When I first found out I was pregnant, I knew I wanted to have as natural of a pregnancy and labor as possible. I had one appointment with my OB/GYN shortly after I became pregnant. She gave me her schedule of tests & procedures and I knew right away that that was not the kind of pregnancy I wanted. It didn’t take me long to decide that I wanted to use a midwife. And luckily for me, my husband was 100% supportive of that decision.

As I am writing this, I am 25 weeks pregnant. And as always, I am not a doctor. I encourage you to speak to your doctor to make your decisions. I am not trying to encourage or discourage you from making health decisions. I am simply sharing what I have decided to do for myself.

What Is A Midwife?

 “Obstetrician” means “one who stands by” and “midwife” means “with woman.” A subtle difference that summarizes the different birth philosophies. Midwives treat pregnancy as a human condition whereas obstetricians treat pregnancy as a medical condition. The obstetrical mind-set is to take no chances and therefore orders more tests throughout pregnancy and labor. However, these tests come with their own set of side effects and possible complications (see what tests I am opting out of and why here). Obstetricians generally have strict protocols they follow. Midwives tailor the labor to the mother’s needs and wants.

A certified nurse-midwife (CNM) is a registered nurse who has completed graduate-level programs in midwifery and is certified by the American College of Nurse-Midwives. Midwives may work in hospitals, birthing centers, or will come to your home for a home birth. They provide a full range of health services for women including gynecologic, family planning, preconception, childbirth, treatment of sexually transmitted infections, and postmenopausal care. While midwives are oriented to natural care, they are able to prescribe medicine in most states. They are able to perform standard tests during pregnancy (like sonograms, blood tests, etc.). Midwives are fully trained medically professionals.

Lower Cesarean Rates

In 1970, the cesarean rate in the United States was about 5.5%. Twenty years later in 1990, the rate was 22.7%. Another 20 years in 2010, the rate was 32.8% (source 1, 2). There are definitely times when a cesarean delivery is necessary for the health of baby and mom due to complications. Those cesareans save lives. And if it was medically necessary, of course I would chose a cesarean. However, many cesareans for healthy pregnancies without complications are unnecessary and do more harm than good. The World Health Organization estimates that 5-10% of births have a medical need for a c-section, not 32.8%.

So why are 1 in 3 women in the US delivering via cesareans?

• Estimated large baby: This study shows a “significant error in the estimation of fetal weight [and] can lead to unnecessary obstetric intervention.” The mean estimated birth weight was 3.2 kg (7 pounds) and the mean actual birth weight was 3.07 kg (6 pounds, 12 oz). In 40% of the cases, there was an error by more than 10%. One out of every three American women who have an ultrasound are told they are having “big babies” (>8 lbs 13 oz). Although only 1 out of 10 are actually born big. Big babies are the 5th most common reason for having a c-section. One study showed that women that were told they were having a big baby (but didn’t) had triple the induction rate, more than triple the c-section rate, and quadruple the rate of maternal complications (including hemorrhaging, infection, need for antibiotics, and fever) than women who were told they weren’t having a big baby but did deliver a big baby. (source)
• Labor induction: Failure to progress: “Failure to progress” is the number one reason for unplanned c-sections in the United States; resulting in 35% of cesareans performed in 1st time mothers. One out of every 3 c-sections performed for failure to progress happened after less than 3 hours of pushing for 1st time moms. Doctors determine failure to progress based on a 1955 study called the Friedman’s Curve. The results of this study show the average amount of time it took women to reach different stages of labor. However, today, on average women are older & weigh more and birth methods have changed quite a bit (forceps used less often, pitocin & epidurals used more, mothers having fewer children [ie less births of a 3rd, 4th, 5th, & so on child]). These differences drastically change the timing of the labor process and shouldn’t be used as a modern guide. Today, the average labor time is longer than the average in 1955 when the Friedman’s Curve was made. If doctors go by that curve, then half of labors today are slow and have a “failure to progress” and need to be induced (source).
• Labor induction: Past due date: The estimated due date we use in the US is 40 weeks after the last menstrual period. However, studies have shown that the actual average length of pregnancy is 40 weeks and 5 days and can vary up to 5 weeks. Induction is happening often as early as 39 weeks. A study shows that 26% of women’s due date was changed based on an ultrasound in the 3rd trimester. The date was changed based on the estimated baby weight. But as I mentioned above, 40% of the time there is an error of more than 10% of the baby’s weight. So if your ultrasound shows the baby to be larger than average or larger than he/she is, the due date is often moved up to an earlier date. Furthermore, having a higher body mass index before getting pregnant and an older maternal age increase the length of the pregnancy (both weight and age averages are increasing nationally). (source 1, 2).
• Previous cesarean: A very common misconception is that once a woman has a cesarean, she has to have a cesarean for all future births. In 2006, the repeat cesarean rates were 92%. Although 74% of women who attempt a vaginal birth after cesarean (VBAC) have a successful vaginal birth. Evidence shows that having a repeat cesarean is a preference decision and is a safe & reasonable option for most women. (source 1, 2).
• Financial reasons: Let’s face it. Money talks. On average, planned cesarean deliveries take less time and are billed at higher amounts than vaginal births with no complications. One study shows that for-profit hospitals in California are performing cesareans 17% more than nonprofit hospitals. In 2011, the average cost of a hospital vaginal birth with no complications was $10,657 and the average cost of a hospital cesarean birth with no complications was $17,889; a increase of 67%.  (source 1, 2, 3)
• Casual attitudes about surgery: Americans are very tolerant to medical procedures and surgeries. We spend the most per capita on health care yet have the 8th lowest life expectancy rate. This attitude is carried on to our labor practices. We have a very casual attitude about cesarean surgery and see it as a very common & routine form of labor & delivery (source).
• Unaware of the downsides of cesarean: Because of our casual attitude towards surgery, often doctors don’t discuss the risks and patients don’t ask. Here are some downsides to having a c-section:
  • Prolonged recovery from birth and extended hospital stay
  • Wound infection (incision site, uterus, bowel, or bladder)
  • Hemorrhage or increased blood loss (1-6 women per 100 require a blood transfusion)
  • Painful adhesions from scar tissue
  • The maternal mortality rate for a cesarean is higher than with a vaginal birth
  • Cesarean babies are more likely to have breathing and respiratory problems shortly after birth
  • Cesarean babies are 50% more likely to have lower APGAR scores than those born vaginally
  • Cesarean babies are 46% more likely to have diarrhea up to age 12 months
  • Cesarean babies are 5 times more likely to have environmental allergies (ie  dust, animals, pollen, etc.)
  • Cesarean babies are almost twice as likely to develop asthma by the age of 8
  • Increased food allergies 

The reason for increased health risks for cesarean babies is because when a baby is delivered through the birth canal, he/she gets a good, healthy dose of good bacteria from the mother’s vaginal canal. These good bacteria boost the immune system and aid digestion. (source 1, 2, 3, 4, 5, 6, 7, 8)

So How Is a Midwife Different?

The cesarean rate for women using midwives ranges from 1.8% to 12.7%, depending on the study. Compared to the national average of 32.8%, that’s a big difference. Midwives use medical intervention far less than obstetricians: less epidurals, less induction, less anesthesia, less use of forceps, and the list goes on. Midwives follow the woman’s natural birthing process and work with her to make her more comfortable & treat it like the natural process that it is. Whereas physicians treat the delivery like a medical condition that needs to be “fixed.” Midwives trust that the baby will come when ready and know that there is up to a 5 week variation in the due date. Whereas physicians look at the due date as a rule and any variation is “wrong.”  (source 1, 2, 3, 4, 5, 6)

Higher Breastfeeding Rates

Women that use a midwife have a higher successful rate of breastfeeding. A big contributor is that midwives understand the importance of immediate skin-to-skin contact immediately after delivery. Skin-to-skin care is placing the naked (without a diaper) baby chest down on the mother’s bare chest, then covering you both with blankets to keep warm and dry. This should start immediately after birth and last at least until after the 1st breastfeeding session. And also rooming together while in the hospital is important. In the US, only 54.4% of vaginal hospital births implemented skin-to-skin care, and the rates are lower for cesarean births.

Babies who received skin-to-skin care were twice as likely to be successfully breastfeeding at 3-6 months. The skin-to-skin practice results in less breast pain for mothers, more effective suckling during the 1st feeding, and more stable heart rates. Babies that were separated from their moms at birth were 12 times more likely to cry. During skin-to-skin care, a premature baby’s overall growth rate increases because they are able to sleep better, resulting in a more efficient use of calories. (source 1, 2, 3, 4, 5)

For information on how to implement skin-to-skin care after a cesarean, see here and here.

Flexible Birth Position

57% of US women give birth lying down on their back with her head raised at a 35% angle. It’s easier to monitor the vitals of the baby and the mom in this position, lower risks of tearing. and possible less blood loss. However, women that give birth in upright positions (sitting, kneeling, or squatting) are:

• 23% less likely to need forceps or vacuum-assisted delivery
• 21% less likely to have an episiotomy
• 54% less likely to have abnormal fetal hart rate patterns 
• Women with walking epidurals (they are able to move around) have a shorter labor and pushing phase in an upright position

Evidence shows that it is beneficial for the mother to be in the most comfortable position possible during labor, whether that is upright, lying down, or changing positions throughout labor. Midwives encourage this and encourage the mothers to get in any position that is most comfortable. My midwife discussed this with me at my 1st visit. She said that given my back surgery history, it will be very important for me to keep as much pressure off of my back as possible, meaning she will discourage me from laying on my back. She continued by saying it will be important for me to communicate any discomfort in my back so I can change positions when needed. (source)

Cost Effective

Many insurance policies cover the cost of a midwife delivery the same as an obstetrician delivery, regardless if it is in a birth center, hospital, or at home (although home births have a lower cover rate than in a hospital or birthing center but sometimes the total cost of a home birth is less than the copay for a hospital birth). Because midwives use less modern medical intervention, the costs associated are less than using an obstetrician. How much less depends on your area, your birth location (home, birth center, hospital), what modern medical intervention the mother needs or chooses, etc.

• Home births cost about 1/3 as much as hospital births
• Average costs of different births in 2011:
  • Vaginal birth at a birth center: $2,277
  • Vaginal birth at a hospital (no complications): $10,654
  • Cesarean birth at a hospital (no complications): $17,889

(source 1, 2)

But Is It Safe?

 Yes. A midwife led delivery is safe. The CDC reports that births attended by certified nurse midwives compared to births attended by physicians had:

• 19% lower infant death
• 33% lower neonatal mortality (infant death occurring in the 1st 28 days of life)
• Mean birth weight 37 grams heavier (low birth weight is an predictor of infant mortality, subsequent disease, or developmental disabilities)
• Better birth outcomes even after sociodemographic and medical risk factors were controlled for in statistical analyses

So What Did I Chose?

I chose a midwife with the delivery in a hospital. Midwives deliver in hospitals, birth centers, or at your home. I have a history of back surgeries and have a fusion in my spine. Because of that, my risk level is a little higher. So I opted to deliver in a hospital setting just in case anything goes wrong and medical attention is needed immediately. If I did not have that history, I would have probably decided on a birth center. 

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