Congratulations, you're pregnant! Let the decision-making
begin. Choosing a health care provider to care for you and your
baby during your pregnancy is one of the biggest decisions
In the United States, women's choices once were limited to
an obstetrician or a knowledgeable family doctor. But in recent
years midwives became another alternative for women with low-risk,
In Europe, midwives assist at more than 70% of normal vaginal
births. Though midwives delivered only 7% of American babies in
2003, that percentage has been increasing since 1975. But most
Americans aren't sure what midwives do, how they're
trained, or if they're even available. Is a midwife a viable
option for you?
The History of Midwives
The word "midwife" comes from Old English and means
"with woman." Midwives have helped women deliver babies
since the beginning of history. References to midwives are found in
ancient Hindu records, in Greek and Roman manuscripts, and even in
As early as 1560, Parisian midwives had to pass a licensing
examination and abide by regulations to practice. Not all midwives
had this level of education, however. English midwives received
little formal training and weren't licensed until 1902. America
inherited the English model of midwifery.
Early American midwives usually learned their craft through
apprenticeship and tradition. They were not educated about
scientific advances in fighting infection through hygiene and drugs
such as penicillin. By the early 20th century, women and their
babies were more likely to die under the care of midwives than
under the care of doctors.
Around this time, American medical doctors began a campaign
against midwifery in the press, the courts, and Congress. They
cited the poor outcomes for mothers and babies under the care of
midwives. Doctors might also have viewed midwives as
Whatever the doctors' motivations, the rate of
midwife-attended births dropped during and after the campaign. But
the widespread criticism from the medical establishment prompted
the foundation of the first certified American nurse-midwifery
school in 1932. It aimed to incorporate the necessary medical
training into midwifery's traditional approach to pregnancy and
What Kind of Training Does a Midwife Have?
Midwives today come from a variety of backgrounds. The subtitle
a midwife uses will indicate the level of education and training.
Most American midwives are
certified nurse-midwives (CNMs)
- have at least a bachelor's degree and may have a
master's or doctoral degree
- have completed both nursing and midwifery training
- have passed national and state licensing exams to become
- are licensed in every state
- may work in conjunction with doctors
About 96% of births assisted by certified nurse-midwives occur
certified midwife (CM)
a registered nurse but otherwise meets the same qualifications as a
certified nurse-midwife. Because this certification has only
existed since 1996, there are few CMs. Currently, only some states
recognize this certification as sufficient for licensing.
may or may not have a college degree or a certification.
Direct-entry midwives may have trained through apprenticeship,
workshops, formal instruction, or a combination of these. Not all
states require them to work in conjunction with doctors, and they
usually practice in homes or non-hospital birth centers. But not
every state regulates direct-entry midwives or allows them to
certified professional midwife (CPM)
is certified by the North American Registry of Midwives after
passing written exams and hands-on skill evaluations. Direct-entry
midwives and certified nurse-midwives can apply for this
certification. They're required to have out-of-hospital birth
experience, and usually practice in homes and birth centers. Their
legal status varies according to state.
What's the Midwife's Philosophy?
A midwife's education stresses that pregnancy and birth are
normal, healthy events until proven otherwise. Midwives view their
role as supporting the pregnant woman while letting nature takes
Midwives also focus on the psychological aspects of how the
mother-to-be feels about her pregnancy and the actual birth
experience. They encourage women to trust their own instincts and
seek the information they need to make their own valuable decisions
about pregnancy, birth, and parenthood.
Of course, many medical doctors (MDs) share these values. But an
MD may be more likely to use
and medical technology - such as ultrasound, continuous fetal
monitoring, and the option of pain medications during birth - as a
standard part of care during pregnancy and labor.
High-risk pregnancies undoubtedly require this approach. But
many midwives find it unnecessary for most uncomplicated
What Does a Midwife Do?
Midwives generally spend a lot of time during prenatal visits
addressing a woman's individual concerns and needs, and will
stay with her as much as possible throughout labor. They sometimes
encourage physical positioning during labor such as walking around,
showering, rocking, or leaning on birthing balls. Midwives also
usually allow women to eat and drink during labor.
Certified nurse-midwives, like doctors, may use some medical
interventions, such as electronic fetal monitoring, labor-inducing
drugs, pain medications, epidurals, and episiotomies, if the need
arises. However, a certified midwife, certified professional
midwife, or direct-entry midwife may not legally be allowed to use
these techniques without a doctor's supervision. And birthing
centers may or may not be equipped for these procedures.
Midwives of any licensing degree cannot perform cesarean
sections (C-sections). If one were required, an obstetrician would
have to perform your delivery. If any potentially life-threatening
complications suddenly arose during delivery, midwives should also
involve an obstetrician.
trained in basic life support for newborns and, in the event of
sudden complications with your baby after birth, can care for the
baby until a pediatrician or
(an intensive-care specialist for newborns) is available.
Is a Midwife Right for You?
Several studies have shown that midwife-supervised births
produce excellent outcomes with fewer medical interventions than
average. Midwives' patients use electronic fetal monitoring
less often and tend to have a reduced need for epidurals,
episiotomies, and C-sections for successful deliveries. To some
degree, this stems from the fact that midwives see only low-risk
patients with uncomplicated pregnancies. But some researchers
attribute the need for a minimum of medical intervention to the
midwives' natural approach to the management of labor and
delivery, which may reduce a woman's fear, pain, and anxiety
Midwifery is not advisable for women with higher-risk
pregnancies. Those expecting
twins or multiples
and those with prior pregnancy complications, gestational diabetes,
high-blood pressure, or chronic health problems of any kind before
pregnancy should discuss their options with their primary health
care provider or an obstetrician. Certified nurse-midwives who
practice in major medical centers and work very closely with
obstetricians and perinatologists (specialists in high-risk
pregnancy) may take patients with risk factors. But midwives in
solo practice or who practice in limited medical facilities
generally do not.
A major difference between doctors and midwives is the
doctors' ability to intervene surgically when necessary, and to
deal with complications that arise. Midwives can't perform
C-sections and some can't administer drugs or anesthesia. If
you feel more comfortable having those options immediately
available, a doctor may be the right choice for you.
What if Something Goes Wrong?
Midwives are trained to recognize the signs of trouble in
pregnancy and labor. If a complication develops at any time, the
midwife should consult a doctor. If your midwife doesn't
already have a practice agreement with a doctor, be sure to find
out what will be done in case of a complication.
If you plan to deliver at a non-hospital birth center or at
home, an emergency back-up plan is especially critical. If you must
go to the hospital, your midwife will go with you and will continue
to support you throughout your labor.
But it's a good idea to get answers to these questions:
- What training or equipment does your midwife have to handle
- How far will you be from the nearest hospital?
- Do they have fail-safe transportation?
Finding a Midwife
You can decide to use a midwife at any time during your
pregnancy. Women often turn to midwifery a few months before their
due dates, when they begin to seriously consider their birth
To evaluate your medical needs, most midwives will request that
you bring your prenatal care records to your first meeting. Few
midwives will accept a patient well along in pregnancy unless she
has had adequate
Interview a prospective midwife carefully. Investigate the
midwife's background, certifications, experience, and emergency
procedures. Because you'll be closely involved, make sure your
personalities mesh. Do you feel comfortable with the midwife? Can
you talk easily?
To locate a midwife, try asking your obstetrician-gynecologist
(OB/GYN), family doctor, and friends for a referral.
Larissa Hirsch, MD
Date reviewed: February 2008
Previously reviewed by:
Serdar H. Ural, MD
Note: All information is for educational purposes only. For specific medical advice,
diagnoses, and treatment, consult your doctor.
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