There are a lot of questions about midwifery, perhaps because there are a lot of misconceptions about midwives. What exactly is a midwife? Who should see a midwife? What’s the difference between a midwife and an obstetrician? Or a doula?
Karen Jefferson DM, CM, FACNM, is a doctor of midwifery, now retired after decades of delivering babies. Jefferson currently sits on the board of directors of the American College of Nurse-Midwives.
In Jefferson’s words, “It’s easier to say ‘what does a midwife do,’ than ‘what is a midwife’?” Ultimately, she explains, “Midwives provide relationship-based health care in the context of the perinatal cycle. They are specialists in physiologic birth.”
Midwifery has gotten some press in the last few years (both good and bad) with the hit BBC period drama Call the Midwife and more recently Hungarian director Kornél Mundruczó’s harrowing Pieces of a Woman. It’s no wonder people are confused about the profession of midwifery: It’s shown as something either old-fashioned and antiquated or something completely divorced from science and professional care.
A midwife is not a witch doctor, does not have to be a hippie, doesn’t necessarily carry crystals, and doesn’t hate your OB-GYN. Midwives are practitioners who care for women at any point along their reproductive journeys. While midwives often attend births and care for expecting or postpartum moms, they can also see patients for well-woman care from puberty to menopause. They work in hospitals, birth centers, and people’s homes.
A midwife has extensive education and years of experience before she catches her first baby, and can do a lot of things other medical professionals can do, like administer IVs and write or manage prescriptions.
A (very) brief history of midwifery
“Unfortunately, the perception of midwifery in this country was determined in a way by its history,” Jefferson explains. “The development of nurse midwives came about in the early 1920s through the extinction of midwives, of Black midwives, indigenous midwives, immigrant midwives. Those midwives were considered dark, dirty, uneducated.”
Like many other medical professions, midwifery had little standardization before the eighteenth century. Mentorship and experience were the primary modes of education for the job. In the eighteenth century, formal training programs, curricula, licensing processes, and other standards for midwives came on the scene, varying by region or state. Up until the 1900s, nearly all births took place at home, overseen by midwives.
Anesthesia hit the scene in the mid-nineteenth century, which shifted births from homes to hospitals. As Jefferson points out, this transition also meant birth professionals consisted more of upper-class white men and less of lower-class women (and particularly women of color). Medicine itself went through a change at this time, becoming more of a business and less of a home-based mission. Pharmaceutical companies expanded and became a driving force in the field of medicine.
“There was a confluence of factors. Medicine was professionalizing. Nursing was professionalizing. It was a turf war in a way." Jefferson says racism played a part. “The idea was to get those dark, dirty, uneducated indigenous midwives out.”
By the 1950s, the majority of births occurred in hospitals, increasing to 97 percent in the 1960s. Midwifery saw a resurgence in the 1970s, alongside the women’s liberation movement, especially as awareness increased of what was really happening with hospital treatments like “twilight sleep”—a procedure in which expectant mothers were given what they were told was a cocktail of drugs that would help them “sleep” through labor and delivery. In truth, what happened was anything but sleep. Women would thrash, scream, and bang their heads.
The “twilight sleep” cocktail consisted of primarily scopolamine and morphine, although other drugs like cocaine, opium, and other herbs were added. As a memory inhibitor, scopolamine, a large part of the “cocktail,” allowed women to forget the trauma, and the morphine caused women to lose their conscious awareness and help limit the pain. But the combination made women uninhibited and even psychotic. (If you’re a fan of Netflix’s The Crown, you may have had a glimpse of this brief, but horrifying trend in maternity care in season two.)
By the 1980s, the American Medical Association introduced regulations to prohibit midwives from practicing without physician supervision.
OB-GYN vs. doula vs. midwife
For those who are confused about midwifery, it might not help that the specialty goes by many different acronyms (and therefore education and training) attached to it. U.S. laws about practicing midwifery vary by state, as does licensure.
The three most common midwifery acronyms are CNM (Certified Nurse Midwife), CM (Certified Midwife), and CPM (Certified Professional Midwife). CNMs are certified according to the requirements of the American Midwifery Certification Board (AMCB) and are able to practice legally in all 50 states. CMs take the same national certification examination as CNMs, but are only recognized and able to practice in a handful of states. CPMs are nationally certified through the North American Registry of Midwives (NARM), and if a license is available it is issued by the state(s) in which the midwife practices.
Then there are, of course, lay midwives, also called traditional midwives. Jefferson prefers to call these caregivers “birth attendants.” They have no formal education and for various reasons choose not to go through the hoops of legislation and licensure. That being said, they can rack up a lot of years of experience. These types of caregivers tend to exist in rural areas.
Since midwives specialize in physiologic birth, they can pretty much care for any pregnancy that doesn’t need surgical care. They provide prenatal and postnatal care. If at any point a woman needs surgical care, she can be transferred to an OB-GYN. Some midwives work in partnership with OB-GYNs and physicians for this very reason.
While OB-GYNs can do many of the same things midwives do (like pre- and postnatal care), in addition, they specialize in surgical needs. According to the American Board of Obstetricians and Gynecologists, “Obstetricians and gynecologists are physicians who, by virtue of satisfactory completion of an accredited program of graduate medical education, possess special knowledge, skills and professional capability in the medical and surgical care of women related to pregnancy and disorders of the female reproductive system.” Their history and culture is more hospital-based, while midwives’ is more home-based.
When it comes to a woman's choice between OB-GYN and midwife, ultimately, patients make a choice based on what they feel more comfortable with. Many moms need surgical care, as births and pregnancies don’t always go as planned. Both OB-GYNs and midwives can be cooperative providers to expecting moms to meet their needs as they arise.
A doula is a completely separate type of caregiver. Unlike midwives and OB-GYNs, doulas are trained companions and patient advocates who support women during pregnancy, childbirth, and the postpartum period. While plenty of organizations and individuals provide training and education for doula work, there isn’t a standard set by any one organization declaring how much or what type of training you need to call yourself a doula. In theory, a doula could complete a weekend workshop and attend a birth as a companion, while a midwife or OB-GYN needs years of schooling and experience. (And licensed midwives do often take offense to being mistaken for doulas.)
Who should see a midwife?
In no uncertain terms, Jefferson exclaims, “Everyone! Midwifery is for everyone!” She goes on to say there is currently a definitive resurgence in midwifery. “The numbers will take time. But we’re at a very special moment. Finally the policymakers and politicians are recognizing disparities in outcomes, particularly maternal/child health outcomes.”
There have now been decades of intentional research to prove the benefits of midwifery for maternal/child health outcomes. These outcomes include reduced cesareans, greater satisfaction, less frequent use of interventions, increased rates of breastfeeding, and decreased rates of preterm birth and even neonatal death.
One such study is the Strong Start for Mothers and Newborns Initiative, a federal four-year, multi-site project published in 2020 that evaluated enhanced prenatal care interventions for women enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) who were at risk for preterm birth. Moms in the care of midwives delivering at a birth center had babies who were 26 percent less likely to be born preterm. The mothers themselves had a 40 percent lower cesarean rate, were twice as likely to have a successful vaginal birth after Cesarean (VBAC), and had 21 percent lower childbirth costs.
Another perk of this initiative was that it proved exceptional in reducing racial inequities. There were no differences by race for these markers. In a society where Black women are three to four times more likely to die from childbirth-related risks (that’s a three to four hundred percent increase), that’s huge.
Is a midwife for you?
Midwives are professional, educated healthcare providers who can care for women at any point in the perinatal cycle. Is a midwife right for you? Only you can decide. The good news is that midwives practice in many locations—home, birth centers, and hospitals. So there are lots of options for what feels comfortable to the expectant mother.
From my personal experience having two pregnancies and births with midwifery care, I can’t imagine it any other way. In the future, I may need more hospital-based care. But I am grateful for the midwives who stood by my side during some of the most transformational moments of my life.