What is a Midwife?

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The first thing I recommend to any newly pregnant person is to take some time and effort to find the BEST care provider for their particular pregnancy.  This is a task that is often overlooked and can seem daunting to first time parents. Many pregnant people continue seeing their trusted OBGYN for obstetric care out of mere convenience.  While the relationship that has already been developed is beneficial, it is important to consider that our wants and needs may not be the same as our care provider’s expectations or philosophy of care.  Communication is an integral part of creating the perfect birth team, and being on the same page as our care providers lays the groundwork for a great birthing experience. 

With the rising maternal health crisis in our country, it is important that we educate ourselves about our bodies and make the best possible informed decisions about our care.  The midwifery model of care supports this process. Dr. Timothy J. Fisher, OB-GYN residency program director at Dartmouth Hitchcock Medical Center and assistant professor of obstetrics at the Geisel School of Medicine at Dartmouth University, states that “the midwifery model of care emphasizes normalcy and wellness. It empowers women and gives them greater ownership of their health, their pregnancy, and the outcomes of that pregnancy based on choices that they’re able to make.” In honor of National Midwifery Week, let’s explore this option and understand the different experiences we might have with a midwife. 

What is a midwife and how does midwifery differ from obstetric care? 

A midwife, like an obstetrician, is a trained professional who helps pregnant people through their pregnancy, birth and after the birth of their babies.  The major difference between obstetric and midwifery care is philosophy. A midwife has been trained to work with pregnant people through pregnancy and birth as a natural, physiological experience, whereas an obstetrician is a trained surgeon that has been specifically trained to help patients with complications through their pregnancies and births. Obstetricians are doctors whose education is based around treatment and how to intervene when necessary, while a midwife’s education is based around supporting birth as a normal physiological process. There are also differences in practice. In a birth without complications, a midwife will support the pregnant person throughout the entire labor, while an obstetrician will usually appear at the end of the pushing phase to deliver the baby and the placenta. 

In what types of settings does a midwife work?  What does a birth experience look like in each of these settings? 

Midwives work in multiple settings.  Where with most obstetricians, you are limited to a hospital birth, when choosing a midwife you can find practitioners who specialize in home births, birth center births, and hospital births. In each setting, a midwife will be prepared with the appropriate tools and medications necessary for a safe and healthy birth experience.

Hospital birth with a midwife: A hospital based midwife offers low-intervention birth support with the convenience of hospital amenities. Just as an obstetric patient, the midwifery patient labors at home and is admitted in triage between 4-5cm dilation. The midwife works with the patient intermittently throughout the birth and plays an active role in the patient’s birth experience. If the patient prefers medication like an epidural, an anesthesiologist is available to administer. Think of a hospital midwifery experience as a hospital experience with a more patient-centered model of care.

Birth center birth with a midwife: A birth center midwife is similar to a hospital birth midwife with the exception that the patient will labor at home, come to the birth center to have an unmedicated birth at around the same time of admission as the hospital (4-5cm), and return home within a shorter time frame than they would with a hospital birth — usually 3-6 hours compared with a 24 hour hospital stay. The midwife will remain in close contact with the patient for the first few weeks. Just as with an obstetrician or hospital based midwife, they will see the patient at a six week follow up appointment. This is a great alternative for patients who don’t have an ideal home environment to give birth and don’t have access to hospital based midwifery. 

Home birth with a midwife: Home birth midwives offer much more personalized care than other providers.  During prenatals the midwife will take extra time with their patients to better understand the wants and needs for their pregnancy and birth.  This may not be possible with a hospital based midwife or obstetrician who usually work in larger practices with larger amounts of patients and stricter schedules. It is typical to receive at least one home visit so that the home birth midwife can become acquainted with the patient’s home. As soon as labor begins, the midwife and her assistant will come to the patient’s home and offer support until the baby is born. They will clean up any messes, tuck the new parent and baby into bed, and make plans for home follow up visits before leaving. They will maintain regular contact until the patient is released from care.  

Psychologically, birth is one of the greatest paradigm shifts of our lives.  Studies have shown that birthing parents’ memories of their experience are clear even decades afterward. Proper support during labor can be life changing.  So how do we know that we’ve made the right choice? How do we know that we’ve found the perfect care provider? There are so many questions that we should ask ourselves when considering what type of care provider we want and whether the care provider we are interviewing is a good fit.  If you’re not sure where to begin in finding the right care provider for you, I’ve created a free printable guide that covers questions you should ask yourself and your care provider when making this important decision. If you’d like to know more about how the midwifery model of care and childbirth education will play a integral role in the de-medicalization of birth, you can read about it in depth here.

The De-medicalization of Modern American Birth:  Finding Balance through Childbirth Education and Midwifery

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Over the centuries, birth has been revered by cultures around the world as a sacred rite of passage, and celebrated with dramatically different spiritual, medical and cultural rituals.  Through the development of western medicine and the transition toward obstetric care from traditional midwifery, we have nearly lost the importance of mind-body connection during birth, and in turn, the spiritual and psychological significance that birth has on the female condition.  This has resulted in a shift toward medically treated care and minimized focus on individualized, support-centered care in our society, which has brought a rise in prenatal and postpartum depression, as well as higher cesarean rates and other medical interventions.

The 20th Century Shift Toward Obstetric Care

During the early 20th century, traditional immigrant and African midwifery in America was replaced with modern obstetric care, and for the most part, midwifery was only utilized in underprivileged communities of color.  White birthing parents were fully transitioned into obstetric care, and by “1921, the majority of [individuals] who gave birth under conditions that were indigenous, eclectic, spirit based, and not according to the standards of modern medicine, were the rural black birthing [individuals] of the South” (Kelena Reid Maxwell, Oct. 2009). Traditional methods of childbirth had been replaced with hospital-centered care, medication and later, machine monitoring.  

The spiritual and psychological processes of learning to trust, surrender control, and listen to our bodies during labor were nearly lost within the modern medical system. Fear-based mentalities that we are unable to safely handle the difficulties of birth without being medicated and carefully monitored by machines and obstetricians became the social norm leading into the 21st century.  Birth had fully transitioned from a normal physiological experience to a hospital based medical experience enmeshed with unnecessary intervention, and without evidence of effectiveness.

Currently, the United States holds the highest rate of maternal mortality in the developed world, which continues to rise as it declines elsewhere.  According to this National Geographic article, “more than 700 [birthing parents] die each year in the U.S. from causes related to pregnancy or childbirth. Black [individuals] have a maternal mortality rate three times higher than that of white [individuals]. At least 60 percent of maternal deaths are preventable.”

Minimizing Unnecessary Intervention while Increasing Support

The WHO estimates that almost 15% of birthing parents develop complications during pregnancy and childbirth.  In these cases, obstetrics can be life saving and beneficial. But in the other 85% of birthing parents, obstetric intervention may be unnecessary and pull focus away from support-based care, which can cause a significant impact on the birthing parent’s psychological health during and after childbirth.  This is where midwifery, a medical profession that focuses on normal, uncomplicated birth and continuous support during labor, can play a significant role.

According to a Canadian study of factors influencing parents’ satisfaction with the birth experience, “[birthing individuals] cared for by midwives were three times more likely to be satisfied with their care (OR 3.32 [95% CI 2.26-4.86]) when compared with obstetrician-led care.”   New guidelines by the WHO suggest that a greater focus on childbirth education, and a collaborative midwifery-obstetrician model of care (where care is provided primarily by midwives, and obstetricians provide 24-hour back-up support without competing clinical duties), along with insurance reforms that equalize fees for vaginal and cesarean births, can reduce overall cesarean section rates. An article from the British Journal of Medicine states that the de-medicalization of birth will require “taking pride in a low cesarean rate, developing a culture of birth as a normal physiological process, and having a commitment to one to one supportive care during active labour.”

In 2012, the University of Toronto published a paper in the Cochrane Database of Systematic Reviews. That report, which analyzed over 15,000 births, found that parents with continuous labor support are more likely to have a shorter, spontaneous vaginal birth and less likely to have a cesarean; they are less likely to require medication, and less likely to report dissatisfaction, while their babies are less likely to have low five-minute Apgar scores. This evidence shows that in most cases, when parents birth in a natural, physiological way, there are fewer complications for parent and child.  

Education is KEY.  

Continuous support is KEY.  

Insurance reforms that equalize fees for vaginal and cesarean births are KEY.  

Obstetricians and midwives working together to create a better system of care is KEY.  

There is no excuse for the United States to have such high maternal mortality rates. Use your voice, make an informed choice. Hire a doula. If you are experiencing a low risk pregnancy, do your research and find a care provider who specializes in low intervention and continuous labor support. We can make a difference in modern maternal care, but until we take steps to make change, there will be no change. Let’s make a conscious decision to make things better for birthing parents in the American medical system.

“There are two primary choices in life: to accept conditions as they exist, or accept the responsibility for changing them.”

— Dr. Dennis Waitley

Why I doula…

Your body is not a lemon. The Creator is not a careless mechanic. Human female bodies have the same potential to give birth as well as aardvarks, lions, rhinoceri, elephants, moose and water buffalos. Even if it has not been your habit throughout your life so far, I recommend that you learn to think positively about your body.” 

— Ina May Gaskin

Every birth has the potential for transformation, and every person should have the opportunity to have an empowering birth experience. Too often, in the modern American medical system, our mental and emotional well being are overlooked during birth. The care provider’s main focus, as it should be, is on the physical well being of the birthing parent and infant, and many times they are too distracted  to attend to a parent’s personal wishes.  We are too busy to realize how integral emotional well being is in the birth process, and often rely on synthetic hormones and invasive practices which may be unnecessary intervention on behalf of the clock. Informed consent is only listed in the fine print and rarely discussed in depth during the time of intervention. We are given the reasoning that it is merely standard procedure and expected to go with the flow of hospital practices. While there is such a wealth of information on the subject of birth, the thought of sifting through it all can be daunting. There are so many options, so many possibilities. I find it eye-opening when I try and grasp the understanding that every birth for every person is different from ALL other births.

I have had two experiences with birth in our modern medical system. The first was when I was in my early twenties. I was a young, newly married and broke college student, and since I was no longer eligible to piggyback on my parents’ medical insurance policy, I was pushed through the Medicaid system. I was given basic care, and I use the term “care” loosely. That was my first experience of being minimized to a number. I miscarried at nineteen weeks. I was devastated. The pain of suffering and loss was excruciating. The doctor on call treated me as if I was a waste of time, something that wasn’t worth her effort or compassion. My family stood by in horror, not knowing what to do other than follow the doctor’s orders, shocked at her lack of empathy. My postpartum visit came along and I was somehow given a sales pitch for an antidepressant without the doctor even asking me how I was feeling. I left that experience traumatized and full of questions.

My second pregnancy was nine years later. I was clear from the very beginning that I wanted as little medical intervention as possible during labor. I researched day and night and ultimately decided on low intervention care at a birth center with a midwife.  My sweet husband was supportive of every choice I made, and went above and beyond to support me through the experience. I took a comprehensive childbirth education course and the more research I did, the more fascinated I became by the female body, and the more passionate I became about helping my peers who were experiencing pregnancy to see all of the amazing possibilities of childbirth; and perhaps more importantly, to believe in themselves and their bodies.

We decided not to hire a doula since I planned to have the continuous support of my mother and sweet husband during labor. I had compiled so much information, I knew what I wanted, and I was as prepared as I could be with my stack of books and evidence based research. It took the experience of childbirth for me to realize the importance of a doula, even when you have ALL the support. I couldn’t have asked for a better team. We all worked tirelessly, around the clock until we finally met our beautiful baby girl, born after 17 hours of active labor (and many more previous hours of prodromal labor). She was 7lbs 15oz of pure magical beauty. My life was changed forever.

My passion about the entire pregnancy and childbirth experience only grew with time. I had initially assumed it would diminish as I moved into a new chapter of my life, but I experienced an unfolding of the opposite scenario. I found myself encouraging my peers to educate and advocate for themselves, to require a client-centered care experience from their providers, to really see what a powerful experience birth can be when given proper support.

My belief is that every person deserves the opportunity to have their desired birth. Whatever the vision, I believe we all need to educate ourselves about our bodies, about interventions and what they mean for comfort, mobility and health. Every person should go into their birth feeling empowered to bring a child into this world, knowing all options and understanding the depth of each option. I believe, as birthing parents this is just as much our duty as it is our right. There is something magical that happens at birth. We can choose to lean into that magic and learn something from it. Two years after the birth of my daughter I stepped forward and made it my mission to encourage and support parents and their families through this miraculous journey into parenthood. It was one of the best and most rewarding decisions I’ve ever made.