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.