By Ali Weatherford in consultation with Jessica Good

Midwifery care means getting prenatal, birth, and/or postpartum health care from a midwife. The origin of the word “midwife” boils down to “with wife” or “with woman”.

Since the beginning, women going through pregnancy and birth were usually cared for by another woman or women. These women were named “midwives” in middle English. These were people who had some special knowledge or experience related to pregnancy, childbirth, postpartum, and infant care.

Traditionally, they gained knowledge through experience in their community. Through interest or necessity, they were present for births in their communities and began to have an understanding of the process. They were called on to attend births, and through apprenticeship and experience, were often able to manage normal as well as difficult or complicated situations. They would then go on to train other women in this specialty, and many midwives became highly skilled through experience and this passing on of wisdom.

Midwifery has undergone some major changes over the centuries, and while it has nearly come to the point of extinction, it has not been lost. In our country currently, midwives attend a very small percentage of births. In other countries, those numbers are much higher. There seems to be an upward trend though, which might be a very good thing for our maternity care system.

What Is Different About Midwifery Care?

Since physicians and hospitals have dominated prenatal care and birth, the kind of care that people receive has changed. In many significant ways, there have been improvements. There is no doubt about that. Morbidity and mortality rates have seen a significant drop with the increase of technology and advanced medical care. I’m sure we would all agree that is the most important thing.

However, this has not been without some consequences. For a lot of reasons, our medical system is not equipped to deal with the large numbers of people who are giving birth, and the care has had to become a lot more automated and fast. This means that there are some gaps in care. The missing pieces are creating some unintended problems, and it’s important to look at that and find answers. Midwifery care might be a solution to some of these problems.

Typical midwifery prenatal care involves longer visits. People receive the basic checkup procedures just as they would at the doctor’s office, but then there is more.

• A midwife will usually discuss a person’s mental health and offer coping strategies to help them keep stress levels down. This is a critical piece of prenatal care, since we know that high levels of stress can cause pregnancy and birth complications.
• A midwife will usually discuss prenatal nutrition in depth. They may request that their patients keep a food journal so they can keep up with the amount of critical nutrients they are getting. It’s especially important to eat well during pregnancy, and there is a significant amount of research showing that good prenatal nutrition can minimize complications and help people feel their best during pregnancy. A midwife will usually recommend that their patients eat enough protein daily, that they are including healthy fats as part of their regular diet, that they are eating plenty of fruits and vegetables for some additional micronutrients and recommend that they limit sugar intake and other unhealthy foods.
• A midwife will also encourage some healthy exercise. Research does also show that a healthy amount of movement in pregnancy can help people feel better, while also minimizing complications.
• A midwife will likely offer strategies for better sleep since we also know that being well-rested can improve outcomes and general health and well-being.
• A midwife is likely to offer referrals for other practitioners when needed. This might include an obstetrician (OB) or Maternal Fetal Medicine (MFM) specialist if a person has a situation that comes up putting them in a high risk category. It might also include referrals for pelvic floor physical therapy or chiropractic care when someone has a need. And there are other providers that a midwife might recommend to their patients when it’s an issue that is outside of her scope.
• There are so many components to having a healthy pregnancy, and a healthy pregnancy can lead to fewer complications in labor and birth, and in the postpartum recovery. Unfortunately a lot of these things are not part of the standard prenatal care in our country.

A typical prenatal visit with a midwife lasts 30 minutes to one hour. A typical prenatal visit at an Ob-Gyn practice usually lasts 10-15 minutes. Most people report that they do not receive any or much instruction on prenatal nutrition, mental health, exercise, sleep, etc. during their prenatal checkups, and are rarely offered referrals for outside specialized care.

This healthy pregnancy care and guidance is a critical missing piece. Even though the OVERALL the morbidity and mortality rates are lower now that people can access good medical care and hospital birth for complicated situations, we are not doing the best that we can. Our maternal and infant mortality and morbidity rates are higher than that of many other developed nations. If the beneficial aspects of prenatal midwifery care could be integrated into our standard prenatal care, it’s very likely that the rates would improve even more.

Midwives also provide excellent care for low risk physiological birth. This means that people who choose to minimize interventions and medications for their births tend to have better outcomes with midwifery care. Midwives tend to spend more time with their patients during labor and birth, and they are able to offer more strategies for managing birth without medical intervention and medication so that people are more successful and safe.

If midwifery care in birth centers was more available and paid for by insurance or if midwifery care could be more integrated into the hospital birth setting, we can assume that there would be lower rates of birth interventions. Interventions can be expensive. They can also lead to lower levels of satisfaction for patients and even potentially higher rates of birth complications or cesareans. A marriage of midwifery and physician care could mean a significant improvement in maternity care overall.

Where do Midwives Work?

Midwives can be anywhere that people are giving birth! Many midwives only attend home births. They may provide prenatal care either in the patient’s home, or in an office/clinic. Other midwives work in a free-standing (not attached to a hospital) birth center where they provide prenatal care and attend births. Midwives who work outside the hospital system are providing care in what is sometimes called a community birth setting.

Some midwives work on staff at a hospital where they attend low risk births. Some midwives are part of a private Ob-Gyn practice, seeing low risk patients and attending low intervention births. Still others are part of a private practice of midwives who see patients for prenatal care in their clinic and attend their births at a local hospital. This might be called a hospital-based midwifery practice.

What Kind Of Training Do Midwives Have?

Midwives usually receive a similar level of education related to pregnancy and birth as a physician would.
They are licensed and qualified to provide the same level of prenatal care for low risk pregnancies. They can ensure that patients are offered all of the appropriate testing and screening.

Many midwives can also prescribe and use certain medications for their patients. They can attend vaginal low risk births. The big difference is that they do not receive training or experience in surgery and technology focused interventions. This would include cesareans and forceps or vacuum assisted births, or some other high risk or complicated cases.

There are different types of midwifery credentials. The credential they have most often depends on what kind of education they had before entering graduate school for midwifery. Most midwives graduate with either an MSN (Masters of Science in Nursing) or a DNP (Doctorate in Nursing Practice) with an emphasis in Nurse-Midwifery. Most midwives working in a hospital setting are Certified Nurse Midwives (CNMs). This means that before they went to graduate school for midwifery, they received a degree in nursing and hold an RN license. With this credential, a midwife can offer the most options for care in any setting.

Certified professional midwives (CPMs), and Certified Midwives (CMs) also provide a high level of care, but most often in community birth settings. A CM attends graduate school for midwifery and has an undergraduate degree in a health related field other than nursing. A CPM may not have an undergraduate degree prior to entering midwifery training, and their training may not require a graduate degree but does usually require knowledge and experience in community birth settings and they must complete certain courses and demonstrate specific competencies.

Can Midwifery Care be Integrated into our Current Maternity Care Structure?

There are already some great examples of how midwifery care can be integrated into a more medicalized maternity care system. In countries such as Sweden, Australia, New Zealand, the UK, Norway, Germany, Switzerland, France, and the Netherlands, midwives outnumber Ob-Gyns significantly. These countries also have maternal mortality rates that are most all significantly less than half of the U.S. rates. These are high-income countries practicing advanced medicine while also providing a midwifery model of care for the majority.

In the United States, there are many barriers to this kind of integration, but it’s not impossible. There are already hospitals and private practices providing a midwifery model of care with midwives comprising a significant percentage of their workforce. Moontower Midwifery is a great example of this more recent change in my local area of Austin, TX. They are a private practice of midwives who administer prenatal and postpartum care in their clinic and attend births at a local hospital.

There are also community birth settings providing comprehensive and even low cost prenatal care by midwives. Sometimes these centers include birth services, and sometimes it’s only prenatal care and/or basic gynecological care. This is often in an effort to help offset the shortages of resources in certain areas. Most people don’t realize that 36% of counties nationwide are considered maternity care deserts. This means they have no obstetric hospitals or birth centers and no obstetric care providers. This is a shocking statistic, and one that many experts think should be solved by increasing the availability of midwifery care.

Increasing Availability Means A Lot Of Things

There are not enough midwives right now to support this kind of expansion. Many states need to improve their licensing requirements and guidelines for practice authority for midwives. Insurance companies and federal and state sponsored health care plans need to increase coverage for midwifery care. When midwives are fully recognized and authorized as maternity care providers, and can be well paid for their work, more people will be able to enter the field and increase the workforce. This will hopefully lead to an increase in midwifery training programs and the availability of residency programs for midwives which are necessary for their licensing and career options.

Once all of these changes are in motion, the availability of midwifery care will likely increase and hopefully lead to improved maternal health outcomes in the United States.

I love progress and helpful technology, but I also believe that it shouldn’t be used thoughtlessly. I believe that our maternity care system made that mistake when midwifery care was nearly eliminated through smear campaigns and misinformation. Midwifery is one of the oldest professions and until fairly recently was how maternity care was delivered.

During the 1800’s, physicians who were at the time almost all white males, began to explore childbirth with more interest. Before that, it was the realm of midwives. Doctors began to oppose midwife-assisted birth and launched campaigns against the profession. The goal was to promote new methods and technology with pain relief at its center. By the start of the 1900’s, about half of births were in hospitals attended by physicians even though most of these doctors had very little training in obstetrics and almost no experience.

In rural areas, midwives continued to provide the majority of maternity care until the 1940’s, and many of them were black. At that point, changes in law, educational restrictions for women and especially black women, and more negative campaigns by the medical field led to the near extinction of midwifery care in general, and especially of black midwives.

Even when more formal midwifery training programs began, there were so many legal restrictions in place for midwives, a general sense that midwifery care was not a legitimate profession, and that midwives were not competent. Also, these more formal paths to becoming a midwife were often restricted to only white women, and left out so many people who could have carried on the wisdom and legacy of the original midwives in those areas.

Undoing these mistakes can’t be an easy process, but worth the effort. It’s important to be open to new technology and knowledge, but it’s also critical to hold on to the wisdom and practices that work well. The integration of the new and the old, of the science offered by the medical field combined with the intuition, nurturing, and wisdom that can only be provided by experience. All of these aspects are key to providing the ultimate in care.

Watch our video conversation with Midwife Jessica Good of Moontower Midwifery & Wellness.