Meet the “Birth Workers”

May is the International Doula Month! I was inspired to create a post just for these wonderful birth workers but I know there is a lot of confusion about who they are and what they actually do! I get a lot of questions about the differences between an OB, a midwife, a doula and a nurse… and even with having many, many years under my belt as a provider in the birth room, there are still so many confusing aspects to what goes into each role and how they are defined. So, I wanted to create a blog that goes into depth about the different roles and approaches to maternity care so that you feel like you understand it… even if just a little bit better. Women’s health and maternity care remains very fragmented and there is still a lot of opposition and a lack of understanding of how we can all work together, build on the strengths of one another and create an approach that is symbiotic for the ultimate wellbeing of the individuals and families we serve. We haven’t gotten there yet, but I have a dream that someday soon we will work together seamlessly, as a true team, putting our differences aside and remembering why we got into birth work or medicine in the first place…  Evidence Based Birth ® has done a fantastic job of defining the different roles and approaches so a lot of the information in this post was collected from their wonderful resources. So, let’s dive in!

PHYSICIANS: In the U.S. the majority of births in 2017 (89.2%) were attended by physicians. These physicians specialize as OBs (obstetricians), DOs (doctors of osteopathy) and Family Practice doctors. Only 9.9% of births were attended by midwives and we will discuss the different types of midwives a little later on. The U.S. and Canada are seen as kind of anomalies as far as developed countries go in that the majority of births are attended by physicians and not midwives. Everywhere else in the world, the majority of births are attended by midwives as opposed to doctors. For example, in 2009 there were 31,186 midwives compared to only 1,600 OBs in the United Kingdom. The history of maternity care in the U.S. and the suppression of midwifery is what has led to this unique difference and it has a rich and complex history which could be an entire blog post on its own… maybe for a different day! I think it should be mentioned that the practice of midwifery is an ancient tradition and significantly outdates the practice of medicine (for as long as women have been around to have babies!). Okay back to medicine, let’s break down the definition and training of each type of provider who may attend births. OBs are specialists who provide medical and surgical care to women and they may serve as a primary care provider or as a consultant to care. They complete a bachelor’s degree and an M.D. or D.O. medical program for a total of at least 8 years of educational training. They then go on to complete a four-year residency in obstetrics and finally sit for their board exam to obtain certification from the American Board of Obstetrics. Family Medicine physicians specialize in the comprehensive health care for people of all ages. The 8 years of undergrad and graduate training is followed by a three-year residency. They are board certified by the American Board of Family Medicine and may have an optional fellowship in order to perform cesareans. All of these physicians are experts in pathology and surgery and utilize an approach describes as the Medical Model of care in which pregnancy is seen kind of like a disease state or pathological process that requires an emphasis on testing, monitoring and intervention to treat/cure the cause. This is different than the Midwifery Model of care and we will cover that next!

MIDWIVES: Midwives approach maternity and women’s healthcare using the Midwifery Model of care and oversee “normal” or uncomplicated pregnancy and birth. The Midwifery Model views pregnancy and birth as a normal physiologic process that strives to take into account the individuality of the woman and her family (aka family centered care). It is a holistic model that supports physical, psychological, spiritual and social wellbeing.  Midwives are trained to understand the limits of their scope of practice and identify when to consult/refer to MDs when needed (high risk conditions/complications). Because I am an evidence junkie, I wanted to include some of the evidence on the midwifery led model of care compared to the shared or medical model of care. According to Cochrane review results of 15 RCTs (RCT = highest quality research study): Midwifery-led care resulted in less amniotomy (artificial breaking of water), less epidural use, fewer vacuum/forceps births, less episiotomy, fewer preterm births, increased spontaneous vaginal births, less fetal/newborn deaths and no adverse effects. The evidence speaks for itself! Now back to the different types of midwives… to make things even more confusing there are different types of midwives and they are recognized differently state by state as well. Just as there are different trainings for the different types of physicians, as previously described, there are different trainings for the different types of midwives. A Certified Nurse Midwife (CNM) is a registered nurse who has completed a master’s degree in midwifery which is usually a minimum of four years of education. The graduate program’s clinical practicum includes a set of minimum clinical competencies (number of hours, visits and births) kind of like a medical residency. After graduation, they sit for their board exam and are certified by the AMCB (American Midwifery Certification Board). CNMs are recognized in all 50 states and they attend births in the hospital and in community birth settings as well (birth centers and home). CNMs are also primary care providers, have prescriptive authority (can prescribe medicine) and can care for women throughout the lifespan (from puberty to menopause). Now direct-entry midwives (DEMs) differ in their training and background experience. They are midwives who are educated in midwifery without a nursing degree. There are many different educational pathways for the various types of direct-entry midwives which include self-study, apprenticeship or institutionalized education as well. They are regulated and recognized differently state by state but include Certified Midwives, Certified Professional Midwives, Licensed Midwives and Registered Midwives. They usually attend births in birth centers and your home depending by state. Certified Midwives (CMs) have a background in science or health related field/degree other than nursing and go on to complete a master’s degree in Midwifery. They have an equivalent education in midwifery compared to CNMs but have no nursing background. They can attend hospital births; however, there are very few practicing in the US and are only recognized in 5 states. Certified Professional Midwives (CPMs) are the most common DEM in the US who attend births in community settings (outside the hospital). There are two educational pathways for CPMs which usually takes anywhere from two to five years to complete: the portfolio evaluation process apprenticeship or the MEAC-accredited educational program in which they complete minimum hours/births/experiences. They are board certified by NARM (North American Registry of Midwives) and licensure varies by state (recognized by 34 states). Certification does not require an academic degree but is based on demonstration of competency. I do want to make sure to mention that Traditional Midwives (the original “midwife” dating back to the beginning of time!) still attend births today, they choose to not be certified or licensed and may not have any federally recognized “formal education” and believe that midwifery should not be legislated. This highlights the education controversy which deserves its own blog post in its own right but I wanted to offer a brief introduction to the differences in midwifery in our nation. This is such a confusing topic even for someone who is becoming a midwife, so I hope that these brief explanations offer a starting point for your better understanding to guide your decisions when selecting the provider you choose to attend your birth. 

DOULAS: OKAY! We have made it! This post was inspired by the month of May: the International Month of the DOULA! This is the month to bring awareness to the idea that doulas should be recognized as the valuable, evidence based member of the birth care team that they are. “Evidence based” means that research has shown that labor support from doulas is both risk-free and highly effective. I personally believe that doulas are the most underutilized (only 6% of births in 2012 had a doula present) and underrecognized members of the birth team… and that if everyone who gave birth in America had a doula by their side, we would see major improvements in some of our nation’s most devastating statistics of maternal morbidity and mortality (the worst of developed nations). A brief review of the history of doulas recognizes that as birth moved into institutionalized settings/hospitals in the 1940 and 50s, women were separated from the age-old support network of the women who knew them best and who had supported birthing people for the centuries of birth in the community and at home and was then ultimately replaced by “strangers” (nurses and doctors). The role and “invention” of the doula aimed to address this loss and embodies the support of trusted experts and wise women. SO! What exactly IS a DOULA?! A doula is a professional companion who is trained in labor support who provides support and guidance throughout pregnancy, birth and the postpartum period in the form of information, advocacy, emotional support and reassurance, continuoushands-on labor support and comfort measures and the facilitation of healthcare team/birthing person communication. They can be viewed as a kind of “best friend” who is an expert in the birth room with no other bias or influence other than to provide you with what you and your baby may want and need. When I explain to people that I am becoming a midwife, they often confuse this with a doula… now, I am never offended by this misunderstanding and as you now understand, from the paragraphs before this, how confusing and complex the term and various types of “midwives” are, we know that it is not their fault that there is misinterpretation. So I do want to take a moment to explain what a doula is NOT… they are not medical professionals, they do not perform clinical tasks nor do they “catch” the baby, they do not give medical advice nor diagnose conditions, they do not replace the birth partner and they should also never judge you for the decisions you make. It is important to highlight the secondary benefit of these limitations because with these in mind they can care for you with less bias or legal influence behind their ultimate purpose of supporting YOU (which doescomplicate the other roles of the birth team). One of the most important aspects of doula support is the provision of “continuous support”. It is a common misconception that birthing people will have continuous support while laboring in a hospital, whether that be by their attending provider or a nurse, but the reality of hospital obstetrical care does not always allow for continuous support by one of these professionals. Nurses have many, many other responsibilities other than hands-on “labor support” and they also differ in their training and interest on how to provide comfort measures even if they are available to provide this type of support. The doula only has oneresponsibility and has specifically been trained in this area… to provide continuous support to the birthing person and birth partner. The support and presence doulas provide have a remarkable influence on how women may perceive labor pain… it is such a beautiful and astounding phenomenon which cannot be overstated. Dr. Amy Gilliland has attempted to explain this phenomenon as an Attachment Effect theory, where the birthing person directs attachment seeking behaviors to a doula and the doula responds in a unique way leading to a surge in oxytocin and a diminishment of stress hormones that directly affects the birthing person’s pain response. OK, you knew it was coming… evidence junkie time! A 2017 Cochrane review of 26 studies with over 15,000 birthing people revealed the immense benefits of continuous support vs no support: women with a doula had a 39% lower relative risk of having a cesarean and 15% higher likelihood of having a spontaneous vaginal birth and continuous support not only increased birth experience satisfaction overall, but additionally decreased the relative risk of using pain medications by 10%, decreased the relative risk of having a low 5 minute APGAR score by 38% and that continuous support shortened labor by 41 minutes on average! The Evidence Based Birth ® team created a conceptual model for continuous labor support that is provided by doulas to help explain how these enhanced outcomes may be achieved. Being an expert in the birth room, doulas additionally can offer an advocacy presence as well, but we must be careful to define doula advocacy carefully and EBB® defines it as “supporting the birthing person in their right to make decisions about their own body and baby”. Doulas are not able to make decisions for you and it is ultimately up to the birthing person and their partner to make these decisions. Some EBB ® examples of how a doula can help you advocate for yourself is assisting in the development of a birth plan, encouraging you to ask questions and voice preferences, asking you what you want, supporting your decisions, amplifying your voice, creating space and time for decision making, facilitating communication with the heath care team and describe what is about to happen. So, as you hopefully can see, there are so many benefits to doula support and I hope you at least feel motivated to explore this option for yourself for your pregnancy and birth journey. Like everything else in the birth world, doulas are not a one size fits all and finding the right one for you and your family is a lot like dating! Do a search and reach out to some of the doulas in your community to schedule your “first date” to see if it’s a good fit! I know that doulas come with an increased financial burden and it is definitely a privilege to be able to have this additional support… however, doulas-in-training usually offer their services at a discount so I hope you know there are options if you are financially stressed. Everyone deserves access to doulas and the numerous benefits they provide, and I hope that one day they will just be a “given” and provided in all birth settings for every birthing being. The evidence is there to support this hope, now we just need to see the evidence translated to practice. Please feel free to contact me for the Evidence Based Birth® signature article all about the evidence on Doulas.

I believe in the power of intention and postulation so, to conclude this blog post, I would like to declare a proclamation and manifesto for the future of maternity and womxn’s healthcare… I will continue to work towards and be an activist for this goal and dream of a future where every birthing being has a comprehensive team of birth workers who understand, respect and love each other just as much as they understand, respect and love the birthing beings they serve. A symbiotic relationship and team for each birthing being comprised of a midwife, a physician to consult/collaborate/refer to if/when needed, a birth assist/nurse and a doula who work effortlessly in devotion to the ultimate, holistic wellbeing of the beautiful, unique lives in their hands who have entrusted the team with this honor.