People ask pregnant women a lot of questions. What names are you considering? When are you due? Do you know if it's a boy or a girl? Are you planning a natural childbirth, or do you want an epidural for the pain?
That last question hints at the controversy that surrounds childbirth in the United States. There are two major schools of thought about childbirth in this country. One camp, which includes the American Medical Association and the American Congress of Obstetricians and Gynecologists, holds that the best place for a woman to give birth is in a hospital with a doctor present. The other camp believes that women gave birth for centuries without hospitals or doctors, and that childbirth shouldn't be considered a medical procedure but rather a process controlled by the woman herself, with the assistance of a midwife or a doula. Midwives oversee the medical parts of the birth, including the actual delivery, while doulas provide constant emotional and physical support and comfort to the mom-to-be.
For centuries, all births were attended by midwives and doulas, women who had learned their trade through decades of experience or through apprenticeships. In Europe, midwives and doulas still assist in the majority of births. In the U.S., however, midwives and doulas lost their status at the end of the 1800s, when doctors took over the job of childbirth. With knowledge about hygiene and the latest medical procedures, doctors had a better success rate of a childbirth that kept both mom and baby alive than the midwives did -- and they took to the press to make sure the country knew that. Medical interventions such as aesthesia, cesarean sections and episiotomies became commonplace.
But in recent decades, women have been embracing more natural ways to give birth. These women were influenced by second-wave feminists, who urged women to take control of their bodies, as well as books such as "Spiritual Midwifery" by Ina May Gaskin. "Spiritual Midwifery" was a widely read work that explained that birth would be better without a doctor or an epidural; by giving birth naturally, women were simply doing what their bodies had been made to do.
As a result, women began forgoing medication, giving birth at home and employing the services of midwives and doulas rather than shopping around for an obstetrician. So what exactly do midwives and doulas do? What's the difference between them? And why are they still so controversial?
Using a Midwife During Childbirth
Midwives are mentioned in the Bible, as well as ancient Greek and Roman texts. The term, however, isn't one-size-fits-all. There are several different types of midwives and midwife certification programs in the United States, but many of the debates about this profession center on two kinds of midwives:
- Certified nurse-midwives (CNMs) have training as nurses and as midwives. Many CNMs have a master's degree in nursing as well as course work in midwifery; all CNMs are certified by the American College of Nurse-Midwives. CNMs tend to work in hospital settings.
- Direct-entry midwives may not have done any scholarly work in nursing or in midwifery; it is more likely that they trained through an apprenticeship or in a workshop.
Direct-entry midwives carry on a long tradition of learning midwifery from an experienced midwife, but these midwives are at odds with the conventional medical community. While CNMs may oversee births in a hospital setting or a stand-alone birthing center, direct-entry midwives often manage home births -- a practice frowned upon by the American Medical Association. Doctors say it's far too risky for any woman -- no matter how healthy her pregnancy -- to give birth without ready medical care, as birthing tragedies can happen within mere minutes. Home births and the use of direct-entry midwives are illegal -- though it's the midwife, not the mother, who's prosecuted -- in many states, which drives the practice underground (home births can be legal if a CNM or a physician attends). In recent years, legislators have tried to regulate the practice, so that if something does go wrong during a home birth, the midwife can bring the laboring woman to a hospital without legal repercussions.
However, there are many certified nurse-midwives available should a woman want to pursue a hospital birth, and some studies provide evidence that using a midwife can result in better health outcomes than using a physician. In a 1997 study of low-risk pregnancies in Washington state (low-risk meaning that the woman was young, healthy and had experienced a routine pregnancy), researchers found that women who used a midwife needed fewer interventions such as episiotomies or cesarean sections and received less pain medication. The difference in cesarean rates was notable: only 8.8 percent of the midwives' patients needed one, compared to 13.6 percent of obstetricians' patients and 15.1 percent of family doctors' patients [source: Lewin]. For women who desire a natural childbirth, these numbers are important and speak to the benefit of a midwife who can educate and support them through childbirth.
If a midwife is monitoring the laboring woman's vitals, watching for signs of fetal distress and catching the baby, then what is the doula doing? We'll explore this role on the next page.
Using a Doula During Childbirth
"Doula" is a Greek word that's usually translated as "female servant." Unlike midwives, doulas don't make any medical decisions during childbirth, nor do they undertake any clinical actions, such as catching the baby. Rather, most doulas describe their work as "mothering the mother." They provide emotional support for the birthing woman with techniques such as massage, wiping her forehead with a cool cloth, leading relaxation exercises and suggesting positions that will make the stages of birthing easier. And they remain with the woman throughout the birth, no matter how long it takes, whereas physicians are known for popping in and out of the room, and even midwives may have several clients they need to attend to.
Studies have shown that doulas can have the same beneficial effect on the birthing process as midwives do. Not only is the caesarean rate reduced by half, the need for an epidural is 60 percent less and labor time is 25 percent shorter for women who use doulas [source: Gilbert]. The use of a doula may also influence a mother after her child's birth; in one study, women who had a birthing assistant were rated more sensitive, nurturing and loving to their infants [source: Gilbert].
That's not to say doulas are without their detractors. Doctors and nurses may be wary of another person in the room, and one doctor wrote an editorial in a medical journal to say that a doula could affect a doctor's ability to provide excellent patient care [source: British Medical Journal]. These medical professionals may be concerned that there's no standardized training or certification process for doulas; essentially, anyone can deem him or herself one, though the Doulas of North America organization does offer a course. Some new fathers may feel that a doula is usurping their supportive role, though there are plenty of men who are grateful that someone can step up when they get a little woozy.
Doulas charge anywhere from a few hundred dollars to $1,000 for their services, which usually include some pre-birth consultations in addition to the birth. Post-partum doulas are also available on an hourly rate; these doulas help with the family's adjustment to a new baby by providing services such as cooking, cleaning, breast-feeding assistance and running errands. While these fees have meant that doulas are only affordable for wealthy women, some doulas will work on the barter system or a sliding-fee scale, and many cities are experimenting with volunteer programs that provide free or low-cost doulas to low-income women.
If you want to hire a doula or a midwife, you'll need to do your homework -- as we mentioned, the certification programs and training regimens vary, so you'll need to quiz prospective birth attendants on their backgrounds and philosophies. If you just want to learn more about childbirth and parenting, then see the links on the next page.
- Barton, Adriana. "Male doula's are the new delivery fixture." The Globe and Mail. Jan. 8, 2008. (March 30, 2011)http://www.theglobeandmail.com/life/parenting/pregnancy/delivery/male-doulas-are-the-new-delivery-fixture/article658892/
- BMJ - British Medical Journal. "Doulas May Indicate Failings in Patient Care, Warns Doctor." ScienceDaily. Dec. 1, 2009. (March 30, 2011)http://www.sciencedaily.com/releases/2009/12/091201192109.htm
- Brauer, David. "Hand holding for moms." Salon. Dec .7, 1999. (March 30, 2011)http://www.salon.com/life/feature/1999/12/07/doula
- Elton, Catherine. "American Women: Birthing Babies at Home." Time. Sept. 4, 2010. (March 30, 2011)http://www.time.com/time/magazine/article/0,9171,2011940,00.html
- Gilbert, Susan. "Benefits of Assistant for Childbirth Go Far Beyond the Birthing Room." The New York Times. May 19, 1998. (March 30, 2011)http://query.nytimes.com/gst/fullpage.html?res=9901EEDE1639F93AA25756C0A96E958260
- Granju, Katie Allison. "The midwife of modern midwifery." Salon. June 1, 1999. (March 30, 2011)http://www.salon.com/people/bc/1999/06/01/gaskin
- KidsHealth from Nemours. "Midwives." February 2008. (March 30, 2011)http://kidshealth.org/parent/pregnancy_center/childbirth/midwives.html
- Lewin, Tamar. "Midwives Deliver Healthy Babies with Fewer Interventions." The New York Times. April 18, 1997. (March 30, 2011)http://query.nytimes.com/gst/fullpage.html?res=9C02E7DA103FF93BA25757C0A961958260
- Liptak, Adam. "Prosecution of Midwife Casts Light on Home Births." The New York Times. April 3, 2006. (March 30, 2011)http://www.nytimes.com/2006/04/03/us/03midwife.html
- Meltzer, Marisa. "What's an abortion doula?" Slate. April 27, 2010. (March 30, 2011)http://www.slate.com/id/2251917/
- Oregon State University. "Conflict Between Doctors, Midwives Over Homebirth." ScienceDaily. May 15, 2009. (March 30, 2011) http://www.sciencedaily.com/releases/2009/05/090511151616.htm
- Paul, Pamela. "And the Doula Makes Four." The New York Times. March 2, 2008. (March 30, 2011)http://www.nytimes.com/2008/03/02/fashion/02doula.html
- Reaves, Jessica. "Use of Midwives Rises, Challenging the State to Respond." The New York Times. Sept. 23, 2010. (March 30, 2011)http://www.nytimes.com/2010/09/24/us/24cncmidwives.html
- Sullivan, Nancy. "A Short History of Midwifery." MidwifeInfo. March 6, 2002. (March 30, 2011)http://midwifeinfo.com/articles/a-short-history-of-midwifery
- Tesoriero, Heather Won et al. "Families: One Labor-Intensive Job." Time. March 12, 2001. (March 30, 2011)http://www.time.com/time/magazine/article/0,9171,999442,00.html
- Time. "Medicine: Rebirth for Midwifery." Aug. 29, 1977. (March 30, 2011)http://www.time.com/time/magazine/article/0,9171,915357,00.html
- Time. "Medicine: Return of the Midwife." Nov. 20, 1972. (March 30, 2011)http://www.time.com/time/magazine/article/0,9171,712201,00.html
- WebMD. "Certified Nurse-Midwives, Certified Midwives, and More." Dec. 20, 2009. (March 30, 2011)http://www.webmd.com/baby/certified-midwives
- WebMD. "To Doula or Not to Doula." Feb. 19, 2001. (March 30, 2011)http://www.webmd.com/baby/news/20010219/to-doula-not-to-doula
- Wickersham, Rachel. "Question: What's the difference between a midwife and a doula?" Pregnancy Today. (March 30, 2011)http://www.pregnancytoday.com/expertqa/pregnancy-checkups-and-tests/what-s-the-difference-between-a-midwife-and-a-doula-could-a-7162/
- Wilgoren, Jodi. "'Mothering the Mother' During Childbirth, and After." The New York Times. Sept. 25, 2005. (March 30, 2011)http://www.nytimes.com/2005/09/25/national/25doula.html