some may work in birth centers. Though there continues to be controversy and skepticism about homebirth, many studies have proven it to be a valid option for women with low to no risk factors, attended by a qualified midwife. Outcomes are just as good, if not better than birth outcomes in hospitals. Direct entry midwives and home birth is still illegal in sixteen states. This is a distressing infringement on women's rights. Many believe the legislation is being sustained by wealthy lobbyists for hospitals and health care providers who would lose money if birth occurred in homes. It is certainly being sustained by ignorance. It's significant to note that direct entry midwifery and home birth is legal in thirty four states.

Newly pregnant women should consider all of their options when choosing a care provider. Women are consumers in the birth market, and as such, they deserve to expect the highest level of service and quality from the professionals that they hire to care for them. Importantly, remember that although obstetricians have a vital role as maternity surgeons, midwives have shown time and again to have the best outcomes for healthy mothers and infants.

References;
The North American Registry of Midwives
American Collage of Nurse Midwives
Geography I.Q.

"Certified Nurse-Midwife Effectiveness in the Health Maintenance Organization Obstetric Team", Bell, Kenneth, and Mills, Jack I., Obstetrics & Gynecology; Vol. 74, No. 1, p. 112-116, July 1989.

Cochrane Pregnancy and Childbirth Group, the Cochrane Library Issue 1, 2002.

Eugene R. Declercq, PhD, the Transformation of American Midwifery: 1975 to 1988, American Journal of Public Health, May 1992, 82, 5, p. 683.

Expecting Trouble: The Myth of Prenatal Care in America by Thomas H., Jr. Strong.

National Association of Childbearing Centers Survey Report of Experience 1987-1989.

The Thinking Woman's Guide to a Better Birth by Henci Goer.

Technology in Birth: First Do No Harm by Marsden Wagner, MD.

About the author:

Trina is a full time mom to son Jace, and is doula and childbirth educator practicing in the West Texas area. Please visit www.baby-yourway.com to learn more about her services.