How to Choose a Midwife

By Jeanne Faulkner, RN, a labor nurse in Portland, Oregon

More women are choosing midwives, but lingering myths and confusion mean that many moms-to-be still have questions. We've got answers.

Midwives are being rediscovered by growing numbers of pregnant women today. According to the National Center for Health Statistics, in 2006 (the most recent figures available), they attended a record-busting 317,168 births 7.4 percent of all U.S. births; 96.7 percent of them took place in hospitals, 2 percent in birth centers and 1.3 percent in homes. To help you decide whether to go the midwife route, here are answers to some of the most common questions.

What advantages do midwives offer?

The Midwives Model of Care views pregnancy and birth as normal events; as a result, midwives suggest and perform fewer interventions than are typical with most obstetric care. Midwives focus more on nutrition and education, says Judi Tinkelenberg, C.N.M., R.N., clinical director of Sage Femme Midwifery Service and Birth Center in San Francisco. We do fewer routine, often unnecessary tests for example, we don't automatically do ultrasounds if they're not needed. We make decisions with patients based on informed consent. Midwives also spend more time with patients than most OBs do, which means they often offer more personalized care.

What exactly does midwife mean?

All midwives provide prenatal and postpartum care, attend labors and deliver babies. Some provide additional services, such as routine gynecologic exams and contraception care. But do your homework; anyone can call herself a midwife. Here are the distinctions:

>>Certified midwives (C.M.) meet American College of Nurse-Midwives (www.midwife.org) requirements, but they do not need to be nurses.

>>Certified nurse-midwives (C.N.M.) are nurse- practitioners who are certified by the American College of Nurse-Midwives.

>>Certified professional midwives (C.P.M.) meet North American Registry of Midwives (www.narm.org) certification standards.

>>Direct entry midwives (D.E.M.) are educated through self-study, apprenticeship, midwifery school or college- or university-based programs that don't include nursing. They include certified midwives and certified professional midwives.

>>Lay midwives are sometimes called traditional, unlicensed or granny midwives. These women are educated through self-study and apprenticeships, and while they may be highly experienced and skilled, they aren't certified or licensed.

>>Licensed midwives (L.M.) can practice in a particular jurisdiction, usually a state or province.

For more information on the different types of midwives, go to www.mana.org.

What's the best kind of midwife?

That depends on whether you want a hospital or out-of-hospital birth, a low-intervention or medicated one. The most important thing is to make sure anyone you're considering is qualified and experienced. Direct entry midwives and certified nurse-midwives have different educational pathways, but they're all well-trained and competent, says Geradine Simkins, D.E.M., C.N.M., M.S.N., president of the Midwives Alliance of North America. Most C.N.M.s deliver in hospitals, while C.P.M.s have specific training and expertise in out-of-hospital births.

The Institute of Medicine and the National Commission to Prevent Infant Mortality praise the contributions of certified nurse-midwives in reducing the incidence of low-birth-weight infants and call for their increased utilization.

Is it safe to go with a midwife?

Yes, as long as you have no pregnancy complications or risk factors for birth complications. For 60 to 80 percent of low-risk pregnancies, it may be even safer to go with a C.M. or a C.N.M. than with an obstetrician. That's because midwives use less fetal monitoring and over-diagnose fetal distress less often, which means fewer interventions, such as C-sections and forceps- or vacuum-assisted deliveries. Studies show that C.N.M.-attended births are associated with 31 percent fewer low-birth-weight babies and 33 percent less neonatal mortality.

If you have certain health risks, including obesity, diabetes or hypertension or are carrying multiples, you might still qualify for midwife care, but only if it's coordinated with an OB. If you want to give birth at home, make sure your midwife has protocols for a quick transfer to a hospital in case of an emergency.

How do costs and care compare with those of obstetricians?

Midwifery care can cost less overall, but C.N.M.s are sometimes paid similar rates as OBs. Insurance companies currently pay for most C.N.M. services, and under the new federal health care legislation, certified D.E.M.s will also be covered.

As for whether the midwife you see for prenatal visits will deliver your baby, it's the same as if you were seeing an OB. Many private practice midwives make a special effort to be at their own patients' births, even when they share call with partners, says Karen Parker Linn, a C.N.M. in Portland, Ore. In shared practices, several midwives work together. Patients see different ones during pregnancy and deliver with whomever is on call, though midwives sometimes come in for patients with whom they've formed a special bond, Linn adds.

Do doctors respect midwives?

Most hospital-based midwives are well-respected by OBs. Out-of-hospital midwives? Not as much. Most out-of-hospital births are safe, but when trouble arises and patients are transferred to hospitals, doctors sometimes feel like the clean-up crew for high-risk deliveries.

"Midwives are fantastic options for low-risk women," says Kathleen Harney, M.D., chief of obstetrics for Cambridge Health Alliance and the C.N.M-managed Cambridge Birth Center in Massachusetts. Their philosophy and training are more focused on birth as a healthy, natural process. Doctors are trained to think something adverse may happen, she explains. The truth is somewhere in between. Working in concert with midwives reminds OBs not to be overly interventionalist.

5 questions to ask a midwife

1. What is your training, experience and certification, and do you have references?

2. Where do you deliver at home, in a birth center and/or in the hospital?

3. What percentage of your prenatal patients do you actually deliver yourself?

4. For an out-of-hospital birth, what's your emergency backup plan?

5. Do you take medical insurance?