Midwives and doulas are making strides in very different populations. Parents-to-be who intentionally seek a birth experience outside of a hospital might choose the services of a midwife and/or doula. In other — and very different — circumstances, birthing persons who do not have access to a hospital or physician could benefit greatly from alternative forms of care. Midwives and doulas can provide personalized care for those who seek it and also serve those with fewer available options.
These two care provider roles serve distinct but related functions and often work together. A midwife provides medical care during pregnancy, birth, and the immediate postpartum period. A doula provides the birthing person and family with emotional and physical support and education but does not perform clinical tasks. Many birthing people choose to have both a midwife and a doula.
Certified nurse-midwives (CNMs) are typically registered nurses who complete a master’s degree-level midwifery program accredited by the American College of Nurse-Midwives. They then take a national certification examination. Certified professional nurse-midwives (CPMs) are not hospital-certified nurses but also have extensive medical training. Licensed midwives (LMs) may not have a nursing degree.
Making the choice
Back in 2015, The New York Times reported, “Doulas are a growing force in the ever-changing culture of maternity, at once a manifestation of the growing demand for personal service (the doorman, the yoga teacher, Amazon Prime) and a backlash against the perceived overmedicalization of birth, with its high rates of cesarean sections.”
Patient preference and healthcare advances are driving an increasing number of women to deliver outside of a hospital. Women with low-risk pregnancies and the ability to choose may seek a holistic birth approach that prioritizes their wants and needs during the birth experience. They may also prefer to deliver in free-standing birth centers, which are hospital alternatives that use fewer medical interventions and have a wellness focus.
Birth centers and good outcomes
Free-standing birth centers, where midwives typically provide care, have doubled their numbers of births over the past 10 years to almost 20,000 per year at over 400 such centers in the U.S. in 2022. Even though this number represents only .5% of annual U.S. births, the number continues to rise.
Researchers have found that birth centers provide better outcome rates, including fewer preterm births, fewer low birthweight babies, fewer cesarean births, and higher rates of breastfeeding than hospital-based perinatal care. Individuals who choose this type of birth setting may already have lower risk factors, but quality of care also contributes to their success.
Midwife or doula?
Speaking from personal and professional experience, doula Hanna Goodwin explained the attraction of midwives, doulas, and birth centers. “Most medical teams have an infant-centric model of care that can often neglect the full well-being of the birthing person. And while the birth is a big moment for the baby, it is a life-changing moment for the birthing person as well. I’ve been present at births where the process felt overly medicalized.”
Yet not everyone considering care from a midwife or doula knows how to find these types of providers or whether their services are covered by their health insurance. Even if they are covered, midwifery services may count as out-of-network and are reimbursed at a lower rate, making this type of care less accessible for some patients.
Two models of birthing care
Godwin described two main models of birthing care: the midwifery model and the medical model. In the midwifery model, providers view pregnancy and childbirth as normal physiological events for which they only use interventions when risks arise. In the medical model, providers view pregnancy and childbirth as medical events where the aim is to prevent risks before they have the chance to appear. This may lead to the use of interventions that some feel could be unnecessary.
Godwin observed that there is a broad spectrum of variation between the two models. Midwives in the U.S. tend to practice somewhere on the midwifery end of the spectrum while OBGYNs tend to practice within the medical model, with some exceptions.
How to make the decision to use a midwife or doula
For women wanting more control over decisions regarding their care during pregnancy and birth, the midwifery model may better align with their goals. For example, individuals who have the goal of a nonmedicated birth may prefer the midwifery model’s emphasis on communication and collaboration between care providers and the birthing person.
Godwin advised those who are deciding between the two models to weigh the risks and benefits of interventions. Some key questions to ask include:
- What are the provider’s C-section rates? Resources such as ICAN provide information on individual providers. High C-section rates could be an indication of higher rates of medical intervention.
- What are the provider’s VBAC (vaginal birth after previous C-section) rates? VBAC rates higher than 60% are a good indication that providers listen carefully to the client’s preferences and share the risks and benefits of vaginal births rather than defaulting to a C-section.
- What are the provider’s episiotomy rates? Higher rates could indicate unnecessary use of this procedure, which could lead to slower healing and negative long-term effects for the patient.
When weighing whether to seek the services of a midwife or doula, the following additional factors could influence the decision:
- Whether the provider encourages an open discussion about the birthing person’s birth plan and its benefits, risks, and alternatives — including both the ideal scenario and what would happen if an induction or C-section becomes necessary.
- Whether the birthing person can choose not to have an IV insertion if there is no risk that indicates a need for IV fluids.
- Whether the provider’s facility encourages and/or allows free movement during labor, which may make labor easier and faster, instead of being restricted to a bed.
- Whether the birthing person can eat and drink during labor, which has shown to help reduce stress and pain.
- Whether clinicians have had training on movement and positioning when dealing with asynclitism in labor (oblique malpresentation of the fetal head causing failure of progress), which has been shown to dramatically reduce cesarean birth rates.
- The provider’s policies on the use of Pitocin, a medication for inducing labor.
- The provider’s policies on the use of vaginal swabs after C-section, which when placed in the baby’s mouth, provide exposure to beneficial bacteria typically found in the birth canal.
- The provider’s policies for prescribing opioids such as oxycodone as pain relievers after C-sections, which can lead to addiction and accidental death.
How midwives and doulas can help those who lack access to care
Because midwives and doulas can work outside of traditional medical models, they can provide care for birthing persons living in areas where maternity care is scarce or lacking. Also, with a goal of using fewer medical interventions, these providers can keep costs down while still providing quality care and good outcomes.
With their emphasis on holistic wellness and emotional and physical support, midwives and doulas may also better understand the communities in which they work. Understanding cultural differences, providing care in remote or underserved areas, and skillfully communicating with families can help bridge care gaps in what the March of Dimes called maternity care deserts in the U.S. in a 2022 report.
Hospitals and health systems face challenges reaching people in underserved communities who fall through the cracks of the U.S. healthcare system because they do not have access. The portability, mobility, flexibility, and personalization of the midwifery model not only works to serve birthing persons who choose to go outside the medical model — it could also better serve those who are outside of the medical model through no choice of their own.
Promoting Vaginal Birth: A Guide To Understand and Lower the Cesarean Birth Rate
Currently in the U.S., we are faced with a high rate of cesarean births, which brings associated short- and long-term risks to both birthing people and babies when these procedures are not medically necessary. Hospitals, providers, and nurses need insights into the factors driving these high rates — and access to effective strategies to promote vaginal birth and maintain cesarean birth rates at targeted levels.Download the research brief →