There is ample evidence of the benefits of midwifery care for uncomplicated pregnancies, including lower rates of inductions, episiotomies, and cesareans. So why aren’t midwives more widely used in the U.S. (like they are in the rest of the world!)?
Dr. Melissa Cheyney talks with Adriana all about midwifery care including the different types of midwives, their certifications, where they practice, and the importance of OBs, perinatologists, and midwives working together to provide you with the right amount of care (instead of “too much, too soon” or “too little, too late”).
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- The Uplift Lab website
- Midwife‐led continuity models versus other models of care for childbearing women, Cochrane systematic review
- Mapping integration of midwives across the United States: Impact on access, equity, and outcomes, PLoS ONE
- Midwifery linked to better birth outcomes in state-by-state “report card”, The University of British Columbia, Faculty of Medicine
- Obstetrician and Nurse–Midwife Collaboration: Successful Public Health and Private Practice Partnership, Obstetrics & Gynecology
- Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State, Obstetrics & Gynecology
- A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies, ProPublica
- Community-Based Doulas and Midwives, Key to Addressing the U.S. Maternal Health Crisis, The Center for American Progress
- Millions of Americans are losing access to maternal care. Here’s what can be done, NPR
- Understanding Relative Risks In The Community Birth Setting: An Interview With Researcher Melissa Cheyney, Midwives Alliance of North America (MANA)
- Birth: Issues in Perinatal Care, the journal which Missy edits
- You can download research papers that Missy discussed, including:
- Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States
- Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America – Statistics Project 2.0 Dataset
- Homebirth Transfers in the United States: Narratives of Risk, Fear, and Mutual Accommodation
- Transfer from Planned Home Birth to Hospital: Improving Interprofessional Collaboration
- Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making
- Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009
- What About Pain? How do fear and tension relate to pain? Taking Charge of Your Health and Wellbeing, University of Minnesota
- The Performance: Sex Like Birth, a hilarious YouTube video
Related Birthful episodes:
- Flowing with Your Birth Hormones
- What You Need to Know About Birth Models (Birth What?)
- Cesarean Risk: What’s Your Place of Birth Got to Do With It?
Why a Midwife Might Be Just What You Need
Hello and welcome to Birthful, Mighty Parent or Parent-To-Be! I’m Adriana Lozada and as we continue with our care provider series, today it’s going to be all about midwives!
My guest for this is none other than professor of clinical medical anthropology and community midwife, Dr. Melissa Cheyney.
Missy, as she’s most commonly known, is also the co-director of Uplift, which is a research and reproductive equity laboratory at Oregon State University. There she serves as the Primary Investigator on more than 20 maternal and infant health-related research projects.
This is going to be a juicy conversation where we talk not just about midwifery care, but also about the different types of midwives, how some midwives are able to do more than just attend births, and where they practice, because midwives are not just for homebirths, even though that is a common misconception. Midwives, many of them, do practice in hospitals.
During our talk, Missy also shares three incredibly insightful sets of questions to ask your provider if you are considering a community birth (meaning having your baby at home or in a birth center).
Now, if you’ve listened to the episodes in this series with Dr. Stu and Dr. Bootstaylor, you heard them talk about how the perinatal system would really benefit from a restructuring toward the better integration of all care providers. Meaning, to have midwives, OBs, perinatologists (or Maternal Fetal Medicine specialists), nurses, doulas… everyone working collaboratively to provide you the care you actually need at the level you need it when you need it.
Missy echoes this sentiment and goes deeper into how this interprofessional collaboration could be a key piece toward improving outcomes and providing appropriate care, especially given the increase in perinatal healthcare deserts that are being created in the U.S., where people have no obstetric hospitals or birth centers or obstetric providers near where they live, as hospitals close their Labor & Delivery departments or just shut down altogether. And it probably won’t surprise you that these healthcare deserts are disproportionately harming rural communities and people of color.
Making midwives and midwifery care more accessible to these communities— and to everyone, really— would really make an impactful difference. You can help with that by adding your voice to the efforts of organizations that are working to implement changes in policy. Some suggestions where you can learn more are marchformoms.org, blackmamasmatter.org, and nationalpartnership.org
You’re listening to Birthful, here to inform your intuition.
Adriana Lozada: Welcome, Missy. It is great to have you here.
Melissa “Missy” Cheyney: Thank you. I’m happy to be here!
Adriana: Yeah, and this is the topic I’ve been wanting to do for so long! I can’t tell you how excited I am to finally be tackling midwives and midwifery care, ’cause it is so vital and important. But before we jump into the topic itself, why don’t you tell us a little bit about yourself?
Missy: Sure. So I am a clinical medical anthropologist and study midwifery, globally and with a special focus in the United States. And the overall aim of my research has been to try to think through how culturally-matched midwives— so, midwives who are embedded in the communities that they’re serving— how they can be used to help reduce preventable maternal and infant death, and suffering around the world.
And in addition to being a medical anthropologist who sort of likes to think about, sort of, larger cross-cultural issues— I’m also a midwife myself. So I have the credential of CPM (or Certified Professional Midwife), I’m also licensed in my state, and I have a small business practice, and I also provide back-up midwifery care in a birth center in my town.
Adriana: Mhm. And you just went through several of the things that I wanna definitely dig deeper into today. You know, like, for example, what is that CPM (Certified Professional Midwife)? How does that differ from other types of midwives? But before we get into that, let’s take one step back and go deeper into: What is midwifery care? And: How is that different from what OBs do?
Missy: Yes, so I think that’s such a fundamental question! So, I’m gonna sort of give you an answer, but then I think we should try to nuance it a little bit. So, first and foremost, when I think about the midwifery model of care, and when I talk about it with my students, one of the things that I think is so important to stress is that we are trained as providers, and really often share a perspective that birth is, in itself, not inherently dangerous, that healthy women have evolved to be able to give birth over multiple generations, and most of what happens around birth can occur without major medical interventions. So, that means that the fundamental place where care begins is with the assumption that most pregnant people, when they’re adequately supported and are overall healthy, that what they really need in pregnancy and in childbirth is support and nurture and close monitoring, just to make sure that everything is unfolding safely. What they don’t need as a matter of course is massive medical intervention. And in our country today, we do medically-manage the majority of births.
And so midwifery sort of holds open this space that questions whether all of those interventions are always or routinely necessary. So, that is not to be confused with a stance that would say those are never needed. So, y’know, to summarize, it is essentially the fundamental belief that, with support, most women’s bodies will birth in a relatively really straightforward way. And then in a small number of cases, women can benefit from closer and more medicalized care. So, that’s the fundamental assumption.
And then the other thing that is really important about the midwifery model of care, is that this leads our care to be highly-individualized. And so prenatal care and birthing care are really centered on the needs of the family. And we do not focus solely on clinical need— we tend to see the whole person before us. And so we like to take into account the psychosocial, the spiritual, the community, the cultural, as well as the clinical needs of the people that we’re serving.
Adriana: And which I find is a very important nuance, like you were saying— of the midwifery model of care, versus a more active management model of care— because birth is such a mind-body connection event. Like, you are all in— it affects all parts of your being. That’s sort of… Not taking into account your psyche, your feelings, your emotions, your past experiences, and just looking at your body, like kind of a machine with parts, y’know, and that health approach that we have here in the U.S. of, “These are all individual parts,” that we view through this narrow lens, it does a disservice to the person that’s giving birth.
Missy: Yes. Yes, absolutely. Our minds and bodies are deeply-integrated, and the emotions that we feel when we’re experiencing our labors and our births deeply affect our hormone levels, which affect the way, for example, our uterus contracts. So it’s not possible in this day and age with the amount of research that we have on the mind-body connection to discount the importance of meeting the psychosocial needs of the laboring person.
And the way our society has unfolded in the way we’ve come to manage birth over time in the last three or four generations has really become focused on medical management— and what that prevents us from seeing sometimes is the degree to which other social factors play as important, if not more important, of a role in how the birth unfolds. And so the midwifery model of care is really about seeing the whole person, and putting back together the mind and the body and treating the whole person.
And when we do that, research really shows that that birth unfolds in a much more healthy way. There’s less of a need for intervention. Labors are shorter. The need for cesarean section is reduced when we treat the whole person. When we take into account what, say, they feel anyway— which is that birth does not feel like just a clinical event to them. It is for most women, one of the most important days of their lives. And they’re never going to forget it. So to treat it as a series of steps— where you put on the robe, you get your IV, you lay in the bed, we put on the monitor— that does not resonate with how most people see their birth day.
And so the midwifery model of care is about bringing back the spiritual, the social, the communal, the familial aspects of what is going to be a very memorable day, either for good or for bad, either for better or for worse, when people look back on their experience.
Adriana: And I find that the midwifery model of care doesn’t affect, obviously, only the day you’re giving birth, but I have clients that go to give births in all sorts of different settings with all different kinds of providers, and it is always remarkable to me, the comments that they make when they happen to go from one type of practice to another, of how different the prenatals are in one type of care versus the other.
Missy: Yes, absolutely. So, within the midwifery model of care, we really value longer, highly-individualized prenatal visits because we see as care providers that when a person goes into labor, it is a very different situation if she goes into labor feeling strong and confident and capable, and as though she can really trust her provider because she’s developed a relationship with them over the course of their care, versus going into labor feeling fearful.
Y’know, in our society, many people have either negative or certain tenuous associations with the hospital: they fear procedures that may be painful, or they may associate the hospital with other times they’ve been there, which were, y’know, less-than-happy or -joyful. And so people can go into labor feeling quite nervous, not knowing who’s going to attend them or what their outcome can be or will be. And so those are very different places to be in at the onset of labor. So, providing really intensive prenatal care, our aim is to prepare women to feel strong and capable and ready to face what their labor brings to them. And that can’t be done very well just in labor— that needs to start earlier in the prenatal period.
So that does shape our prenatal care. It leads to longer visits in the community setting (and those are births that happen at home and in the birth center). Studies show that midwifery care unfolds during prenatals that are about an hour long; in standard obstetric care, you’re looking at prenatals that are closer to 20 minutes unless there’s, y’know, a significant complication that they might be trying to deal with. So there, the visits are longer, but they also cover a wider range of materials related to keeping the body as healthy as possible— so lots of emphasis on nutrition, on self care, on exercise, on, sort of, the mental and psychological preparation for what lies ahead… And that simply takes more time.
Adriana: Yeah. And it impacts the outcome of how things unfold as well. I always like to tell my clients, during our prenatals, to think of pregnancy as early, early, early, early, super early labor, and that the things that they do during that time can have a very direct impact on even the length of how things flow during the birth itself.
But I think it’s a good distinction for us to make right now that we are not trying to knock OB care. I think one of the things that was pivotal to me when I started doing this work was understanding that we’re talking about two very different categories of practices/approaches, doing the same work, because that’s how we do it here in the U.S. Whereas if you look to other models— in, say, Europe— where midwives and OBs stand more side-by-side, but understand that even though they have an overlap in care, their purviews are different.
Missy: Yes, I think that is so critical, and it’s important to really start this conversation by making the point that midwives cannot practice safely without collaboration with our colleagues who are obstetricians. We have to understand that obstetricians are trained surgical specialists and that skill set that they bring to birth, it’s absolutely critical and can mean the difference between life and death for a mother or baby in a small number of cases. And we can’t in any way disregard the care that they provide.
I think what we’re struggling with in our country is trying to find the appropriate use of various expertises relative to the situation of the pregnant person before us. So what is so very different about the United States— relative to, let’s say, the Netherlands— is that normal, healthy, low-risk women, when they get pregnant, they say, “I need to call my midwife,” not, “I need to call my obstetrician.”
And it is understood that midwives are the primary maternity care provider, and that you certainly may see an obstetrician over the course of your care if a complication develops, you then may be referred back into midwifery care if it resolves— but that kind of fluidity where low-risk, healthy women see midwives, and obstetric care is reserved for those women with more medically-complicated pregnancies, and then even for with perinatologists, for those that are significantly medically-complicated. That kind of hierarchy doesn’t exist in quite the same way in the United States. So here you can have perfectly healthy, low-risk women, with no risk factors, who receive obstetric care simply because that’s all that’s available in their community.
Not because they want more medicalized care or because they need more medicalized care, but simply because we have this really interesting sort of proportion of attendants at birth that’s pretty different from other places. So in the U.S., about 89% of births are attended by obstetricians and 11% are attended by midwives. In most high-resourced countries, that would be flipped— so the vast majority of women would receive midwifery care. And that doesn’t mean that that would necessarily be at home or a birth center; that could certainly be in— in many cases is in— the hospital. It’s just that the primary care provider is a midwife, unless there is an indication for obstetric care.
And that allows obstetricians in other countries to practice at the top of their license using this expertise, this skill set that is really unique to them. And it allows midwives to practice within their own scope, which is normal physiologic birth. That is very much disrupted in our country because of a long history of for-profit medicine that has substantially medicalized even low-risk birth.
Adriana: Yes, absolutely. And I feel that, in the past years, a few years especially, there’s been more of an interest in paying more attention to how the system is not quite serving us properly. Because, I mean, if all these interventions that we were doing were providing better outcomes, then that would be one thing… but we’re not seeing a correlation in terms of those outcomes with the amount of effort and money that is being placed on them, so it’s the system itself is screaming for a change. And I think the first step is realizing these differences in the system, because most people just go, like you said before, “Oh, I’m pregnant. Let me call my OB,” and they don’t even understand that midwives are out there. So having said that: What are the things that you would say very specifically that midwives don’t do, that OBs do do?
Missy: Yeah, so that’s a great question. And the thing about midwifery care is it’s often more about what we don’t do as a matter of course, versus “don’t do at all.” I think there’s some really clear distinctions. For example: cesarean sections are performed by an obstetrician and so are assisted vaginal births (so that would be with forceps or vacuum extractions). So midwives will assist in those procedures, but the primary providers, if you’re getting to that point, are typically going to be obstetricians. However, the overlap in what we do is actually… Has a little bit more to do with frequency. So, whereas some obstetricians or many obstetricians might see multiple interventions as standards of care— so everyone would get an IV or almost everyone would get an IV, everyone or almost everyone would have continuous electronic fetal monitoring— midwives may sometimes need to start an IV. I certainly have in my career, but I don’t do it for every person! The vast majority of women I care for receive their fluids by drinking, by using a straw— and I would not use an IV unless there was significant maternal dehydration, or if I was trying to replace blood volume after a hemorrhage. So it wouldn’t be a matter of course, though I have that skill. Midwives also typically will suture less frequently than obstetricians, especially in community settings where, with good perineal support and management of the timing of pushing, we can often help people to deliver over an intact perineum.
So it is not necessarily that we have a completely disparate set of skills! It’s just the frequency with which they’re used can be much, much less, for midwives. Part of that is that we are typically serving low-risk clientele, and it is very important not to compare apples to oranges. Obstetricians are often caring for a higher-risk population— although they also do care for completely normal, low-risk women as well, and in those instances, there is often much higher levels of intervention. In fact, when you look at the international literature on outcomes for midwifery care, one of the things that is really consistent cross-culturally is that midwifery care reduces the level of intervention for mothers and babies across the board. So that is a real, important distinction of that model of care.
Adriana: And I think it also speaks to that appropriate use of expertise of, if you have a healthy person that has a flowing birth, they’re gonna require less interventions. And if you step back and just let things unfold, then it’s just gonna happen. Whereas if you’re looking at it with a magnifying glass of “Every single thing might be a problem,” and if we circle back to considering what we know impacts the hormones and the psyche, if that energy of anxiety comes in because you’re seeing something that might not quite be how you want it to be, and then that energy of anxiety presents itself, it’s gonna be a little contagious to the birthing person. And if they’re starting to think more and be more anxious, then the hormones they need for birth are not gonna flow that much, and so then there’s a feedback loop that I don’t think is talked about often enough.
Missy: Agreed. That is really critical. And, y’know, in my field, as a medical anthropologist, one of the things that informs anthropology is we study birth not only cross-culturally, but across species and over evolutionary time. And one of the things that all primates have in common is an evolved strategy to avoid giving birth under predatory danger. And so it’s impossible for us to labor when we are terrified.
The hormones that we experience when we’re scared— cortisol, adrenaline, catecholamines— actually prevent effective uterine contractions. And this is, y’know, highly-valuable if you’re in the jungle or in a forest, you don’t want to give birth to a highly-vulnerable infant when there’s predatory danger available. And so for primates to stop their labor and to move to a safer space and to wait to birth until their offspring is likely to be safe, makes a lot of sense. This is a lot harder though, in a hospital, where typically there are some time-based protocols for how long labor could last. And so we really need to find ways to work to reduce sort of the fear-tension-pain cycles that women can get into in labor, that can delay labor and— as you well know, being a doula— midwives and doulas are some of the most effective ways to bring those stress levels down.
We call it the “tend-and-befriend” in the literature. So, when you are in the presence of another person that you know well, that you feel comfortable with, that allows these stress hormone levels to lower and to stop them from inhibiting labor contraction. So oxytocin— the hormone that causes uterine contractions— can rise in the bloodstream and be more effective in the uterus if it’s not competing with stress hormones.
So, y’know, we may think through one model of care that giving Pitocin— which is a synthetic form of oxytocin— into the vein to speed labor is an option… But another way to speed labor is to help reduce maternal distress and to help her feel safe and comfortable in a warm dark space, where her body can do what it would do if it were not stressed out.
So, those are two different tactics for helping to speed labor and they have different consequences for mothers and babies. Because if you give intravenous oxytocin or oxytocin into the bloodstream, you can cause very, very strong contractions that are quite painful and non-physiologic. And that often leads to women wanting to have an epidural or some kind of other pain management. And then you get into something that we call the snowball effect, where one intervention leads to another intervention. So in the midwifery model of care, what we would like to do first is try a low-tech, high-touch intervention, to see if that can help with the progress of labor, before jumping to something like an intravenous drip of Pitocin. So there are two relatively different approaches that have consequences for both the mother and the baby.
Adriana: And I do have an episode that I did a while ago, with Sarah Buckley on the hormones of labor, so I’ll link it to the show notes. And also I did one episode with Robbie Davis-Floyd, talking about all the different models of birth in healthcare, including the technocratic and the holistic and the humanistic, so I’ll link to that as well.
So, Missy, now that we’ve talked about how midwives in general approach the birth process… What are the different types and classifications of midwives?
Missy: So this is a great question. The United States is very much unique cross-culturally, in that it has three different credentialing routes to becoming a professional midwife. So those are the Certified Nurse-Midwife (or CNM), the Certified Midwife (or CM), or the Certified Professional Midwife (which is the CPM).
These credentials— even though they’re distinct credentials— they have a lot of commonalities in them, in that they all have some combination of didactic course learning as well as more hands-on methods of internship and apprenticeship. So these different trajectories are really a reflection of the fact that midwifery was deeply suppressed in the United States. And so, y’know, in the early 1900s, the vast majority of births occurred at home— close to 100%, almost all attended by midwives. And by 1935, that had completely inverted and the vast majority of births were now attended in hospitals by obstetricians. And so, as midwifery made a comeback— we call it the “Midwifery Renaissance”— what happened is that you have these… a more complex trajectory of different forms of midwifery popping up around our country. And so it’s a little more complicated in the United States to talk about different kinds of midwives.
So Certified Nurse-Midwives become nurses first, and then go on and do graduate-level work that takes them to the credential of CNM (or Certified Nurse-Midwife). And the vast majority of Certified Nurse-Midwives in the United States today practice in hospitals, with a smaller percentage practicing in birth centers and at home, so in the community setting.
There is a separate credential called the CM or the Certified Midwife, that’s only available in a few states on the East Coast. And this is a credential for individuals who want to be midwives, but have a bachelor’s degree in something other than nursing. And so they take the same exam and meet the same standards for CNM, but do not necessarily become nurses first.
And then the CPM is the most recent credential. And this is a credential that was developed in the early nineties to allow what had been called “lay” or “traditional” midwives to become professionalized. And so CPMs— that’s what I am— CPMs either are trained through an accredited midwifery school, or many practicing CPMs today (a little over half) were trained more informally through apprenticeship solely. No matter how you acquire your skill set, CPMs must all pass a standardized examination and a practical exam for skills to be able to get their CPM (or Certified Professional Midwife).
So you’ve got those three credentials, and then to make it even more complicated state-to-state, there are different credentials that are offered for by a state. So in Oregon, for example, where I live, I became a CPM— but my state offers licensure for CPMs. So I carry a CPM and also something called an LDM, which stands for Licensed Direct-Entry Midwife, and “direct-entry” simply refers to the fact that CPMs do not become nurses first. We go directly into midwifery training and then become certified as midwives without the nurse credential, which is very common cross-culturally, especially in Canada and in Europe.
So those are the categories. I will say there’s one other category, that are much less common in the United States, and those are midwives who refer to themselves as “traditional,” “lay,” or sometimes “plain” midwives. And these are essentially uncredentialed midwives who attend typically only homebirths, and they often do so because they prefer the complete autonomy of staying outside the system. So they may not want to be bound by rules and regulations, but they want their practice to be guided completely by the people that they serve— so those are uncredentialed or “traditional” midwives.
Adriana: In that conversation, I think we also have to bring in— because of the state licensures that you mentioned— is that, in some cases, it’s almost as if, in some states, some types of midwives are “outlawed.” And it’s not that, per se, that they are outlawed… it’s more like you can’t… because you can’t really make homebirth illegal… but that seeking out midwives for homebirth care in those cases is not allowed. Could you… I know I’m getting into muddy territories in my head… Can you clarify all that, that I was trying to say?
Missy: So let me say that you’re not the only one to think this is muddy! We sometimes call this the “alphabet soup” of U.S. midwifery, because there are so many credentials! Before I talk about the differences, I want to say something that I hope people will really hear as the take home message: There have been numerous studies done looking at outcomes, for births that occur in community settings (so these are at home and in birth centers), and they are attended by a variety of different kinds of midwives with different credentials, and it is very important that we don’t overestimate the degree to which licensure and credentialing have an impact on outcomes. The most important factors that determine outcomes of births are the risk profile of the pregnant person and the degree of systems integration (so that is how smoothly and freely midwives can collaborate with medical providers when needed).
So even though we’re going to say a lot about, y’know, sort of how to see through the muddy waters of U.S. midwifery around credentialing— and I will send you, I’ll provide you with a link so that you can allow people to come and see some of this work— it really is important to remember that the effects of these different credentialing routes on outcomes play very little role relative to those other factors I mentioned (which are the risk level of the pregnant person and the degree of systems integration that the midwife is functioning in).
Adriana: This reminds me also of another episode that I’ll link because, I mean, this is not exclusive to midwives, this whole thing of looking at the system and looking at the big picture and the enormous effect that can have on outcomes. So for example, in terms of the episode that I’m thinking, I’m sure you’re familiar with the work of Dr. Neel Shah and his research on how the biggest indicator for risk of a cesarean is not your health, your healthcare provider, your history, your socioeconomic status… but actually just the hospital that you walk into.
Missy: Absolutely. These are systems-level factors and they are by far the most important component of what we’re thinking about. So I do think it is important that we work towards allowing midwives in every state to have access to licensure and certification. It’s very, very difficult for midwives to practice effectively in states where there’s no legal protections for them. And that is a very, very important factor in outcomes. So I do feel that it’s important to say something about credentialing; I just don’t want it to overtake the conversation. Part of why things become so muddy is that when we are talking about the credentials— the alphabet soup, the letters that come after midwives names— but also the various places of practice, right? Because you’ve got: home, birth center, and hospital. CNMs and CMs can practice in the hospitals, but CPMs cannot and traditional midwives cannot. And then within the community setting of home and birth center, you can have CNMs, CMs, and CPMs all practicing at, but traditional midwives typically only practice at home. So oftentimes the alphabet soup of credentialing also gets confused with this array of birthing places or locations. And so it can become quite confusing.
Adriana: And that’s definitely quite a bit to sort through! Let’s talk a little bit about what people need to consider, then, when looking for a midwife?
Missy: Yeah, I think that’s a really important question. I’m gonna answer that by telling you what we know from the research people do consider, and then also give you some recommendations. When women are interviewing potential midwives, just as when they’re interviewing doulas, what we know from them is that they certainly may ask questions about education and about training, but what women are really doing is asking, “Who do I feel safe with? Who do I feel a connection with? Who do I want to be with me, to hold my hand, to support me, to keep me safe, to monitor me through what will be a very significant point in my life?” And so we don’t want to overestimate the degree to which clinical decision-making affects how people choose their practitioner. It’s much more often about bedside manner. And I think this speaks to the really intense psychosocial needs of people who are laboring and giving birth. And we have, as a society, tended to downplay that or underemphasize that.
Now, I think also when people are thinking about who to hire as a midwife, it is worth asking questions related to probably three areas:
One is trying to understand the experience level of the midwife that you’re working with. Where did they go to school? How were they trained? How long have they been practicing? So getting some sense of their experience level is really important in asking about their credentialing can help you figure that out.
Secondly, I think it’s important to ask about what kinds of emergency safety, medications, and procedures they’re comfortable with and are able to offer. So for example, I do birth in a homebirth setting primarily, and people often ask me “What happens if I’m bleeding too much?” “What happens if the baby isn’t breathing at birth?” And what I will tell them is that “I carry all of the antihemorrhagic drugs that are available to you in the hospital! And I’m trained in how to administer. It’s uncommon that someone will bleed so extensively that they need an intervention in a homebirth setting, but it does happen. And if it happens to you, I will manage it.”
And then secondly, they will ask me “What,” y’know, like I said, they’ll ask me about “What happens if the baby doesn’t breathe?” “All certified and licensed midwives have the same credentials as hospital practitioners do for resuscitating infants. And again, it’s very rare that we need to resuscitate an infant, but when you do need to, it is critical that your midwife have that skill set. That means that I will carry the equipment that’s needed to do that and that I feel comfortable and I’m competent and up on my certification to provide that care for you or for your baby if you need it.” So I do think it is important to ask about that, while keeping in mind that those are rare instances.
And then the third thing that I think is really important to ask about is what is your relationship like with local medical providers? Should I need to transfer to a higher level of care from, let’s say, midwifery care in the hospital to obstetric care in the hospital, how will that work? What if I go into labor intending to birth at home, but my labor is taking a long time and I’m becoming exhausted and I want to transfer to the hospital? What will that look like?
So, unfortunately in the United States medical anthropologists like to point out that we have something called the “home-hospital divide,” and that’s a relatively deep chasm in many states between community providers and hospital birth providers. And this means that often if people are choosing a home or birth center birth, their access to medical backup (if they need it), it’s not guaranteed. And it’s not necessarily smooth— there are many places in our country where local midwives and physicians have worked that out, and can provide very smooth transitions from home to hospital— but it’s not a given. And so it’s very important to ask about that, because about 11% of people who go into labor intending to deliver at home or in a birth center will require a transfer to the hospital sometime during labor.
And I don’t believe that that should be treated as a failure or as a morbidity or as a complication or as a problem, but a normal and expected outcome of care. It is important that we know how to triage births and move them to the place where they can best unfold. And so sort of taking away the stigma of that a little bit, and talking about that really openly with your midwife is very important.
Adriana: And what you were just saying reminds me of two different things that I want to comment on. And it’s regarding the “requiring transfer to the hospital.” So one question is: That 11%, that doesn’t necessarily mean that it’s all emergencies happening? Because, I mean, you… say you have somebody at home that decides, “Y’know what? This has been really long. And I just need the pain meds or I just wanna go to the hospital.” Is that situation included in that 11%?
Missy: That 11% of transfers are almost never emergent. Emergency transfers are very, very rare; they’re less than 10% of our transfers. 90% of the transfers that we have are what you just said, which are slow, non-progressive labors.
Adriana: Right. And that’s a huge, important distinction to make, because if you’re, y’know, considering a birth center or a birthing at home, and 11% of births are gonna require you to go to the hospital because something’s up, that seems like a lot. And that brings up different decision-making, that if you’re saying, y’know, it’s actually 10% of an 11% that is due to something like an emergency…
Missy: So, let me say a little bit more about that then. A classic transport, what this looks like is someone who— it’s almost always a first-time mom, who’s having their first baby and they have a slow-to-start labor and they have been trying to rest, but it’s hard! They’ve got back pain or, y’know, the contractions are painful, and they’re becoming really tired and exhausted. The cervix is changing, but y’know, maybe you’ve been at it now for 24 hours and you’re still four centimeters dilated or five centimeters dilated.
I often say, y’know, that the vast majority of our transfers are the antithesis of an emergency. We could go out for dinner and see a movie, and still not be done with labor and we could walk to the hospital. We could bike to the hospital! They are not emergent. They’re actually the antithesis of emergent. It is that things are moving slowly and the midwife and the family are worried about exhaustion. Not emergencies.
And unfortunately I think the media has portrayed homebirth as a potential emergency. That’s not to say that those never happen, but there are such a small number of the types of transfers that we have. And, y’know, I think the other sort of misconception about the rare times when transfers are emergent, if you think about laboring in the hospital…
And I’m going to bring up a particular kind of complication and it’s called a cord prolapse, and that’s when the water breaks and the cord comes, the umbilical cord comes down before the baby’s head and the baby’s head can compress the umbilical cord. And this is an indication for cesarean, ’cause that can give a lot of stress to the baby. If that happens to you in the hospital room, in the hospital, they are going to have you get on your hands-and-knees, put your chest down towards the bed, and the midwife or the physician will push the baby’s head off the cord, through the vagina, and hold the head off the cord until you can get into the OR— that involves calling in an anesthesiologist, bringing together a team, moving you down to the OR.
If something like that happens at home, you call 911 and you do the exact same thing. And if you live close to the hospital, there is very little time difference between what it takes to prep an OR and get people in there, whether you’re coming from home or a birth center or from a hospital where you’re down the hall.
So, y’know, emergent situations need to be managed very similarly, regardless of where you’re actually coming from. And the vast majority are not emergent. So, I think those are really important things to keep in mind.
Adriana: And then that speaks back to what you were saying of what is the transfer protocol, y’know, from midwifery care to an obstetric care within your setting, be that home to hospital, or birth center to hospital, or even within the hospital from, say— like, we have a big midwifery practice here in one of the hospitals, that it’s a group only of midwives, but anytime a cesarean or an assisted delivery with forceps or vacuum is foreshadowed, then they bring in that collaborative care and tell the person giving birth, “Hmmm, I think it would be great for you to meet this doctor. I’m starting to consult them just in case, but so that something happens, you know their face”— like that doesn’t mean that the collaboration is only exclusive for, or that transfer protocol is only exclusive for homebirths, but regardless of setting.
Missy: Absolutely. We have a saying among midwives that says, “Transfer a complication, not a crisis.” And so part of why we develop the close relationships we do with our clients and monitor them very closely is so that we can see early warning signs of a labor that’s getting off-track. And when you know the person well, and there are no breaks in the continuity of care, so you don’t have patients falling through the cracks due to shift changes. For example, It makes it quite possible to identify early warning signs that you can either use tricks of the trade to get back on track or, when needed, change your place of birth.
I think people make quite a bit of this, but I’d like people to think for just a second about the fact that in the United States, now we say active labor begins at six centimeters. So many women are being encouraged right now to labor at home until six centimeters anyway. So much of our labors are going to have to occur at home. The question is whether those will occur unassisted— where you have someone who is without a doula, without a midwife— wondering when it’s time to go in, or maybe come in and are sent back home saying, “Go home and rest and come back later”? I mean, this can be very disorienting for people who’ve never had a labor before. What they’re experiencing is noteworthy!
So what you’re really saying is that a midwife comes to your home and monitors you, and if everything’s going smoothly, you have your baby at home. If there’s any indication, you change your place from home to hospital, which all women have to do if they’re having a hospital birth anyway, right? So it… We shouldn’t make a mountain out of a molehill. I don’t know. So I think that that does tend to happen. I— one thing I will say is that it is… it can be hard to move places, emotionally and psychologically. So I don’t want to completely poo-poo that, but we shouldn’t overestimate what it means to have to change places at birth. As I say, anyone who’s planning a hospital birth will have to do that. They’ll have to go from wherever labor started to the hospital eventually. And sometimes planned home or birth center births have to do the same thing.
Adriana: Right. And I think it’s more of the difficulty of adjusting your mind in that process, if you weren’t expecting to have to move from one place to another.
Missy: Right. And if you don’t know how you’ll be treated once you go into the hospital… Some women report really excellent care after a transfer, where the staff was very, very sensitive to how they might feel about having to change their birth plan. Staff that bend over backwards to facilitate a normal physiologic birth after transfer!
After people do transfer to the hospital, we know that about 60% go on to have vaginal births. Only 40% will go on to have a cesarean section, which leads to an overall cesarean rate that’s between 5-6% for planned home and birth center births. So even going to the hospital doesn’t necessarily mean that you’ll have a cesarean. It just means that you may have some more supports that lead you to get to your vaginal birth. For example, maybe you’ll have an epidural that allows you to rest and collect your strength so that you can push your baby out, once you get to complete.
Adriana: Yeah. And a key factor there is how that transfer of care also happens in terms of: Is your midwife still allowed to be present, or are they kept aside? And because I think that can be very disruptive… But, I mean, I guess that’s true at any point— whether you were at home or a birth center or hospital, and you were under midwifery care and then had to transfer to OB care— that meant that there was something, some complications in your situation that required that transfer. So I… Yeah, I think I just talked myself out of my question there!
Missy: No, you raise a really great point, because I mentioned people who experience it as very positive. But I also did a study several years ago with a doula and an obstetrician where we interviewed women who had transferred to the hospital, about their experiences of the transfer. We’ve also interviewed midwives who transfer, and the physicians or midwives in the hospital who received them— so, the referring and receiving providers— to try to get a sense of what it’s like to participate in a transfer. And some transfers are not smooth. Some women are met with shaming and blaming and hostility when they come into the hospital and from talking to providers, many of them explain that this came from their own fears. So a hospital provider may quite fearful of taking somebody from a home or birth center setting who they anticipate might be difficult to work with, who maybe doesn’t want the model of care that they have to offer, who are struggling to make the transition to a different model of care and it can be… and they don’t know them well.
And so it can be quite fear-producing for them, and sometimes that leads to poor interprofessional communication during a transfer. And this is so hard for the pregnant person! And what we all need to do as providers is to remember that our focus must be person-centered during a transfer; that the most challenging situation to be in is the person who is in labor. And we have to work together to smooth that transfer, to make it possible for them to adapt and to adjust and to provide space for that wherever possible. And part of that is keeping her with her midwife, because that’s who she’s got a longstanding relationship with and the presence of the midwife can offer support and stress reduction just at the time when she most needs it.
Adriana: And especially knowing that stress reduction is such an important key piece of physiologic birth flow, right? So good. Missy, let’s switch tacks a little bit, and bust a few myths about midwifery, or misconceptions.
And one that I hear a lot as a doula is people not quite knowing the distinction between a doula and a midwife, and, like, asking, “What are you guys? How are you different? What do you do differently?”
So I think that’s a pretty easy one to clarify, that midwives do medical stuff and doulas— and, well, midwives also do the psychosocial stuff— but then doulas just clearly do not do anything medical.
So there’s that one distinction. Another myth is people think that midwives are only for delivering babies and helping with the birth itself, and that’s not true. What other care do midwives provide?
Missy: That’s a great question. And this is really important to think about, y’know, not just in the U.S., but also cross-culturally— because cross-culturally and historically, midwives have been the wise women of their communities and they are often ritual elders or experts in all things related to women’s health and to babies and children.
And so, in the United States, we have for CPMs (the kind of midwife that I am) a much more restricted or narrow scope of practice. So for CPMs, we typically provide only care during the childbearing year. There are actually some states that allow for CPMs to do some “well woman care,” which means they can provide, for example, pap smears or gynecologic exams, but that… those are a small number. CPMs also provide newborn care out to the first six weeks of life for the infant before they’re transferred over to a pediatrician. Now, Certified Nurse-Midwives and CMs, especially those with advanced practice degrees, can provide a whole range of well woman care over the course of the lifespan. And so it is certainly the case that they have a much broader skill set often, in terms of providing well woman care.
Adriana: And see, I didn’t know that. I thought that all midwives were able to do well woman care!
Missy: We can in my state, so that’s good!
Adriana: And all these nuances, right, that we have to figure out…? Missy, before we wrap up, is there anything that you wanted to make sure we got to, about midwives, that people need to know, that we haven’t gotten to yet?
Missy: You know… There is… I think it’s hard for us to continue to talk about midwifery “versus” medical care or holistic “versus” technocratic care. I know that there are real and meaningful differences between the way many obstetricians practice and the way many midwives practice, but I think it’s important to focus on the places where we are converging. And in our country, there is a growing awareness that we’re doing, for example, way too many cesareans. And so in the decades going forward, what I hope to see is more interprofessional collaboration and really creative ways to provide the best possible maternity care to all people in our country. And so we need to think about that creatively— and this dualism or this dichotomy doesn’t always serve us when we’re trying to do that. And I’ll give you two examples:
One is that the United States has a very high number of people who are underserved in rural communities. So, so many women live far from the closest obstetric provider and have to travel great distances to be… to get access to maternity care. It would be amazing if more midwives could be used as obstetric care system extenders to provide in-home prenatal care. That doesn’t mean that every rural woman would have a homebirth or a birth center birth, but they could be provided care in their own communities if midwives could come to them.
And I think there’s a vast under-utilization of midwives in our country. If we could more creatively employ midwives in the ways that other high-resourced countries have modeled for us, I think we could greatly improve outcomes. And that extends to making sure that we have a diversity of midwives to care for our diverse population. Right now, the vast majority of midwives in our country are white, college-educated, middle class women, and we need a more diverse cadre of midwives to be able to provide culturally-concordant care to women of color, to Indigenous women, to rural women. And we have got to start putting our energies towards doing that.
And then the second thing I would say is that there is a popular dichotomy in the international literature where we talk about healthcare systems that do “too much, too soon,” and some that do “too little, too late.” And you can imagine after the conversation today that the U.S. is largely categorized as one that does “too much, too soon.” But because there’s rampant inequality, social inequality, in almost all countries, you can actually have countries where “too much, too soon” and “too little, too late” exist side-by-side. And so we have that in this country, where we have a very high percentage of women who are un- or under-insured, or who never received quality prenatal care and show up in the emergency room never having received quality prenatal care… And that is really unacceptable for a country as wealthy as we are.
So what I would like to see is midwives used more effectively to begin to “right size” our maternity care so that we are not wasting money on unnecessary interventions, but really tailoring our care to the complex psychosocial and holistic needs of all pregnant people. And I think we have the resources and the research to do that. We just need the political will.
Adriana: Thank you so, so much for being on the show today! It’s been really wonderful.
Missy: Thank you so much. It was a pleasure!
Adriana: That was medical anthropologist, midwife, author, and renowned speaker, Dr. Melissa Cheyney. To learn more about the fascinating research Missy and her team are working on, go to upliftlab.org or follow them on Instagram @theupliftlab.
And you can connect with us @birthfulpodcast, on Instagram as well.
In fact, if you are not driving, it would be lovely if you would take a screenshot of this episode right now and post it to Instagram sharing your biggest takeaway from the episode. Make sure to tag @birthfulpodcast so we can see it and we can amplify it.
You can find the in-depth show notes and transcript of this episode at birthful.com, where you can also learn more about my birth and postpartum preparation classes and download your free postpartum preparation plan.
Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.
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Come back for more ways to inform your intuition.
Lozada, Adriana, host. “Why a Midwife Might Be Just What You Need.” Birthful, Birthful. October 19, 2022. Birthful.com.
About Dr. Melissa “Missy” Cheyney
Melissa Cheyney PhD, LDM is a Professor of Clinical Medical Anthropology at Oregon State University (OSU) and a community midwife (on sabbatical). She co-directs Uplift—a research and reproductive equity laboratory at OSU, where she serves as the Primary Investigator on more than 20 maternal and infant health-related research projects, including the Community Doula Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press), co-editor with Robbie Davis-Floyd of Birth in Eight Cultures (2019, Waveland Press), and author or co-author of more than 60 peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-attended birth at home and in birth centers in the United States. In 2019, Dr. Cheyney served on the National Academies of Science, Engineering and Medicine’s Birth Settings in America Study and in 2020 was named Eminent Professor by OSUs Honors College. She also received Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the Midwives Alliance of North America (MANA) Statistics Project. She is the Editor-in-Chief of the journal Birth: Issues in Perinatal Care and the mother of a daughter born at home.
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