When I came up with that title, I was tempted to have a little fun with it, wishing i had some clip art with a picture of a backwoods granny woman with a corncob pipe and a well worn black midwife bag to juxtapose against a photo of a well-groomed white male doctor in surgical scrubs, getting ready to head out to his golf game. Stereotypes aren’t the most helpful thing, although they do sometimes serve to illuminate cultural assumptions about different groups of people. Instead of going down that path—now that I’ve planted the images in your head—I’ll try and give a brief rundown of how midwives differ from obstetricians.
First of all, OBs, obviously, are doctors, specifically, surgeons. Their training is focused o finding and fixing pathology—problems—with drugs and surgery. They are generally very good at this. Midwives, on the other hand, are keepers of normality. We expect pregnancy and birth to be normal, and we are skilled at helping to keep it that way, and recognizing and intervening properly when needed. We don’t prescribe medications or perform surgery, but we have countless tricks up our sleeves for preventing the need for drugs or surgery to begin with.
Doctors go to medical school for many years, and then do residencies before they are finished training. Certified Professional Midwives complete academic training either on our own or through a school, and train through years of apprenticeship with more experienced midwives, generally in out-of-hospital settings, which is where we work. We see and support dozens, if not hundreds, of normal, natural, minimal-intervention births, along with a number of complicated ones, before we ever become licensed. We are so well-versed in the many variations of normal birth that abnormalities tend to scream out at us on the rare occasions that they occur. We don’t expect trouble at a birth, but we recognize it, and are trained to respond appropriately.
Obstetricians care for their patients at 15-minute office visits, typically, and attend births in a hospital setting. Midwives may see clients in an office, or, as I do, visit them in their homes, where their births will occur (unless there is a birth-center in the picture). Our prenatal visits usually occur on a schedule similar to OB care, but each visit tends to last around an hour, most of which time is spent discussing the mother’s health and well-being, not only physical, but emotional and spiritual. We may discuss anything from her marital problems to her chickens. We do the same clinical care as OBs, but that only comprises a small fraction of the visit. I often joke that good midwifery care is 95% catching up on gossip. By the end of a pregnancy., the midwife and client know each other very well and have established a great deal of trust.
One of the biggest differences between OBs and midwives is the power dynamic in our caregiving. In traditional medical care, there is a definite hierarchy between the doctor and patient, with the OB in charge (unless the patient is exceptionally well-informed and feisty). There is typically a good amount of professional “distance” between doctor and patient that keeps the care impersonal and the status quo in place. The doctor orders and prescribes and the patient is expected to comply. Midwives regard our clients as equals; our job is to consult, advise, support, and occasionally act as a lifeguard. Our clients are responsible to make their own best decisions; we offer information and options and facilitate their wishes to the best of our ability. The birth and the baby belong to the client, and are not ours to control or dictate.
This shift in responsibility and ownership of the experience is closely related to another, more pragmatic difference between OBs and midwives. Obstetricians, being doctors, make a fairly huge income, and are sued frequently, so they pay a substantial chunk of their income to carry malpractice insurance, and base a good number of clinical decisions on fear of liability. Midwives make much less money, do not normally carry malpractice insurance, and lawsuits are fairly rare. Because of this, we practice with far less fear of litigation. The downside of not carrying malpractice insurance is that insurance companies will generally not allow us to be in- network providers, and some still won’t work with us at all (many will), which means that most families who want to receive their care from a CPM will pay more out-of-pocket (even though our actual fees are a fraction of what a doctor charges).
While the end goal of midwifery care and obstetric care is the same—a healthy mother and baby, our approaches to getting there are significantly different. Midwives focus on promoting mother/baby well-being through personal, individualized care, emphasizing prevention and holistic health, supporting the natural processes of labor and birth and motherhood as they unfold uniquely for each woman in our care.
Heidi Horner is a state-licensed Certified Professional Midwife with a small homebirth practice serving the Fredericksburg area, including King George, Stafford, Spotsylvania, Culpeper, Orange, Louisa, Caroline, Faquier, and Rappahannock counties. She has been attending births since late 2006 when she became a doula. She has four children, too many pets (not enough chickens), and plays in an old-time country band, the Wayworn Travelers. For more information, see www.motherwithomebirth.com, or Motherwit Midwifery on Facebook and Instagram. She can also be reached at firstname.lastname@example.org.
For more information on the Midwives’ Model of care, see Citizens for Midwifery, cfmidwifery.org. To learn more about CPMs, please visit the North American Registry of Midwives www.narm.org or Midwives’ Alliance of North America www.mana.org.