Midwives and Doulas

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After finding out they are pregnant, some women’s thoughts quickly turn to picking out the perfect baby name or selecting colors and a scheme for the nursery. But there are two other essential choices expectant mothers must make – who will deliver their baby and where?

The answer is not always an obstetrician. A growing number of women in South Carolina and the nation are turning to midwives for maternity care. Some expectant mothers also add doulas to their care teams.

What are midwives and doulas? What should expectant mothers consider when deciding who to turn to for their maternity care?

“The most important consideration is how much control do you expect having over your birth experience,” said Susan Cheek-Williams, a certified nurse midwife at Prisma Health’s Greenville Midwifery Care. “If a woman with a low-risk pregnancy wants low-intervention, high-touch, low-tech care, midwifery is absolutely the way to go.”

Midwives attend approximately 8% of births in the United States, most of them in hospital settings. In 2019, only 1.6% of births occurred out of hospitals, either in birthing centers or at home.

The midwifery model views pregnancy and labor as normal physiological processes, said Lesley Rathbun, founder and director of Charleston Birth Place. Rathbun is dually certified as a family nurse practitioner and a certified nurse midwife.

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“Childbirth is the only wellness event done in a hospital,” Rathbun said. “Childbirth is a normal, physiological, healthy process. Only in the United States is it routine that obstetricians in hospitals care for healthy, low-risk pregnancies. One reason is that there are 30 obstetricians for every one midwife. In the U.K., there are 30 midwives for every one obstetrician.”

Types of midwives

In South Carolina, there are two types of midwives – certified nurse midwives and certified professional midwives.

Certified nurse midwives are advanced practice nurses with at least a master’s degree. They may prescribe medication and can take care of people in the hospital.

The South Carolina Department of Health and Environmental Control licenses certified professional midwives. Some have graduate degrees, while others get their training as an apprentice with another licensed professional midwife. They must meet standards set by the North American Registry of Midwives to be certified.

Because they are not advanced practice registered nurses, they can’t write prescriptions and don’t have hospital privileges, meaning they can only attend births in patients’ homes or at birth centers. If a mother needs to transfer to a hospital, a certified professional midwife has to turn her care over to another health care provider at the hospital.

Benefits of using a midwife

Midwives work with low-risk mothers-to-be. Typically, women who have chronic high blood pressure, heart disease, pre-existing diabetes, bleeding disorders and autoimmune disorders require higher care than midwives provide. Some hospital-based midwives will also care for women who have had previous cesarean sections but want to deliver vaginally.

For low-risk expectant mothers, midwives focus on education, preventing complications and limiting medical intervention unless it’s medically necessary or desired by the patient. During prenatal visits, midwives discuss what to expect in pregnancy. During labor, they often offer water labor and birth.

“The whole model of care is getting to know the patient and providing education on how to maintain a healthy pregnancy. The more educated the mother is, the more likely she is to stay low risk,” Rathbun said.

Midwives can manage certain complications during pregnancy, such as gestational hypertension. They are trained to recognize when further intervention is necessary.

Rathbun said Charleston Birth Place has a 10% to 20% hospital transfer rate.

“We know that not every woman who registers to give birth here will give birth here. We’re going to always err on the side of being careful and take them to the hospital if anything falls out of normal,” she said.

The most common reason for transfer is when mothers have long, difficult labor and need an epidural or Pitocin to get the baby out. She said that sometimes it is determined prenatally that a hospital birth would be better because the baby will be 11 pounds or more, the mother’s blood pressure is creeping up or the baby seems to be too small.

The transfer rate for genuine emergencies is 0.003%, she said.

“We tell people that they have to weigh risk versus benefit in everything you do in life,” Rathbun said. “The biggest risk people have percentage-wise is driving here to the birth center. They are more likely to have an adverse outcome driving in their car than they are having a baby in a birth center once they’ve passed all the screening tests.”

After the baby is born, midwives can provide education and training in breastfeeding, information about contraception and support through the first weeks of motherhood.

“We treat mom and baby as a unit,” Rathbun said.

Doulas provide support

Some expectant mothers hire doulas to help them achieve a happy and healthy birth experience. The doula is not a replacement for a midwife or obstetrician.

“The professions complement each other,” Cheek-Williams said. “The doula’s job is to provide continuous support for the mother.”

Doulas are nonmedical professionals who provide continuous physical, emotional and informational support to women before, during and after childbirth. They are not medically trained and cannot administer medications, monitor the baby or labor, deliver the baby or help make medical decisions.

“Doulas are like a paid labor coach who provides comfort, encouragement and guidance,” Rathbun said.

According to DONA International, the world’s largest doula certifying organization, physical support can include comforting touch, counterpressure and breathing techniques. They can assist with birth plans and facilitate communication between families and the health care team. In addition, they can provide family bonding and help new mothers with breastfeeding support.

INFOGRAPHIC: Midwives/Doulas by the Numbers.

By Cindy Landrum

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