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OB or Midwife?

Eight years ago when I had my first son, I initially met with an OB-GYN recommended to me by a friend. I adored him—as well as his partners: a dynamic team of certified nurse-midwives. After learning that midwives tend to spend a lot of time with patients, have relatively few patients who require Cesarean sections and also encourage medication-free deliveries, I decided to have a midwife from the practice deliver my baby.

While OB-GYNs remain the go-to professionals for baby delivery in the United States, midwives are growing in popularity. In 1989, certified nurse-midwives delivered 3.2 percent of all U.S. babies. In 2008, that number had risen to 7.5 percent. Choosing who will deliver your baby is a highly personal decision. If you’re trying to choose between an OB-GYN or a midwife, here’s a look at the differences and similarities between them, plus seven questions that will help you make the final call.

M.D. vs. midwife: the basics Most people know that OB-GYNs have had four years of medical school. They have also completed a four-year residency program in which they are trained to be surgical-medical doctors, and many have also completed a three-year fellowship to specialize, for example, in infertility or gynecological oncology. Yet, many people don’t realize that midwives are also highly trained health care professionals, says Carolyn Havens Niemann, C.N.M., a certified nurse-midwife at Princeton Midwifery Care in Lawrenceville, N.J.

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The majority of midwives earn bachelor’s degrees, then work as registered nurses and go back to school for a two- or three-year master’s degree program in midwifery, according to the American College of Nurse-Midwives (ACNM). The professional designation is C.N.M. for certified nurse-midwife; in Rhode Island, New York and New Jersey, it’s C.M. for certified midwife. C.N.M.s and C.M.s can prescribe drugs, including pain medication.

Both are licensed and highly regulated health care providers in all 50 states and, yes, your health insurance covers their care if you’re delivering in a hospital. Most will also cover some share of a birthing center delivery, but home births are generally not covered. More than 96 percent of births attended by C.N.M.s and C.M.s happen in hospitals, while a little more than 2 percent are in birthing centers and only about 1.7 percent at home.

The birth experience “Midwives are the experts in normal pregnancies,” says M. Christina Johnson, C.N.M., director of professional practice and health policy at ACNM in Silver Spring, Md. Johnson says her profession is often best known by this saying: low tech, high touch. Midwives use technology such as fetal monitors, but rely heavily on their clinical experience.

OB-GYNs, as a profession, have a different reputation and set of skills. “There’s the perception that the physician is more likely to intervene in the birth,” says OB-GYN Jennifer Niebyl, M.D., professor of obstetrics and gynecology at the University of Iowa in Iowa City. That’s partly because they can. Unlike midwives, they are trained to manage high-risk pregnancies and can perform surgeries. Midwives can’t do C-sections (though some may assist in the operating room). OB-GYNs can also use forceps and vacuums to facilitate delivery, whereas midwives are legally prohibited from doing so.

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And, indeed, research shows that OB-GYNs are more likely to use interventions (e.g., epidural anesthesia, episiotomies and instrument deliveries). A 1997 study published in the American Journal of Public Health compared two groups of women with low-risk pregnancies. The researchers found that C.N.M.s used 12.2 percent fewer interventions than physicians. The same study found that the women who saw midwives rather than OB-GYNs had 4.8 percent fewer C-sections. Yet, more importantly, research has also shown that fetal and maternal outcomes are equally good when comparing OB-GYN and midwife births.

Choosing your caregiver Niebyl and Johnson say that who you have deliver your baby boils down to what you need. If you’re grappling with the decision between an OB-GYN and a midwife, the best thing to do is to start by answering these seven questions:

1. Is a vaginal birth your priority? As a profession, midwives are ardent supporters of vaginal births. OB-GYNs may or may not be. “You should ask about the doctor’s C-section rate and philosophy,” recommends Niebyl. If it’s important to you, make sure your care provider supports vaginal birth.

2. Do you want your caregiver with you during labor? “Nurse-midwives offer a lot of labor support. They spend more time with patients than a physician can because we get pulled in so many different directions,” says Niebyl. If you have a doula (someone trained to support and help advocate for you through labor and delivery) or other support system, though, this may not be a deal breaker for you.

3. What are your plans for pain management? “In a hospital setting, lots of midwives’ patients ask for and get epidurals,” says Niebyl. However, midwives will likely encourage trying medication-free methods to manage pain first. “We usually look for pain management techniques that support the natural process,” says Judy Berk, C.N.M., a certified nurse-midwife at Brigham and Women’s Hospital in Boston. “That might mean showers, massage, acupressure techniques, homeopathy, switching positions or trying a birthing ball.”

4. What are you hoping will happen at the hospital? More OB-GYNs than midwives have strict protocols. Some doctors want their patients in bed with an IV, hooked up to a continuous fetal monitor. Midwives generally encourage patients to move around and are also more likely to use intermittent rather than continuous monitoring, according to Johnson. Speak to your OB-GYN well before your delivery date to find out about his or her policies for childbirth in the hospital—and make sure they mesh with your expectations.

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5. Do you want (or need) more support and advice for your transition to parenthood? “Midwives do a lot of counseling for nutrition and exercise and also on the emotional changes that happen when it comes to becoming a parent for the first time or adding another child to the family,” says Berk.

6. Are you considered high-risk? “I encourage healthy patients to go to the nurse-midwives,” says Niebyl. “But OB-GYNs are trained to manage someone with diabetes or other complications.” Some midwives, though, co-manage higher-risk patients alongside OB-GYN colleagues; that means you may see both a midwife and an OB-GYN during your pregnancy. Who ultimately delivers your baby will likely depend on your medical circumstances.

7. What does your gut say? Justine Arian, a doula and birth coach in Huntington Beach, Calif., urges women to trust their instincts about whom they choose to deliver their babies and even where. “Meet different doctors and midwives and visit hospitals or birthing centers. Ask yourself, ‘Is this where I see myself giving birth?’ ” says Arian. You can be sure you’re not making decisions based on unfounded fears by taking the time to educate yourself about your options. “Women have to give birth where they feel safest and most supported,” she says.

Last year with the birth of my second son approaching, I faced all these questions again. I was thrown a curveball and ultimately needed a C-section with my first son, so my choice the second time around was a little more complicated. I could attempt a vaginal birth after C-section (VBAC) with a midwife in a hospital, but my gut told me a VBAC wasn’t the right decision for me. In the end, I received nearly all of my prenatal care from my midwife, but an OB-GYN delivered my son by C-section. This was the best choice I could make for my family, and the outcome was fantastic—all 7 pounds, 7 ounces of him.

The second time around. If you had a Cesarean section with your first child, a midwife may still be an option for your second baby—even if a C-section has been recommended. Midwives don’t perform surgery, but you can certainly discuss with your OB-GYN or midwife the possibility of a vaginal birth after C-section (VBAC). Right now, whether a midwife or an OB-GYN can offer VBACs is often dictated by a hospital’s policy. For home births, the midwife can make the call.

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