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Should You Use a Midwife?

When I first announced to my family that I wanted to have my baby delivered by a midwife in the hospital, I was met with serious disapproval from all sides.

"You mean there isn't going to be a doctor there?" my father-in-law asked, aghast. And my husband, sensitive '90s type though he is, feared that I was putting myself and our baby in peril for the sake of some feminist ideal. But to me, a hospital birth with a certified nurse-midwife (CNM) -- a registered nurse with a master's degree or certificate in midwifery, the art of delivering babies -- was a way to get the best of both worlds: modern technology and natural medicine. I would experience a midwife's supportive care in a comfortable birthing room, just a few feet away from the emergency medical equipment I hoped wouldn't be needed.

As it turned out, I had a difficult labor, but my midwife was there for me every step of the way. She encouraged me to experiment with different positions. She told me to hang in there when it became apparent that I was dilating slowly. And after several hours of painful contractions that didn't spur any progress in labor, she supported my decision to opt for Pitocin and an epidural. True, a labor-and-delivery nurse might have done the same things, but because this midwife had been my primary caregiver for months of prenatal appointments and had helped me develop my birth plan, I felt comfortable taking her advice.

I wasn't alone in wanting both state-of-the-art technology, should I need it, and a midwife's gentle touch. After decades in the cultural doghouse, midwifery has shed its image as something antiquated and risky -- for back-to-nature types only -- and is now at the forefront of obstetrics. Today hundreds of thousands of mothers-to-be, wary of the medicalization and regimentation of traditional hospital deliveries, are turning to nurse-midwives, who treat pregnancy and birth as a natural process that shouldn't call for much medical intervention.

According to the American College of Nurse-Midwives in Washington, DC, CNMs presided over more than 270,000 births in 1997 -- the vast majority in hospitals -- up from fewer than 20,000 in 1975. And birth centers, where midwives have traditionally provided care for low-income women, are now popular across the economic spectrum. (Many birth centers cannot administer epidurals, so they may not be the right choice for everyone.)

Not only are midwives turning up all over, they've also been radically professionalized since the beginning of the natural-birth movement in the '70s. In those days, most practitioners were lay or "direct-entry" midwives, who learned the trade through non-degree-granting programs and apprenticeships and who performed mainly home births. Today, direct-entry midwives are outnumbered by CNMs, who've been trained to handle everything from ultrasounds and episiotomies to pain relief and Pitocin.

But is the move to incorporate midwifery into the medical mainstream good news for women and their babies? You bet. According to the latest research, women with low-risk pregnancies whose deliveries are supervised by CNMs undergo fewer inductions, receive fewer episiotomies, require less anesthesia, have more vaginal births after cesareans, heal more quickly and are more satisfied with their experience than those who give birth under a doctor's care. Perhaps the most striking contrast is the c-section rate itself: Studies show that about 13 percent of women who were attended by a nurse-midwife during labor ended up with a c-section. The national average, by comparison, is 21 percent. Of course, midwives generally work with women whose pregnancies are considered free from major problems, which accounts for some of the difference.

Nevertheless, the evidence of the benefits of midwife care is so compelling that more and more obstetricians are being won over. "There's no question that women who deliver with nurse-midwives do just as well as those who use doctors, as long as physicians are available to handle emergencies," says Kenneth Bell, M.D., medical director at Kaiser Permanente in Anaheim, CA. "And in some ways -- as in the c-section rate -- they're definitely doing better."

So what, exactly, do these pregnancy practitioners do, and how can you determine whether using one is the right choice for you?

Not Just Birth Coaches

In addition to being registered nurses, CNMs have spent one to two years acquiring clinical midwifery skills. While a few go on to get advanced obstetrical training, most CNMs deal exclusively with the 80 to 90 percent of women whose pregnancies are considered low-risk. (High-risk pregnancies include those in which the woman is carrying two or more babies, has a history of preterm labor, or suffers from a condition such as diabetes, heart disease, or severe hypertension.) And although they're best known for supervising childbirth, CNMs also receive training in prenatal and well-woman care, which covers gynecological exams, Pap smears, and counseling on everything from lactation to contraception to menopause.

Because of their overall approach, however, midwives are more than stand-ins for doctors. "Obstetricians have been taught that pregnancy and labor are disasters waiting to happen," says Bruce Flamm, M.D., an obstetrician at Kaiser Permanente in Riverside, CA, who often argues the case for CNMs to the medical establishment. "That means that OBs tend to use more medical interventions and pay less attention to the emotional concerns of women." Midwives, on the other hand, offer a more thorough and compassionate type of care, Flamm adds.

In addition to covering the prenatal basics -- monitoring weight and blood pressure, listening to the fetal heartbeat -- some midwives provide information about nutrition and exercise as well as alternative therapies for childbirth pain relief such as acupuncture and homeopathy.

They also take an interest in the personal lives of their patients. Deborah Shurman, a mother of four in Augusta, ME, recalls a prenatal appointment during which she was particularly upset. "The midwife took my blood pressure, frowned, and then took it again," says Shurman. "Then she leaned forward, put her elbows on her knees and asked me outright, 'What's happening in your life? Let's talk a bit.'" At that point, Shurman burst into tears and started talking a real blue streak. "My husband had left me just a few days before," she explains, "and it was a very difficult period. The midwife reminded me to take time for myself and to look after my own needs, too."

Even a midwife's office may look different from that of the typical obstetrician. Catherine Gorchoff, a CNM in Santa Rosa, CA, decorated hers with antiques, floral paintings, and scented candles to mask any medicinal odors. "Making my office look different is one of the ways I try to set a healthy outlook on the whole pregnancy," Gorchoff explains.

Labor of Love

But according to mothers who extol the praises of midwives, it's in the delivery room that CNMs work their particular brand of magic. During the many fits and starts of a typical labor, midwives work to keep a woman motivated and on the move. "We walked the hospital corridors in something like a conga line -- me, my husband and my midwife," says Terez Giuliana of Lansdowne, PA. "My labor lasted 14 hours, and she was there for me the whole time -- unlike the labor nurse, who was in and out, and went off her shift before my baby was born."

This kind of constant attention and moral support is one reason women who deliver with midwives tend to need less medical intervention, says Marie Bridges, a CNM in West Columbia, SC. "One hospital procedure often leads to the next," she explains. Fetal monitoring confines a woman to bed, which would prevent her from taking advantage of some strategies that many women find helpful in reducing contraction pain, such as walking or standing in the shower. That, in turn, might make her more likely to want an epidural, which could make it more difficult for her to push. At that point, Bridges says, the possibility of a forceps delivery or a c-section increases. "Because we stay right by her side, encouraging her to shift positions and offering hot showers and massage, a woman can often avoid this whole cycle."

Midwives who work in birth centers, which are geared toward natural childbirth, have even more techniques at their disposal. Whirlpool baths, for instance, are standard at most centers, and for many women, they do make a significant difference. "The birth center was great," says Lynne Anne Baker of San Diego, who had her first baby in a center but had to have her second in the hospital because of a slight medical problem. "If more women had hydrotherapy -- just getting in a shower or bath is helpful -- they'd be able to do it without drugs."

When emergencies do arise, midwives can often resolve the problem, or at least hold down the fort until the doctor arrives. When Sandra Van Rossem's labor was cut short by a prolapsed umbilical cord -- the cord was preceding the baby down the birth canal -- her midwife quickly reached in to keep the baby's head from pressing down on his only means of life support. In this position, the two women were transported on a gurney to the operating room, where a doctor took over for a c-section. "If she hadn't been so skilled, I might have lost the baby," says Van Rossem, a mother of three in Bay Shore, NY.

Hospital, Birth Center, or Home?

Although there seem to be no disadvantages to working with a CNM in tandem with a doctor and delivering in a hospital, other types of midwife care have drawbacks that should be considered carefully.

A home birth with a direct-entry midwife, for instance, has potential risks. In an emergency, a woman would need to be transferred to a hospital, meaning crucial time could be lost. Plus, a home birther may find emergency personnel less than sympathetic. "Unfortunately, I've known doctors who think that anyone stupid enough to attempt a home birth deserves whatever happens to them," says Don Creevy, M.D., an obstetrician in Portola Valley, CA.

Birth centers have potential pitfalls as well. While all CNMs have physician backups, the doctors are not usually at the center, so again, a woman would have to make the trip to a hospital if anything serious went wrong. In addition, some women are uncomfortable with the "up-and-out" philosophy of many centers. "I had two separate tears from the birth, so I wanted to rest for a while," says Karen Prince of Silver Spring, MD, "but the nurse-midwife made it very clear that I couldn't crash there. I was home five hours after my baby was born."

Any woman who is considering a birth-center delivery -- especially one who's never experienced labor -- should also think about the no-epidural policy of many centers. Even mothers who were determined to have natural childbirth (like myself) have been known to reconsider in the middle of a particularly long or difficult labor.

Looking Ahead

Despite the growing consensus that nurse-midwifery is safe and effective, the profession still faces traces of opposition. Some physicians see CNMs as an economic threat, particularly those midwives who go into independent practice; others condescend to what they perceive to be the hippie in Birkenstocks who's not performing genuine medicine.

But with the focus on the bottom line (see "How Much Do Midwives Cost?"), and women continuing to demand the best in pregnancy care, most experts agree that midwifery is the wave of the future. The state of Florida, for instance, which has a shortage of practicing obstetricians due to the extremely high cost of malpractice insurance, recommended not long ago that 50 percent of low-risk births be supervised by CNMs. Deanne Williams, executive director for the American College of Nurse-Midwives, expects the trend to continue: "Our goal is to produce 10,000 CNMs by the year 2001," she says. In order to reach that figure, the number of midwife-attended births should more than double from what it was about three years ago.

The glowing reports from women who have delivered with midwives certainly suggest that pregnancy care is headed in the right direction -- even if the changes are a while in coming. "I still meet people whose eyes widen when I say I had my baby with a midwife," says Peg Conway, a mother of two in Cincinnati. "They say, 'You did what?' as if I had the baby in the backyard or something." But Conway was thoroughly delighted with the whole process. "Not only was my midwife there the entire time, but she came by my hospital room the next day and asked me if there was anything I wanted to talk about," Conway says. "I wouldn't have done it any other way."

The history of midwifery

1550 B.C.

The Ebers Papyrus, an Egyptian medical text, contains guidance on midwifery

1000 B.C.

The Book of Genesis describes the midwife-assisted birth of Tamar's twins

5th Century B.C.

A Roman physician writes that a midwife "must have a healthy mind...and long fingers with nails cut short"

1400-1600 A.D.

Some European midwives are burned as witches

Early 1600s

Male physicians in Europe begin attending births of the wealthy, promising safer and quicker deliveries

1620

Midwife Brigit Lee Fuller attends three births on the Mayflower as it sails to the New World

1760

English midwife Elizabeth Nihell criticizes physicians' surgical approach to childbirth

1800s

Competition from doctors forces European midwives to practice primarily among the poor

1910

Midwives attend 50 percent of U.S. births; physicians entering a new specialty, obstetrics, campaign to discredit them

1911

Massachusetts is the first state to outlaw midwifery; several other Northeastern states follow

1914

Middle-class women flock to hospitals that offer the promise of painless childbirth in the form of "Twilight Sleep"

1926

A prominent obstetrician writes that, among other things, midwives are "filthy and ignorant"

Early 1930s

Midwives attend 15 percent of U.S. births; the first U.S. nurse-midwifery school opens in New York City

Early 1950s

The baby boom leaves OBs with too many births to handle; some promote nurse-midwives as the best way to deal with the overflow

1965

Competition from doctors and CNMs, as well as laws prohibiting its practice, nearly eradicates lay midwifery in the U.S.

Early 1970s

Beginning of grass-roots natural child-birth movement prompts a small resurgence in lay midwifery

1971

American College of Obstetricians and Gynecologists recognizes nurse-midwifery as a profession

1975

First non-hospital birthing center, staffed by CNMs, opens in New York City

1986

First national organization established to develop credentials for lay midwives

1994

CNMs attend 5 percent of U.S. births, a 47 percent increase in just four years

2000

5,000 CNMs and 4,000 lay midwives practicing in U.S.; 45 accredited nurse-midwifery training programs in operation

How much do midwives cost?

The price of midwifery care varies widely, depending on where your baby is born. Your insurance company may narrow your choices by covering only certain options.

  • HOME BIRTHS Direct-entry midwives preside over the majority of home births, though some CNMs will agree to do so as well. Home birthers used to have to pay for everything themselves, but some insurers, attracted to the low cost -- usually about $2,000, versus upwards of $8,000 for an uncomplicated hospital delivery -- are now helping out.
  • BIRTH CENTERS These homey environments are staffed by CNMs, with one or more obstetricians who provide consultation and emergency backup. The cost for prenatal care and delivery is about $3,500. Some insurance companies offer the same coverage for birth-center deliveries as they do for hospital births; others pay only a percentage of that.
  • HOSPITALS Women who opt for a hospital delivery usually work with a CNM who's part of an obstetrical practice, in which case the cost is the same as the standard obstetrician's fee. Most insurers cover 80 percent of the bill.

How to find a midwife

  • American College of Nurse-Midwives operates a toll-free hotline (888/MIDWIFE) that lists CNMs in your area. For general information, call 202/728-9860; write to 818 Connecticut Ave. NW, Suite 900, Washington, DC 20006; or check out the group's website at www.midwife.org.
  • Maternity Center Association publishes a booklet, Journey to Parenthood ($6), with information on choosing a maternity-care provider. Call 212/777-5000 or Write to 281 Park Ave. South, 5th Floor, New York, NY 10010. Visit the MCA website at www.maternity.org.
  • Midwives Alliance of North America can refer you to direct-entry midwives and CNMs in your area. Call 888/923-6262 or Visit their website at www.mana.org.
  • National Association of Childbearing Centers can provide a list of birth centers in your area, as well as information on how to select a birth center. Send a $1 donation to 3123 Gottschall Rd., Perkiomenville, PA 18074.

Amy Cunningham is a writer living in Washington, DC.

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