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The Rebirth of Midwifery
When I first announced to my family that I wanted to have my baby in the hospital with the help of a midwife—and no obstetrician—I detected serious disapproval from all sides.
"You mean there's not going to be a doctor in the room?" asked my father-in-law. And my husband, sensitive nineties type though he is, feared that I was putting myself and our baby in peril for the sake of some radical feminist ideal.
But to me, a hospital birth with a certified nurse-midwife (CNM)—a registered nurse with a master's degree or certificate in midwifery—seemed like a good way to get the best of both worlds: modern technology and natural medicine. My husband, baby, and I would be able to experience a midwife's continuous care in a comfortable birthing room, just a few feet away from the emergency medical equipment I hoped not to need.
As it turned out, I had a surprisingly difficult labor, but the midwife was there for me every step of the way. She encouraged me to move around and experiment with different positions. She told me to hang in there when it became apparent that I was dilating slowly. And after several hours of painful contractions that didn't progress, she supported my decision to opt for Pitocin and an epidural. True, a labor-and-delivery nurse might have done all the same things, but because I had gotten to know this midwife through several months of prenatal care and had developed my birth plan with her; I felt especially comfortable taking her advice.
As it happens, I was not alone in wanting both state-of-the-art obstetrics and a nurse-midwife's gentle touch. Midwifery—which treats pregnancy as a natural occurrence that shouldn't call for much medical intervention—is one of the fastest growing areas of obstetrics and gynecology today.
Over the past ten years, hospitals and obstetricians in private practice have been employing as many CNMs as the nation's 41 nurse-midwifery programs can train. According to the American College of Nurse-Midwives in Washington, D.C., CNMs presided over 176,117 hospital births in 1992—up from just 19,686 in 1975. And birth centers, where midwives have traditionally provided prenatal and delivery care for low- and middle- income women, are gaining popularity with mothers-to-be at higher income levels, too.
"Fifteen years ago, if you'd told me that there would be midwives in every hospital in this town, I would have said you were out of your mind," says Mickey Gillmor-Kahn, a certified nurse-midwife in Atlanta. "But things sort of exploded since then, and now midwives are everywhere."
Not only are midwives turning up in every corner of the childbirth field, they've also been radically professionalized since midwifery reemerged in the seventies. In those days, most of the practitioners were "lay midwives," who learned the trade through non-degree-granting programs and apprenticeships and performed mainly home births. Today, lay midwives are significantly outnumbered by certified nurse-midwives, who practice primarily in hospitals—where 85 percent of CNM deliveries took place in 1992—and have been trained to handled everything from sonograms and episiotomies to administration of sedatives, Pitocin, and epidurals.
The move to incorporate midwifery into the medical mainstream seems to be good news for women and their babies. In 1993, the American Nurses Association in Washington, D.C, released a major review of previous studies which found that women whose deliveries were supervised by CNMs received fewer episiotomies, required less anesthesia, and spent less time recuperating in the hospital than those who gave birth with a doctor. Perhaps the most striking comparison is the rate of c-sections: National statistics for midwives are hard to come by, but in one 12-year study conducted at a major urban hospital, less than 2 percent of women who delivered with a midwife ended up with a c-section. The national rate is close to 25 percent. Of course, midwives generally work with women whose pregnancies are considered low-risk, so the comparison is somewhat exaggerated.
Nevertheless, the evidence of the many benefits of midwife care is so compelling that more and more traditional ob-gyns are being won over.
"There's no question that women who deliver with nurse-midwives do just as well as those who use doctors, as long as physicians are available to handle emergencies," says Dr. Kenneth Bell, an obstetrician and medical director at Kaiser Permanente in Orange County California. "And in some ways—as in the c-section rate, for instance—they're definitely doing better." Bell admits that even some members of his own family are making the switch. "The births of both my granddaughter and grandnephew were successfully managed by CNMs," he says.
So what, exactly, do these pregnancy practitioners do, and why is everyone so excited about them?

Sympathy and Sonograms
In addition to being registered nurses, certified nurse-midwives have spent one to two years acquiring clinical midwifery skills. While a few nurse-midwives go on to get advanced obstetrical training, most deal exclusively with the 80 to 90 percent of women whose pregnancies are considered low-risk. (High-risk pregnancies include those in which the woman is carrying two or more fetuses, has a history of preterm labor, or suffers from a chronic condition such as diabetes, heart disease, or sever hypertension.) And although they're best known for supervising childbirth, nurse-midwives also receive training in prenatal and well-woman care, which covers gynecological exams, Pap smears, and counseling on everything from contraceptives to lactation to menopause.
Because of their overall approach, however, midwives are more than simply stand-ins for doctors. "Obstetricians have always been trained to believe that pregnancy and labor are disasters waiting to happen," says Dr. Bruce Flamm, an ob-gyn in Riverside, California, who often argues the case for CNMs to the medical establishment. "That means that OBs tend to use more medical interventions and pay less attention to the emotional concerns of women." Midwives, on the other hand, view pregnancy as a normal, healthy process, Flamm adds, which can translate into a more thorough and compassionate type of care.
In addition to covering the prenatal basics—monitoring weight and blood pressure, listening to the fetal heartbeat—midwives offer information about nutrition and exercise, as well as alternative therapies such as acupuncture and homeopathy.
They also take an interest in the emotional lives of their patients. Deborah Shurman, a mother of four in Augusta, Main, recalls a prenatal appointment during which she was particularly upset. "The midwife took my blood pressure, frowned, then took it again," says Shurman. "Then she leaned forward, put her elbows on her knees, and asked me outright, What's happening in your personal life? Let's talk a bit.'" At that point, Shurman says she burst into tears and started talking a blue streak. "My husband had just left me a few days before, and it was a very difficult period. The midwife reminded me to take time for myself and to look after my own needs, too."
Even a midwife's office may look different from that of the typical ob-gyn. Cathering Gorchoff, a CNM in Santa Rosa, California, has decorated hers with antiques, floral paintings and scented candles to mask any medicinal orders. "Making my office look different is one way I try to set a healthy outlook on the whole pregnancy," Gorchoff says. "Pregnancy is challenging, and women show have one place where they can feel comfortable talking about it."

Way to Go, Coach
But according to mothers who extol the praises of their midwives, it's in the delivery room that CNMs work their particular brand of magic. During the many fits and starts of a typical labor, midwives keep the woman motivated and on the move. "We walked the hospital corridors in something like a conga line—me, my husband, and my midwife," says Terez Giuliana, a 38-year-old medical proofreader from Lansdowne, Pennsylvania. "My labor lasted 14 ½ hours, and she was there for me the whole time—unlike the labor nurse , who was in the out, and went off her shift before my baby was born."
This kind of constant attention and moral support is one reason women who deliver with midwives tend to need less medical intervention, says Marie Bridges, a CNM in West Columbia, South Carolina. "One hospital procedure often leads to the next," she explains. "Fetal monitoring confines a woman to bed, which can make her contractions exceptionally painful. That, in turn, might make her more likely to need an epidural, which will make it more difficult for her to push." At that point, Bridges says, the possibility of, say, a forceps delivery—or even a c-section—goes up. "Because we stay right by her side, encouraging her to shift positions and offering hot showers and massage, a woman can often avoid this whole cycle."
Midwives who work in birth centers, which are particularly geared toward natural childbirth (as a rule, they don't offer epidurals), have even more techniques at their disposal. Whirlpool baths, for instance, are standard at most centers, and for many women, they make an enormous difference. "The birth center was so much better," says Lynne Anne Baker, a 34-year-old management consultant in San Diego, who had her first baby in a center but had to have her second in the hospital because of a slight medical problem. "If more women had hydrotherapy—just getting in a shower or bath is helpful—they'd be able to do it without drugs."
When emergencies do arise, midwives can often resolve the problem, or at least hold down the fort until the doctor arrives. When Sandra Van Rossem's labor was cut short by a prolapsed unbilical cord—the cord was preceding the baby down the birth canal—her midwife quickly reached in to keep the baby's head fromm pressing down on his only means of life support. In this position, the women were transferred to a gurney and then to the operating room, where a doctor took over for a c-section. "If she hadn't been so skilled, I might have lost the baby," says Van Rossem, a mother of three in Bay Shore, New York.

But Before Signing On
Although there seem to be no disadvantages to working with a CNM in tandem with a doctor and delivering in a hospital—apart from the natural events that can go wrong in any delivery—there are some risks involved in other types of midwife care.
A home birth with a lay midwife can be particularly chancy. In the event of emergency, a woman would have to be transferred to the nearest hospital, meaning crucial time could be lost if the move doesn't go smoothly or if the hospital is, say, 30 miles away. Plus, a home birther may find the emergency personnel at some hospitals less than sympathetic. "Unfortunately, I've known doctors who think anyone stupid enough to attempt a home birth deserves whatever happens to them," says Dr. Don Creevy, an ob-gyn in Portola Valley California.
Birth centers have potential glitches as well. While all CNMs have physician backups, the doctors are not usually at the center, so again, a woman would have to make the trip to the hospital if anything serious went wrong. And some women are uncomfortable with the "up-and-out" philosophy of many centers. "I had two separate tears from the birth, so I wanted to rest for a while," says Karen Prince of Silver Spring, Maryland, "but the nurse-midwife made it very clear that I couldn't crash there. I was home five hours after my baby was born."
Any woman who is considering a birth-center delivery—especially one who's never experience labor—should also think carefully about the no-epidural policy of most centers. Even mothers who were determined to have natural childbirth (like myself) have been known to reconsider in the middle of a difficult labor.

What the Future Holds
Despite the evidence supporting the growth of midwifery, the profession does face some opposition. Some ob-gyns see midwives as an economic threat—particularly those who into independent practice; others condescend to what they still perceive to be the hippie in Birkenstocks who's not performing genuine medicine.
But with the focus on cost-effectiveness, and women continuing to demand the best in pregnancy care, most experts agree that midwifery is the wave of the future. Already, the state of Florida, which has a shortage of practicing OBs due to extremely high cost of malpractice insurance, has recommended that 50 percent of low-risk births be supervised by nurse-midwives. Chuck Honaker, spokesman for the American College of Nurse-Midwives, expects the trend to continue: "Our goal is to produce 10,000 CNMs by the year 2001," he says, "which means that in the next six years, the number of midwife-attended births should more than double."
The glowing reports from women who have delivered with midwives certainly suggest that pregnancy care is headed in the right direction—even if the changes are a while in coming. "I still meet people whose eyes widen when I say I had my baby with a midwife," says Peg Conway, a mother of two in Cincinnati. "They say, You did what?' as if I had the baby in the backyard or something." But Conway was thoroughly delighted with the whole process.
"Not only was my midwife there the entire time, but she came by my room the next day and asked me if there was anything I wanted to talk about," Conway says. "I wouldn't have done it any other way."

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