Call the Midwife

When Kelly LeGendre found out in 2012 that she was pregnant with her first child, the Arizona resident, then 34, knew she needed to seek prenatal care. Unlike most American mothers, however, LeGendre didn’t seek out an obstetrician. Instead, she opted for a midwife.

For LeGendre, the decision was a no-brainer: “I wanted minimally invasive prenatal care and a completely natural childbirth experience,” she explains. She’d known several women who had positive birth experiences with midwives; meanwhile, some mothers who had gone the traditional physician route told her they had been urged to accept interventions that LeGendre didn’t want, like genetic testing, early induction of labor, or IV antibiotics during labor.

LeGendre is part of a small but growing minority of American mothers opting for midwives over obstetricians: In 1989, the first year for which data is available, midwives were the lead care providers at just 3 percent of births in the U.S. In 2013, the most recent year for which statistics are available, that number was close to 9 percent.

The growing popularity of midwifery care is partially a response to rising Caesarean rates, says Eugene Declercq, a professor of community health sciences at Boston University who studies American maternity care. Currently, around a third of all births in the U.S. are Cesarean sections, a number far higher than the World Health Organization-recommended target of 10 to 15 percent. The inflated rate is due in part to longstanding misperceptions in the U.S. medical community about how quickly labor should progress and when medical intervention is necessary.

According to Declercq, the high rates of surgery and other unneeded interventions have led to increased interest in the midwifery model, which is lower-tech, less invasive, and less inclined toward intervention without a clear medical need; a 2011 study in the journal Nursing Economics found that births led by midwives in collaboration with physicians are less likely to end in a C-section than births led by obstetricians alone. According to Ginger Breedlove, the president of the American College of Nurse-Midwives, the real reason for this difference is in the approach to care: Midwives typically promote patience with the natural progress of labor and discourage intervention to speed the birth process. “It’s a different model,” she explains.

Popular media is also playing a role in the rising popularity of midwives, Breedlove says. The 2008 film The Business of Being Born and TV shows like the BBC’s Call the Midwife, for example, are helping to subtly reframe the concept of midwifery in the American mind, moving it from a fringe profession to something closer to mainstream.

Though still a relative novelty in the U.S., midwife-led maternity care is the norm in other developed countries, including most of Europe.* In England, for example, midwives are the lead care providers at more than half of all births. (There, midwife care is considered fit even for royalty; last month Kate Middleton gave birth to her daughter Charlotte under the care of two midwives.) “In England, what they say is, ‘Every mother deserves a midwife, and some need an obstetrician, too,’” Declercq says.

One of the major differences between obstetricians and midwives is the philosophies that ground their training, Breedlove says. Medical education is fundamentally disease-based and curative; as a result, “[OG-GYNs’] focus is more on the sick woman who either has healthcare needs through the lifespan or has complex obstetric needs,” she explains.

In midwifery, by contrast, training focuses on caring for the majority of mothers who have healthy, low-risk pregnancies. Childbirth is accordingly seen as a natural occurrence, not a medical event, and midwives emphasize the importance of prenatal education and developing a strong relationship with their patients. “[It’s] very personalized, high-touch, low-tech care,” Breedlove says.

As a result, Declercq explains, midwives tend to ask different questions about birth than do other medical professionals. For example, in most physician-attended hospital births in the U.S., mothers are hooked up to continuous electronic monitoring equipment to track the baby’s heartbeat and identify possible signs of distress. A 2006 review of three decades’ worth of data, however, found that continuous monitoring offered very little benefit for the majority of births—it was correlated with “reduction in neonatal seizures,” the authors wrote, “but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being”—and was actually associated with a higher rate of C-sections and vaginal deliveries with forceps. Midwives, because of their training to intervene only when it’s medically necessary, tend to question the necessity of continuous monitoring and typically favor intermittent monitoring instead, Declerq says.

The curative skills of a physician are critically important for women with genuine medical needs, Breedlove says, but it can be detrimental to mothers when the physician model “over-medicalizes” normal, healthy pregnancies. “When you begin intervening at high levels for no medical indication, as with premature induction, elective Cesareans, and forcing women to stay in bed and not ambulate during labor,” she says, “you begin to create a cascade of domino responses that intervene with normal physiologic processes and change the outcome of birth.”

Current research suggests the midwifery model may translate to substantial benefits in both maternal and infant health. The 2011 Nursing Economics study, for example, also found that mothers whose care was led by a nurse-midwife had lower rates of episiotomies, drug-induced labor, and vaginal tearing during delivery. Similarly, a 2013 review by the healthcare-research organization Cochrane looked at hospital births in a variety of countries with advanced healthcare systems, including England, Australia, and Canada, and found that women whose care was led by a midwife rather than a physician were less likely to receive pain medication in labor, less likely to experience pre-term birth, and less likely to experience a miscarriage before 24 weeks gestation.

The growing presence of midwives may also help to control the exorbitant medical costs often associated with pregnancy and birth in the U.S. (In a survey of healthcare spending in developed nations, the U.S. spent the most per capita on childbirth, despite its global ranking of 33 out of 179 countries on maternal and child health.) Although midwives are paid less than physicians for their services, Declerq says, the greatest savings stem from the fact that midwives aren’t as inclined to order costly medical interventions for their patients. They also tend to encourage non-pharmacologic methods of pain relief, relying on natural techniques like breathing and massage and emphasizing the power of physical and emotional support for helping women work through labor without analgesics. “The cost of pain management is significantly different [with midwifery-led care],” Breedlove says.

Historically, Declercq says, the fields of obstetrics and midwifery have had a tense relationship, stemming back to the early 20th century, when obstetrics was just rising as a specialty. At that time, spurred by the increasingly popular belief that pregnancy was a dangerous condition requiring care from highly trained specialists, doctors and public-health reformers joined together in a concerted effort to eliminate traditional midwifery. Many U.S. states began to strictly regulate or forbid the practice.

Today, tensions still linger in some parts of the U.S. (In 2010, for example, a group of Oregon midwives filed a lawsuit against the Oregon Health Licensing Agency, alleging that the birthing center where they worked had been the target of baseless investigations.) At the organizational level, however, the last few years have seen dramatic efforts at collaboration between the two professions. In 2011 and again in 2014, leading organizations in each field—the American Congress of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM)—released a joint statement emphasizing the importance of both physicians and midwives in American healthcare and the value of collaboration, rather than competition, between the two. (The subject of home birth remains a point of disagreement, with ACOG continuing to oppose the practice.)

“There are no significant drawbacks and many benefits to engaging with midwives to join our care teams,” says Mark DeFrancesco, the president of ACOG. Collaboration is becoming a matter of some urgency, he explains, due to the growing national physician shortage. Some areas of the country already lack enough obstetricians to meet demand, and the U.S. will be short an estimated 9,000 obstetricians by 2030. “We need to be able to care for America’s pregnant women, and as long as the number of obstetricians remains plateaued, part of the answer lies in midwives,” says DeFrancesco, who himself works with certified nurse-midwives (CNMs) in his private obstetrics practice in Connecticut.

Historically, there have been multiple paths to entry into midwifery, a fact that’s long been a point of concern for doctors: Certified nurse-midwives (CNMs), who complete an extensive nursing education culminating in a graduate degree, can practice legally in all 50 states. But 28 states also allow “direct-entry” midwives, who may enter the profession through an apprenticeship to a more experienced midwife. As a result, the term “midwife” has no standardized meaning in the U.S. “There’s a great deal of confusion,” says Breedlove.

But that situation is changing, and new educational requirements are on the horizon. Since 2010, the International Confederation of Midwives, which represents midwife organizations in approximately 100 countries, has advocated for a standardized minimum level of training for all midwives, not just in the U.S. but globally. The initiative has received widespread support from the major midwifery organizations in the U.S.

Efforts like these, Breedlove says, are important for dispelling stereotypes and bringing midwifery further into the mainstream. Soon, she hopes, “the general public will hear ‘midwife’ and not think ‘hippie, exclusive home birth, uneducated, far-out alternative option.’ But they’ll hear the word ‘midwife’ and it will be like ‘nurse anesthetist’ or ‘neonatal nurse practitioner’—someone who is qualified within their scope of practice and an essential part of the healthcare team.”

That’s a change in status that DeFrancesco fully supports. As the field of obstetrics continues working to improve health outcomes for mothers and their babies, he says, midwives have their own wisdom to offer: “This is a prime opportunity to not just collaborate with midwives, but also to learn from them.”

* This article originally stated that that midwife-led births are the norm, comprising the majority of births, in Canada. We regret the error.