This emphasis on the "disease model" is what separates the modern-day midwife who practices natural, holistic birthing methods from the more popular medical model of medicated deliveries that involve often unnecessary interventions. Midwives approach care of the pregnant woman differently from doctors by emphasizing the woman's emotional and physical well-being, as well as that of her family.
According to the ACNM, CNMs provide primary care to women of childbearing age, including prenatal care, labor and delivery care, care after birth, gynecological exams, newborn care, assistance with family planning decisions, preconception care, menopausal management, and counseling in health maintenance and disease prevention.
Margaret Gore, who used a midwife for the birth of her two children, says, "Midwives devote more time with a patient during office visits and the labor process. My midwives make home visits after the birth (one can better assess patients' needs when you meet the family and see the living environment and it is easier on the patient)."
Midwives and OB-GYNs
In an effort to provide the best possible care, some OB-GYNs and midwives form collaborative practices wherein the practitioners complement each other. ACNM guidelines for midwife practice encourage "obtaining consultation, planning and implementing collaborative management, and referral or transferring the care of client as appropriate," and many states mandate such collaboration.
"We now have a whole generation of doctors who have worked with nurse midwives," says Ravin.
Dr Kevin Lederer, an OB-GYN , says "We all know that good care can be provided by either CNMs or obstetricians. In 80 to 90 percent of cases, either a midwife or an MD would be fine. The MD's job is to search for the?other 10 to 20 percent." Lederer continues, "CNMs generally handle a lower number of deliveries and provide more personalized care. In an office setting where both (a doctor and a midwife) are available, this can provide an ideal combination to optimize patient care and satisfaction."
Ann Jacobs*, a 54-year-old woman who used a midwife, says, "I definitely would recommend the use of a midwife... You, the mother, are her patient and only concern."
How the U.S. compares
Today, only 7 percent of births in the United States are attended by midwives. This statistic is striking, considering that midwives attend approximately 70 percent of births in Western Europe. Midwives have long played a pivotal role in the European health care system. As modern medicine developed in Europe, the practice of midwifery evolved as a parallel specialization to obstetric care provided by doctors.
In countries such as the Netherlands, midwives practice independently as part of the greater health care system. In fact, the Dutch system of care is deemed by the World Health Organization as the ideal system of its kind. Whereas American midwives are viewed as alternative providers of care for pregnant women, in the Netherlands they are viewed as the primary health care providers for pregnant women.
While American use of midwives still lags far behind that of the Netherlands and other Western European countries, the number of midwife-attended births in the U.S. has increased in the past 25 years. In 1975, the National Center for Vital Health Statistics data show that 19,000 births in the U.S. were attended by CNMs while, in 1997 (the most recent year for which data are available), the number was close to 260,000. Still, according to the National Center for Vital Health Statistics, more than 9 out of 10 births in 1997 were attended by a physician in a hospital.
Katie Cooney, a 36-year-old mother who delivered her first two children while living in the Netherlands, says, "In the Netherlands, midwives take care of the pregnancy for prenatal care and for labor and delivery. Obstetricians are considered specialists for high-risk pregnancies. The Dutch definitely view pregnancy as much more of a natural process than in the United States."
Educating the public
So what is being done to improve the perceptions of CNMs in the United States and to bring them into mainstream health care? National organizations, such as the ACNM, and grassroots organizations, such as Citizens for Midwifery, are actively promoting the profession by educating the American public about the benefits of midwifery care. CNMs can legally practice in all 50 states and most enjoy hospital admitting privileges. Midwives have gained recognition from state and national policy initiatives that encourage third-party reimbursement from insurance companies. These victories have been central to improving the perceptions and prevalence of midwifery in the United States.
The most positive aspect of the increasing popularity of midwifery practice, however, is that women now have more options when it comes to managing their pregnancies. As Judith Pence Rooks says in the Journal of Nurse Midwifery (July/August 1999), "the midwifery model establishes the pregnant woman as an active partner in her own care and recognizes her as the primary actor and decision-maker."