"Are you having an ultrasound?" the midwife asked, at my first appointment. I thought there had been a miscommunication: Nobody had told me whether I would have one. "Well, it's up to you," she said. She could explain the pros and cons, but the decision was mine. Welcome to the midwifery model of care. Illustration by Tara Jacoby.
Midwives are an alternative to obstetricians for women with uncomplicated pregnancies. They have training in pregnancy and birth -- often a graduate nursing degree, though more recently they may have obtained a Bachelor of Midwifery -- but they aren't doctors. You can go to a midwife for care during your pregnancy, and they can attend your birth as long as you don't have any serious complications or risk factors. Birth with a midwife is usually more of a low-tech experience than what you'd typically get with a doctor in a hospital.
Midwife care isn't (just) an alternative woo-woo birth option for the granola-crunching crowd. They're committed to giving care that is backed by scientific knowledge, and putting you in the drivers seat. They work with you to carefully consider all options instead of just "we've always done it this way." There are other perks to midwife care, but this was the clincher for me.
I went to a midwife group practice for all three of my pregnancies, and had a midwife at each birth: Once in the hospital, twice at a birth centre. With a midwife, I know I have a greater chance of having a natural birth without surgery or medication -- and that if I do need some kind of intervention, that it was truly needed. I also have the option to deliver at a birth centre instead of a hospital, which has a ton of advantages we'll discuss later.
Midwife care isn't appropriate for everyone, and this is not an advertisement: You might prefer a doctor-and-hospital birth, or your pregnancy might require one. Midwives can't perform surgery and will turn down pregnancies that are "high risk", although that definition may vary. (For example, my midwives would turn you away if you are having twins, or for gestational diabetes that is severe enough to require insulin.) And that's totally fine. But here's why I made the decision I did.
Midwives Put You in the Driver's Seat
The Australian College of Midwives lays out their philosophy here. Some of the notable points are that midwivery:
- is holistic and recognises each woman’s social, emotional, physical, spiritual and cultural needs, expectations and context as defined by the woman herself.
- recognises every woman’s right to self-determination in attaining choice, control and continuity of care from one or more known caregivers.
- recognises every woman’s responsibility to make informed decisions for herself, her baby and her family with assistance, when requested, from health professionals.
- is informed by scientific evidence, by collective and individual experience, and by intuition.
- aims to follow each woman through pregnancy, labour and birth and the postnatal period, across the transition between institutions and the community, so she remains connected to her social support systems; the focus remaining on the woman, not on the institutions or the professionals involved.
The second two explain why the midwives asked me, rather than told me, whether I would have an ultrasound, or a first-trimester genetic screen, or a group B strep test. They asked if I was cool with a shot of oxytocin immediately after birth, and whether I wanted my baby to have the standard eye ointment and Vitamin K shot.
I made the choice for each based on their risks and benefits, and in the case of tests on how actionable they were: What would I do differently if the test turned out positive? In some cases, I departed from the guidelines for reasons particular to me and my medical history.
Most of the other items in the midwifery model of care can be summed up as: Midwives are supposed to respect you as a human being. They ask about your concerns and give you time to talk, and they ask permission before sticking their hand up your hoo-ha (the medical version of a "yes means yes" rule).
There are certainly doctors who work this way, and I applaud them. If I ever have a high-risk pregnancy, you can bet I'll start a search party to find one. I chose a midwife because I know their entire profession is dedicated to this philosophy, and because they have a different perspective than doctors to begin with. Obstetricians' education focuses on what can go wrong in labour, and how to fix it. Midwives are the opposite: They keep an eye out for potential problems, but they know all the variations of normal, and are experts in managing pregnancy and birth with a minimum of intervention.
You Don't Have to Give Birth in a Hospital
Midwives practice in homes, hospitals and an in-between kind of place called a birth centre. Birth centres are equipped to deal with normal births and their minor complications.
My room at the birth centre looked like a comfy bedroom, with a large bed (there was a mattress protector under the sheet, of course), a cradle and a rocking chair and a bathroom with a jacuzzi. One wall was covered in cabinets that opened out to reveal a baby scale and exam table, and all the supplies needed for a birth. When my baby had mucus in her airway and the midwife was concerned about her breathing, an oxygen machine appeared out of nowhere.
I'll admit it: When I was in labour, and the contractions got really painful -- like so bad that even video games didn't help -- I kind of wished I had the option of an epidural for pain relief. An epidural is a hospital thing, and you need an anaesthesiologist to administer it. If you're in the hospital and choose to have an epidural, typically you'll also need fetal heart rate and contraction monitoring to make sure the baby is OK, and to let you know -- because you can't necessarily feel -- when you're having a contraction. Epidurals also have their risks, including a greater likelihood of a C-section, and possibly interfering with the baby's ability to breastfeed in that critical first hour after birth. I had chosen a birth centre, in part, because I didn't want any of that.
Everything in medicine comes with a benefit and a risk, including some things that are common in hospital births. Not being in a hospital is like keeping cookies out of the house or putting your credit card in the freezer: You reduce temptation, but also make it harder to get to the credit card -- or the epidural -- when you really need it.
I had that moment of regret in each of my births, and yet I always felt afterwards that I did the right thing by checking in to the birth centre instead of planning a hospital birth. And I did end up with an epidural with my first baby, so I've had both experiences.
If you're anywhere outside a hospital when you go into labour, you have to plan for the possibility that you might end up in the hospital anyway. That's what happened with my first baby: There was meconium (foetus poop) in the amniotic fluid, which triggered the trip to the hospital: It's a red flag for possible other problems, and if the baby inhales the meconium, it can affect his breathing. Since it wasn't an emergency, no ambulance was called. I, my partner, and the midwife drove the 10 minutes to the hospital in our cars. (That's where I got the epidural. It felt great.)
There are other types of emergencies that could be fatal for mum or baby if they occur outside a hospital, or even sometimes within one. If the umbilical cord emerges before the baby's head, the head can press on the cord, cutting off the baby's blood supply. If the placenta separates from the uterus before the baby is born, that's another disastrous situation.
Both of these are one-in-10,000 risks. On the other hand, hospital interventions can lead to complications that are usually less severe, but far more common.
A Cochrane review, of hospital birth versus home birth for low-risk pregnancies, found that it couldn't recommend either as a clear winner. Another Cochrane review found no difference between midwife care and standard care in serious outcomes like newborn deaths or hospitalisations. Women under midwife care had fewer interventions (like episiotomy or amniotomy) and were overall more satisfied with their care.
So, when it comes to choosing between a hospital and a birth centre, or a doctor and a midwife, you can't choose a situation with no risk; you can only choose which type of risk you're more comfortable with.
Midwives (and Birth Centres) Do Things Differently
At my most recent birth, I checked into the birth centre in the early evening, and the nurse asked if I'd had dinner. Since they encourage walking around while in labour, my husband and I placed a call to the nearby Spaghetti Warehouse (the centre keeps takeaway menus on hand for exactly this reason) and walked the four blocks to go pick up our lasagna. We chowed down, knowing that we both had a long night ahead of us.
At most hospitals, women in labour are told not to eat or drink anything. The standard fare is ice chips (to suck on). But midwives have been saying for years what a recent study confirmed: The rule against eating is outdated and unnecessary.
(Of course, I puked it all up when the contractions got really gut-wrenching, but it was great while it lasted.)
Midwives also tend to endorse walking and changing positions in labour, which can help move labour along and can either relieve pain or distract you from it (heck, you can whip/nae nae in labour if you're coordinated enough).
Doctors are starting to catch on to some practices that have been standard with midwives for a while, like delayed cord clamping once the baby is born. It's hard to generalise across all midwives versus all doctors, so these aren't universal statements. If you're trying to decide between a doctor and a midwife, call them and ask what their policies are.
How to Find a Midwife
A small fraction of births take place in birthing centres in Australia, around two per cent. Depending on where you live, a midwife may be hard to find and a birth centre harder still.
There are very few birth centres in Australia. You can search for a birth centre near you here.
Besides birth centres, some midwives practice at hospitals, and others do home births. You can search for a registered midwife here.
In the spirit of being an active participant in your care, your first step in choosing a midwife (or doctor) should be to read up on pregnancy, labour and birth, and decide what factors are important to you. Then, ask providers about those things specifically. Don't be afraid to ask what percentage of their patients get C-sections, for example.
Since midwives don't handle serious complications, you'll want to ask a midwife what conditions they're able to deal with. For example, if you're having twins, or if you have gestational diabetes, or if you've had a C-section before but want to have a vaginal birth this time, some midwives will refer you to a doctor, while others might be able to include you in their practice. Here is a list of 10 good questions to ask a midwife or obstetrician. If you want to be thorough, this list of 47 questions gets into more detail. You probably won't ask all of them, but it covers a lot of things you might not have otherwise thought of.
Cost is worth considering, too: Hospital births cost far more than births at home or, usually, in a birth centre. Insurance may cover some types of midwives but not others, or they may cover a midwife birth in a hospital but not in a birth centre. You'll want to check your coverage for the midwife and the facility they practice in.
Midwife care isn't for everyone, but if you're low risk and you like making your own decisions, it's an option worth considering. I'm really glad I did.