What Midwives Are and What We Do

Midwife…the word conjures up different images for different folks. One might think of the gutsy midwives of Exodus who saved the Hebrew boy babies, or another, the starched and pressed, bicycle-riding midwives of 1950s East London popularized by tv’s Call the Midwife series. Others think of the hippie counterculture, and babies born in VW buses or on a commune, the granny women of Appalachia, or the African American granny midwives of the rural South. Many from the generation born before World War II were born at home with midwives themselves and think of midwifery as normal, if outmoded.

One common thread (except perhaps for the immediate families of midwives) is a certain element of mystery. Over the last century, obstetrician-led maternity care and hospital birth have become the American norm. Midwifery in our country has become relatively obscure, often misunderstood.

Midwife…a good old-fashioned Anglo-Saxon word that means “with woman.” Contrast this with “obstetrician”, which comes from the Latin “obstare”–to stand before. This is a telling comparison of the typical power dynamic between midwives and our clients, obstetricians and their patients. Midwives are with women on their unique journey through pregnancy, birth, and postpartum. We are consultants, guides, lifeguards, helpers, even friends. We see ourselves and our clients as equals and work to cultivate mutual trust and respect.

I am often asked, how are midwives trained? How do we ensure the safety of mother and baby without twelve years of medical school or at least a nursing degree? How in the actual *&^% can we be qualified to deliver babies and to do it outside the “safety” of a hospital setting?

In this post, I am only going to focus on the kind of midwife I am–a Certified Professional Midwife, or CPM, licensed by the Virginia Board of Medicine. There are other types of midwives, such as Certified Nurse-Midwives (CNMs), unlicensed direct-entry midwives, etc., and their scopes of practice and training vary enough to warrant a separate post.

CPMs have met the training and education requirements designed by the North American Registry of Midwives (NARM), and we are the only kind of midwife in this country specifically trained to work in out-of-hospital settings. CPMs complete rigorous academic training either through self-study or through a midwifery school and must pass the NARM exam (comparable to a bar exam or board exam for lawyers or medical professionals). In addition, CPMs complete several years of apprenticeship under other, more experienced, NARM-approved midwives, and must master a daunting list of hands-on skills ranging from offering a cool drink to a laboring mother to resolving shoulder dystocia, resuscitating a newborn, and stopping a hemorrhage.  Apprenticeship is typically unpaid, not very family-friendly, and often grueling, weeding out anyone who isn’t 200% serious about midwifery.

Typically, by the time a midwife earns her CPM, her adrenals are shot, her hair is turning gray, her home is a disaster, and she has attended a couple of hundred births, some as a doula or assistant/student, and the rest as a supervised primary midwife. She will have seen some weird, crazy, abnormal, even terrifying things go down at some of these births, but the vast majority will have been unmedicated vaginal births, with few interventions, taking place in the mother’s location of choice, surrounded by people she wants there, and everything will have been incredibly normal.  Maybe difficult, long and slow, or maybe shockingly fast, and rarely, almost effortless. Most will have been somewhere in between.

This is one of the keys to how midwives keep the pregnancy and birth normal and safe–we see so much normal that when something isn’t quite right, it practically screams out at us. Normal pregnancy and normal birth, in all their glorious variations, are what we live, eat, sleep, and breathe. We tend to see the rare emergencies coming from a long way off, and we take appropriate measures to head them off if we can or transfer care to a medical setting when it is warranted.

Obstetricians are surgeons. They are trained to fix emergencies and complications, and they generally do it well. Most rarely, if ever, see a truly normal, intervention-free birth, and they don’t spend anywhere near the number of hours that midwives do getting to know their clients prenatally(we typically do 45-60 minute visits throughout the pregnancy, on a schedule similar to OB prenatals). They don’t have the experience to put normal to work for them; they barely know what it looks like, much less how to facilitate it.

Midwives are specialists in normal pregnancy and birth. We have a set of non-medical skills and a focus on preventive care that keep our clients in optimal health so they’ll be good candidates for out-of-hospital birth. Still, occasional emergencies arise.  In my experience, there is a popular misconception that we midwives are nice maternal ladies who hold a laboring mom’s hand and cool her sweaty brow, and catch babies and cook up placentas, but that we won’t have the ability to handle an emergency.  The reality is that we have training in CPR and neonatal resuscitation, just like medical personnel do. We can suture a tear, resolve a shoulder dystocia, deliver a surprise breech, stop a hemorrhage, put in a catheter, revive a fainting dad. We monitor mom’s vital signs and baby’s heartbeat during labor to make sure things are staying on track. That cord around the neck that everyone seems to fear…? Yes, we actually know what to do (or not do) about that, also.

Midwives provide full prenatal care for our clients. We teach them how to keep their pregnancies normal with preventive care and healthy lifestyle choices, We attend their births and stay with them for the critical first hours postpartum. We provide continuity of care; we don’t send strangers in to attend a mom who is expecting us, except in the most dire and rare emergencies. We provide six weeks of full postpartum care for our moms and are the primary care for their babies in that time frame, as well. We offer breastfeeding support, postpartum depression screening, serve as a resource for other beneficial services, and act as a sounding board as the family adjusts to the new addition. We tend to know our clients’ dogs’ names, where they keep their silverware, what they like to eat, and why they picked their baby’s particular name. We are “with woman.” a part of the community, a peer to our clientele, not an authority over them.

But what you really want to know is, are we a bunch of pot-smoking hippies, fringy religious fanatics, or granny women with mysterious herbal remedies and a bottle of ‘shine in our midwife bags? All I’ll tell you is we won’t be showing up for your birth on bicycles in high heels and lipstick at 3am.  The rest…you just never know.