Midwives Go Mainstream

Increasing numbers of women are opting not to have an OB deliver their baby. Here are the facts you need to make that decision.


When Noelle Hawton, 39, vice president of a public relations agency in Bloomington, Minn., gave birth to her first baby in 2000, she experienced a typical hospital delivery. "I had fetal monitoring and an epidural, and the doctor had to use both suction and forceps to get the baby out," she recalls. "It felt a bit like 'us against them,' because I wanted to avoid these things."

Fast-forward two years to Hawton's second pregnancy. This time, her obstetrician's office suggested that because she had no health problems and the doctor was overloaded, it would be fine for her to see a certified nurse-midwife (CNM) who was affiliated with the practice. "The midwife, Deb, took time to listen to me during prenatal visits, and she not only delivered my baby in the hospital, she also stayed with me all the way through my labor," Hawton says. "The two experiences were like night and day. I had an epidural and monitoring again but nothing else, and I felt much more supported because the midwife encouraged me and helped me to be confident and relaxed until my baby was born." In 2005, Hawton gave birth to her third baby with the help of the same midwife. "My only regret was that this labor went so fast, it didn't give me time to bond with Deb again," she says.

Granted, first deliveries do tend to be more difficult than subsequent ones. And a midwife-assisted birth isn't always more uneventful than a doctor-assisted delivery. But the comfort-based philosophy of midwives make it more likely. Perhaps it's why use of midwives has been increasing in this country. In 1975, the first year this information was reported on birth certificates, midwives delivered 19,686 infants in hospitals, or 0.6 percent of all hospital births. In 2003, according to the National Center for Health Statistics, midwives attended 328,153—8 percent—of all births, in hospitals, birthing centers, homes and medical clinics. And the numbers are continuing to rise.

Reasons for the midwife trend According to many experts, the increased popularity of midwives is a response to many factors. One is the rising Cesarean-section rate, which is due at least in part to often-unnecessary medical interventions such as labor induction. Another is the unwillingness of many doctors to let women try to have a vaginal birth after a previous C-section (VBAC). "There is no rationale for the current C-section rate; in some hospitals, it is as high as 30 percent," says Marion McCartney, C.N.M., the recently retired director of professional services for the American College of Nurse-Midwives (ACNM). In 2004, the national C-section rate was 29.1 percent, but according to World Health Organization standards, the maximum acceptable rate is 15 percent. "And we are not getting better neonatal outcomes from more C-sections," McCartney adds.

"Midwives believe in the normal physiology of birth and in letting nature take its course," explains Maureen Corry, executive director of Maternity Center Association (maternity wise.org), a nonprofit organization dedicated to improving maternity care. "Midwives spend a great deal of time educating women during pregnancy so this can happen."

Money may be another factor. Midwives' fees vary greatly depending on location and other factors. However, according to the ACNM, midwife-attended prenatal care and delivery in a birth center costs 21 percent less, on average, than OB care and hospital delivery. Most insurance companies cover certified midwives' services, but check with yours to be sure.

What midwives can and cannot do Despite the popular image of the midwife as a woman who delivers babies in women's homes, the majority of midwife-attended births actually take place in hospitals or in birthing centers located within hospitals. In this setting, if a midwife deems an intervention such as fetal monitoring or labor induction necessary, she can employ it. A certified nurse-midwife always has a relationship with a doctor and hospital in the event of emergency during a birth at a freestanding (nonhospital) birth center or in a woman's home. "And if a woman is deemed 'high risk' at any time during her pregnancy or labor, she will be referred to a doctor," Corry says.

Midwife-licensing qualifications and what they legally can and cannot do vary by state. Although they don't administer epidurals or perform C-sections, they often will assist if a woman needs the surgery. But what most sets midwives apart from obstetricians is the fact that they provide continuous physical and emotional support during labor and delivery. The upside is that women are more likely to be pleased with their birth experience and less likely to have an unwanted C-section.

Choosing a midwife To protect both you and your baby, choosing a properly trained, qualified midwife is essential. ACNM-certified nurse-midwives (CNMs) and certified midwives (CMs) all have at least a bachelor's degree, and more than 70 percent hold at least a master's degree. They have graduated from a nationally accredited education program and passed a rigorous national certification exam. Certified professional midwives (CPMs) are certified by the North American Registry of Midwives after passing a written exam and hands-on skill evaluations. Lay, or direct entry, midwives, a designation that represents no standardized qualifications, may or may not have a college degree or certification. They may have trained through apprenticeships, workshops, formal instruction or a combination of these. Not all states require lay midwives to work in conjunction with doctors, and they usually practice in homes or freestanding birth centers.

Once you've found a midwife you fully trust, it's even possible that a longer-term relationship may develop. "I just saw my midwife again, for my annual gynecological exam," Noelle Hawton says. "She is so caring about me as a whole person. We talk about how work is going now that I have three kids, how my parents' recent health problems are affecting me, if my husband and I are making time for each other and so on. I've actually thought that it would be nice to have her as a friend."