How Midwives Work

Midwife comes from an old English word meaning "with woman," and since women have been the traditional birth attendants throughout history, midwives have existed for as long as babies have been born. There are references to midwives in ancient Greek and Roman texts, and midwives are mentioned in the Bible. Knowledge about midwifery passed from woman to woman, and new midwives were made by apprenticing at an experienced elder's side.

When medical knowledge was scant, however, midwives were often blamed if something went wrong with a woman's pregnancy or a baby's delivery. From the 1400s to the 1600s, midwives in Europe ran the risk of being accused of witchcraft. The 1484 "Malleus Maleficarum," a famous book about witches, claimed that midwives were the most dangerous kind of witch for all the damage they could do to a new family.

As medical knowledge developed, movements began to teach and train midwives. In 1902, Great Britain set up a Central Midwives Board to train, license and regulate midwives, which gave midwifery a sense of professionalism that's common in Europe. At the same time, though, sentiment was moving the opposite direction in the U.S. Obstetrics became a widespread medical practice, and the physicians, perhaps motivated by economic concerns, waged a public relations war against midwives. Doctors showed that with their up-to-date knowledge about medicine, hygiene and surgical options in the event of an emergency, they had better birth outcomes. In 1926, a prominent doctor wrote that midwives were "filthy and ignorant," and going to the hospital to give birth became the thing to do if a family could afford it.

There was one notable exception during these dark days for American midwives. In the early 1920s, a wealthy woman named Mary Breckinridge became concerned that poor, rural women in her home state of Kentucky didn't have access to good medical care. She traveled to Britain, trained as a midwife and founded the Frontier Nursing Service (FNS) in Kentucky. Breckinridge and her midwives kept meticulous records, and they were able to show that they had lower instances of death among mothers and babies compared to doctors, which was particularly remarkable considering that she served poor women.

In the 1960s and '70s, U.S. women became interested in natural birth again. Some women shared horror stories of demonic doctors and traumatic hospital experiences, while others were caught up in the counterculture movement that shunned mainstream institutions like modern medicine. In 1977, Ina May Gaskin, a self-trained midwife, published "Spiritual Midwifery," an underground classic that urged women to take childbirth back from doctors and enjoy every minute of it. Women flocked to Gaskin's commune, the Farm, to train with her, and word spread that childbirth didn't have to be a medical procedure.

At first, using a midwife for childbirth was something that hippies did, but it's becoming more and more mainstream every year. We'll take a look at some modern types of midwives on the next page.

If you're looking to employ a midwife for childbirth, it's important to note that there are several different types in the U.S. These midwives differ on how they received their training. Certified nurse-midwives (CNMs) are registered nurses who possess a bachelor's degree (and more commonly, a master's degree) and who have received an additional one to two years of midwife training. CNMs are certified by the American College of Nurse-Midwives (ACNM) and tend to work in hospitals or stand-alone birthing centers. While CNMs are typically retained for childbirth, they can provide a range of well-woman care, from pap smears and contraceptive counseling to menopause relief. CNMs can practice in every state in the U.S.

Certified midwives aren't nurses, but they do receive their certification from the ACNM, just as CNMs do. They must have a bachelor's degree and attend training from an ACNM-accredited program. Currently, certified midwives can only practice in a handful of states. Direct-entry midwives may also only practice in a handful of states. These midwives may learn their craft through self-study, apprenticeship or in a school setting. They may or may not have a college degree, and they tend to practice in people's homes or in birthing centers.

You may encounter midwives who claim to be certified professional midwives. This is a credential bestowed by the North American Registry of Midwives, and the certification is based on a written exam and hands-on skills evaluations. The idea behind this certification is that it doesn't matter where you learn how to deliver a baby, so long as you know how to do it safely. Direct-entry midwives and certified nurse-midwives may both apply for this qualification.

While there are several types of midwives, there's really only one kind of patient that's appropriate for this type of care, and that's a woman who's having a low-risk pregnancy. That said, the great majority of pregnancies in the U.S. are low-risk. A low-risk pregnancy involves a young mother (generally no older than 35) in good health, with an absence of factors like gestational diabetes, prior difficult births, twins or triplets, or hypertension. Women who don't fit the profile are usually encouraged to see a doctor. For low-risk pregnancies, though, midwives say they can provide a more supportive and compassionate environment for natural birth.

Midwives are trained to recognize signs of trouble in a birth, and some midwives have formed partnerships with obstetricians who will serve as their backup should an emergency occur. Midwives can't perform surgeries, so if an emergency C-section is necessary, so will a doctor. Certified nurse-midwives, because of their hospital backgrounds, are more likely to have these partnerships, whereas direct-entry midwives, who might practice in private homes, are viewed with more suspicion. On the next page, we'll consider the controversial subject of home birth.

About 99 percent of all U.S. births occur in a hospital, but each year, approximately 25,000 women decide to deliver in their own homes [source: Elton]. Women who deliver at home cite the argument made earlier in this article about childbirth becoming too much of a medical procedure; these women claim to be more comfortable in their own beds, with their own things, having a baby on their own terms. These women usually elect to have a midwife in attendance.

In many countries around the world, home births aren't a big deal. In the U.S., however, organizations such as the American Medical Association (AMA) and the American Congress of Obstetricians and Midwives (ACOM) have spoken out against the practice. Midwives claim that with low-risk pregnancies, a home birth is just as safe as a hospital birth, while the medical organizations claim that if something were to go wrong, there'd be a critical window of just a few minutes to perform a surgical procedure or provide advanced medical care. If a midwife had to drive a distressed laboring woman to the hospital, that window might close before the woman could receive care.

Studies support both sides of the issue in this case; some studies find planned home births safe, while others find that fatalities can happen. Doctors and certified nurse-midwives, who are allowed by law to perform home births, usually prefer to work in a hospital or birthing center, so home births are normally performed by direct-entry midwives. The relationship between a direct-entry midwife and an obstetrician can be tenuous at best. If a direct-entry midwife needs to bring a pregnant woman to the hospital, an on-call obstetrician may resent having to oversee a high-risk delivery already in progress (as opposed to monitoring a woman throughout the labor). Some midwives may wait too long to bring the woman to the hospital -- direct-entry midwives aren't allowed to perform home births legally in some states, so they face arrest for showing up with a woman in distress. Some states are considering changing the laws to crack down on home births, but some states, recognizing that legal prohibition might push the practice further underground, are trying to pass laws that allow midwives to bring women to a hospital without legal repercussions.

To some critics, the battle over where a woman will deliver is nothing but a turf war based on economics -- using a midwife can be far cheaper than using an obstetrician, and more insurance companies are starting to cover midwifery services. But even if such controversies didn't exist -- and even if a woman wanted to give birth in a hospital -- she'd still need to ask potential midwives lots of questions about training, experience, certification, backup obstetricians and childbirth philosophies (some women set on a natural childbirth may change their minds halfway through and ask for an epidural, only to be told no by the midwife). If finding a midwife and preparing for other aspects of childbirth is on your mind, then go on to the next page, where there are lots of links that can help you out in your search.

Stuff Mom Never Told You is a podcast that deals with lots of issues related to women, including childbirth. In my time as a co-host of the show, one of the most oft-requested topics by our listeners was midwives. It seems that podcast listeners were immensely interested in natural childbirth and the role that midwives can play in that process, and they're not the only ones -- statistics show that more and more women in the U.S. are employing midwives, rather than doctors, to oversee the arrival of their child.

Though they're a popular option now, midwives have had a rocky road to walk through history. Once branded as witches in Europe, midwives fell out of vogue in the U.S. in the early 1900s when physicians waged an effective public relations campaign that they offered safer services. In the past few decades, however, women have found that giving birth naturally, without medical intervention, can be a very empowering and worthwhile thing to do. Using a midwife can reduce the risk of medical interventions, though these practitioners still have a prickly relationship with doctors.

When we released the Stuff Mom Never Told You episode about midwives, we heard from many listeners who used a midwife and loved the experience. A midwife may not be for everyone, though, so do your research and evaluate your options before making your final childbirth decisions.

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