A century ago, almost all women gave birth at home with a midwife. As medical advances became readily available, obstetricians replaced midwives and the majority of births in America moved to hospitals.
A century ago, almost all women gave birth at home with a midwife. As medical advances became readily available, obstetricians replaced midwives and the majority of births in America moved to hospitals. Today, perhaps as a result of increased medical interventions such as induced labor and C-sections, many women are returning to midwives and choosing to give birth naturally at home or in a birthing center. According to a National Vital Statistics report, the percentage of physician-attended births has steadily declined since 1989, while the the percentage of midwife-attended births has increased.
Although many people still envision midwifery practice as it was in colonial times, the majority of midwives these days have formal training and are certified. There are two main categories: Certified Nurse-Midwives (CNMs) and Direct-Entry or Certified Professional Midwives (CPMs). Both groups share many of the same goals, such as supporting childbirth as a natural process, minimizing technological interventions, providing personal, individualized childbirth education and prenatal care and offering continuous hands-on assistance throughout labor and delivery.
However, there are differences in the type of education and training CNMs and CPMs receive, and there can also be philosophical differences about the safest and best environment for giving birth. If you are considering using a midwife, it is important to understand these differences and to choose one who fits your birth plan best.
The Certified Nurse-Midwife
As the name implies, a CNM is a registered nurse as well as a midwife. In addition to acquiring a nursing degree, CNMs must also graduate from an advanced education program accredited by the American College of Nurse-Midwives and pass a national certification exam. In Tennessee, CNMs are required to have a business relationship with an obstetrician and meet strict requirements of state health agencies. Like doctors, they can write prescriptions, and most CNMs practice in birth centers and hospitals, while some deliver babies at home.
Ann Howard has been a CNM for more than 20 years and currently delivers the majority of her patients’ babies at Baptist Women’s Pavilion Hospital-North Tower. North Tower is similar to a birth center in its flexible policies, labor accessories such as jacuzzis and birthing balls and birthing and recovery suites. However, it has more advanced medical capabilities and staff than traditional, independent birth centers. Birth centers differ from hospitals in attitude as well as technical details. In a birth center, birth is considered a natural process rather than a medical procedure, and technological interventions are minimized.
Howard spends quite a bit of time with patients during prenatal visits, providing more personal care than most obstetricians. She provides all standard blood and lab work for the women she treats; those with normal pregnancies do not need to see an obstetrician. Like most CNMs, she works as a labor coach and stays with the mother from the time she is admitted until after the baby is born.
During labor she monitors the baby and mother for 20 to 30 minutes every hour, but allows her patient to rest on a birthing ball or rocking chair while being monitored rather than requiring her to be in bed. She allows walking and sitting in a whirlpool spa the rest of the time.
Howard delivered both of Liesl and Bryan Dunlap’s sons at North Tower. Dunlap loved the flexibility of the facility, the jacuzzi and birthing ball and the 24-hour rooming-in with babies. She did not consider using a CPM or having a home birth.
“It was important to me to find a midwife who was a nurse and who was associated with a doctor if there were problems,” Dunlap explains. “I wanted the security of having the medical professionals and medical building.”
Although her husband and best friend were on hand to support her through natural childbirth, she says Howard was a tremendous help.
“She encouraged me and helped me to try different positions I had learned but didn’t think about during labor,” she relates.
Dunlap’s prenatal visits with Howard lasted 30 to 40 minutes and the two became good friends.
“I felt like she cared about all of me, not just my pregnancy,” Dunlap says.
Although midwives support natural childbirth, Howard’s personalized care attracts some patients who plan to have an epidural. About 25 percent of her patients have them, although she does advise about the disadvantages. Most birth centers do not offer epidurals.
Howard manages VBACS (Vaginal Birth After C-Section) and has delivered breech babies with an obstetrician present. She also does annual checkups and pap smears, and is covered by most insurance policies. When there are complications, which she notes CNMs are trained to recognize and manage until a doctor can take over, she often co-manages the patient’s care with the doctor.
Howard does not support home births, but will do early discharge for mothers. She feels North Tower is a good compromise between home and hospital birth.
“It offers the advantages of a home-like atmosphere with the backup of advanced medical emergency equipment and personnel,” she explains. “It’s a small price to pay for that 10 percent of the time when there are emergencies.”
The Certified Professional Midwife
Pamela Hunt is a CPM who has been practicing midwifery for 30 years. She lives on The Farm, an eco-community in Summertown, Tenn., where five other midwives reside and hold midwifery workshops. Although they have a birthing cabin on the land for mothers who live long distances away, the majority of The Farm’s patients give birth in their own homes.
Rather than undergoing extensive institutional training, CPMs apprentice with a practicing certified midwife for many years, attending births as well as prenatal and postnatal checkups. There are multiple routes for their education, including midwifery schools and workshops, but they are not required to have a nursing degree. CPMs must pass a national certification exam evaluated by the Midwifery Education Accreditation Council. They do not work for but at times collaborate with an obstetrician and generally practice in homes and birth centers. Like CNMs, they are trained in neo-natal resuscitation and CPR.
Similar to many CPMs, Hunt spends one to two hours with women during each prenatal visit and provides basic prenatal blood work. During early labor she monitors the baby every hour with a fetoscope or doppler — similar to a mini-ultrasound — increasing the frequency of monitoring as labor progresses. She encourages mothers to eat, drink and move about freely during labor and stays with them, coaching as needed, and at least three to four hours after the baby is born. As opposed to most OBs, she does not rush or count during the pushing phase, but allows the process to take its time. She has not performed an episiotomy in 15 years.
Hunt was the midwife for Lindy and Page Thompson when they gave birth to their second child, Samuel, in their Franklin home. Thompson rented a labor tub for both her children and gave birth in water.
She says she gained confidence about home births because of the extensive research she did on the subject, interviewing several midwives. When she felt fearful about any aspect of the prospect she would discuss it thoroughly with her midwife.
“Every prenatal visit was an hour or longer and I would ask a gazillion questions,” she says.
Her husband, who initially took some convincing that home birth was a safe option, was impressed by the knowledge and confidence of the midwives the couple interviewed. A common fear is that there will be unexpected complications that require hospitalization. But Hunt affirms that midwives are trained to spot problems ahead of time, and most women can have a safe home birth.
“If there is a malpresentation you can find that out,” Hunt explains. “If there is a cord problem, you can usually hear it with the fetoscope. We check the woman’s urine at every visit. If there is something wrong, we find out about it before labor starts.”
Giving birth at home with a midwife can also be a very private, personal experience. Thompson said she particularly liked Hunt because she was never in a hurry during prenatal visits or labor.
“One of the many things that is so special about home birth is when you finally go into labor and your midwife comes in, it’s a friend,” she says. “She knows you really well. She knows what might be on your mind. She’s someone you really trust and like, and you’re happy to have her there.”
Thompson feels there is a misconception that parents who choose home birth are more concerned about giving birth in a pleasant atmosphere than the safety of the mother and child.
“It’s not a choice between being safe or having a good experience,” she says. “You can have both if you are well informed.”
She notes you don’t have to be a hippie or have a high tolerance for pain to have a home birth and wishes more mothers would look into natural childbirth and midwifery instead of automatically deciding on an obstetrician.
“Do your homework. Choose a midwife wisely and carefully,” Thompson advises. “Trust yourself, trust your instincts. It is a wonderful, wonderful way to have a baby.”
Amanda Cantrell Roche is a mother and freelance writer residing in Middle Tennessee.