Midwife or Obstetrician? Finding the Right Care Provider for Your Delivery

By: Annie Graham

The right care can transform the experience of pregnancy and labor. When choosing who will provide that care, it is best to consider all of your options — starting with what type of medical professional is best for you. Although the majority of American women choose obstetricians to manage their care during this time, an increasing amount of mothers-to-be across the country are opting to hire a midwife instead. Births attended by certified nurse-midwives in the U.S. nearly tripled between 1989 and 2013 from three to nine percent.

What is a certified nurse-midwife (CNM)?

Although professionals of many different qualifications fall under the umbrella title of “midwife,” such as certified midwives and certified professional midwives, in this post I’ll use the word “midwife” interchangeably with certified nurse-midwife. A certified nurse-midwife, often abbreviated CNM, is a registered nurse who has earned a degree from a nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education.

Midwives’ training is generally based off of a slightly different philosophy than that of obstetricians. While most obstetricians focus heavily on the physical needs of the mother, midwives are trained to provide holistic care. In other words, they work on both the emotional and physical aspects of pregnancy and labor, and focus on the individual’s unique needs in both regards. Midwives work to build a healthy and trusting working relationship with the women and families they care for.

How is working with a CNM different than working with an obstetrician?

The difference in philosophy and training means that you can expect slightly different prenatal and labor experiences from a midwife than from an obstetrician. In general, prenatal visits with midwifes are longer. The additional time is sometimes spent discussing diet and exercise guidelines, which midwives generally emphasize as extremely important. Midwives also spend a lot of time discussing what kind of birth experience the patient would like. For example, midwives might want to talk over whether you would like to go through labor unmedicated or with an epidural. A traditional prenatal visit with an obstetrician can feel more matter-of-fact. Most obstetricians provide a wealth of clinical knowledge and will present all the delivery options to a patient, but will have clear clinical and evidence-based protocols to follow. Furthermore, expecting mothers might also experience subtle differences in care during actual labor depending on which kind of professional they choose. For example, midwives are generally trained to intervene during labor and delivery only when medically necessary. This might feel less clinically attentive for some women.

Aside from these differences in training and philosophy, a CNM is certified to do much of the same practical tasks as doctors when it comes to women’s health. They offer annual exams, reproductive health visits, gynecological care, nutrition counseling and parenting education to their patients. They can also write prescriptions in all 50 states, and provide care during labor and delivery. Midwives and obstetricians also provide care in the same physical settings — more than 96% of CNM-attended deliveries occur in hospitals, while only 2% happen at birthing centers and 1.7% happen at home.

Are there any differences in terms of outcomes?

Many women will have strong opinions about working with a midwife versus an obstetrician, but what can data show us about the difference? Statistically significant data is limited and I highlight a few below.

One study sifted through 710 obstetrician-attended and 471 CNM-attended pregnancies, attempting to find some difference in outcome. Researchers ensured that all women qualified for nurse-midwifery care, and controlled for maternal risk, selection bias, and the invasiveness of care. After these considerations, the main statistically significant differences between outcomes were 1) the percent of infants who remained with their mother for the entire hospital stay (15% for doctor-cared and 27% for CNM-cared), 2) the amount of third- or fourth-degree perineal laceration (23 versus 7%), and 3) the number of complications (0.7 versus 0.4%) (Oakley et al., 1996).

Another study looked at rates of cesarean section among obstetrician and nurse-midwife-managed low-risk private patients. Researchers found that nurse-midwife-managed patients had a lower rate of cesarean section (8.5% versus 12.9%) and operative vaginal delivery (5.3% versus 17%). In addition, physicians used epidural anesthesia and oxytocin for induction and augmentation much more frequently than midwives (Davis et al., 1994).

Finally, a more recent study found that midwife-attended births had care processes characterized by less technology and intervention than doctors, while the neonatal outcomes of their patients were no different. These conclusions were drawn after taking pre-existing risk into account (Cragin, Leslie & Kennedy, 2006).

In short, these studies seem to suggest that midwives disrupt the physical delivery process less, initiate less C-sections, and provide more emotional support than doctors.

This is an incredibly personal decision

The studies mentioned are simply three to consider amongst a vast array of data and information available about which type of care professional is right for you. Ultimately, the best things to consider when choosing a care provider are your own personal goals for pregnancy and the birth experience. Ask yourself key questions like: what kind of relationship do I want with the person delivering my baby? What kind of care do I expect in the delivery room? No amount of statistics can answer those questions. The majority of women who give birth in the United States do so under the care of an obstetrician and that is unlikely to change in the near future.

If you’d like to learn more on the subject, there are resources we recommend that can give you more practical information on this decision.

  • Nycmidwives.org provides a list of over 35 hospitals and practices in Manhattan, and divides them by home births, hospital midwifery services, and private practice midwives.
  • Ourmomentoftruth.com provides a breakdown of midwifery myths set straight and a quick quiz that could help you determine if a seeking a midwife’s care is the right decision for you.
  • The Atlantic and The New York Times have also recently published informative articles about midwifery as a rising trend in the United States.

Research studies cited:

Cragin, Leslie, and Holly Powell Kennedy. “Linking obstetric and midwifery practice with optimal outcomes.” Journal of Obstetric, Gynecologic, & Neonatal Nursing 35.6 (2006): 779–785.

Davis, Lorna G., et al. “CESAREAN SECTION RATES IN LOW‐RISK PRIVATE PATIENTS MANAGED BY CERTIFIED NURSE‐MIDWIVES AND OBSTETRICIANS.” Journal of Nurse-Midwifery 39.2 (1994): 91–97.

Oakley, Deborah, et al. “Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives.” Obstetrics & Gynecology 88.5 (1996): 823–829.

Referenced resources:

http://www.fitpregnancy.com/pregnancy/labor-delivery/ob-or-midwife

http://www.babycenter.com/0_doctor-or-midwife-which-is-right-for-you_9348.bc

http://www.yourchildbirthguide.com/midwife-or-doctor.html

http://www.midwife.org/The-Credential-CNM-and-CM

http://www.theatlantic.com/health/archive/2015/06/midwives-are-making-a-comeback/395456/

https://nycmidwives.org/midwifery-of-manhattan/

http://www.nytimes.com/2012/06/17/fashion/the-midwife-becomes-a-status-symbol-for-the-hip.html?_r=0

http://mana.org/about-midwives/what-is-a-midwife

http://www.ourmomentoftruth.com/mythbusting

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