#5 What Do Midwives Do?

If you prefer a natural delivery without a lot of technological intervention with monitors, induction, and episiotomies, your home or a birthing center is the place you are most likely to find what you envision as the ideal delivery.

As you review your delivery options—hospital or home birth—you will find midwives in both places. With a home birth, you will have a midwife who sees you regularly in her office and comes to your home to help manage your delivery. You will find midwives in birthing centers as well, but for many women in the United States, birthing centers are not an option. However, hospitals also employ midwives to help work with laboring women. Just be aware that the midwife who monitors your pregnancy and delivers your baby in your home is someone you have developed a patient-midwife relationship with, much like the patient-physician relationship found in primary care. However, the midwife employed by the hospital may well be someone you have never seen before and there is unlikely to be an established patient-midwife working partnership.

Midwives are health care professionals who are trained to provide prenatal care for you during the course of your pregnancy and they will continue to monitor you after their delivery. Your midwife will help you prepare for childbirth and can also assist you during labor. Furthermore, midwives are there to monitor you and your baby, and help you avoid the kinds of complications that can turn a low risk pregnancy into a high risk one. From prenatal care to postnatal care, your midwife will support you and advocate for you.

Traditionally, midwives underwent extra training and were given credentials by the state. Nowadays, midwives come in two varieties: those who went through formal training and those who we usually refer to as “lay” midwives. Lay midwives have no formal medical training but instead learned how to manage pregnancy and delivery by working with someone who has had years of experience. Some states choose to give credentials to lay midwives (Minnesota does) while others prefer not to (North Dakota does not). In my opinion, the idea of licensing lay midwives is not a bad idea and is a smart move for everybody. It provides authenticity for lay midwives and it gives the state oversight to the lay community.

I have had the opportunity to work with both lay and credentialed midwives. Frankly, I find working with lay midwives a win-win situation. Since they have no official standing in hospital births, I was considered the delivering doctor of record but I would allow the lay midwives to be present at my deliveries and act as a doula. This way, the patient would have an advocate, something I think important for laboring women, and they would get what they wanted in a secure hospital birth.

While I have never found any fault with lay midwives, I tend to come across boundary issues with credentialed midwives, especially with employed ones. Some hospitals actually employ credentialed midwives to give support to their patients. But if you choose to work with a lay midwife or a midwife who is not a part of the hospital staff, there is a possibility of running into problems if your midwife believes you need to be admitted to the hospital for your delivery. In some areas, your midwife may have a difficult time finding a hospital which will accept you. I was one of the few obstetricians who would accept hospital admissions from midwives. I knew the local midwives, knew they were skilled, and respected their opinions about the need for admission to the hospital. If you are working with a midwife planning a home birth, be sure to ask if she has a good working relationship with an obstetrician at your local hospital.

The state of Alaska has many midwives, which is understandable considering how remote some of the villages are. However, in Alaska, midwives work with obstetricians. A woman planning a home birth sees an obstetrician several times during her pregnancy although most of her prenatal care is provided by her midwife.  That way, if the midwife decides the woman needs to deliver in a hospital, there is an obstetrician ready to receive the patient in a transfer of care. This seems a particularly reasonable and humane way to handle the home birth vs. hospital birth tension.

In the end, it all falls down to your preference. You may want a midwife, but there is no need for one unless you want the benefits that come with having a midwife. This involves prenatal visits, home births, and postnatal care (including assistance on how to take care of your newborn). I think that the need for midwives has more to do with time. Midwives can provide more time to answer your questions and assist you with everything you need for a healthy pregnancy.