Hey there! Are you pregnant and looking for more information about midwives and doulas? Awesome, I’m so glad you’re here because today's episode of Apothecary Wisdom is focused on giving a overview of the crucial distinctions and scope of practice of the different types of midwives, obstetricians, and doulas.
Working in the birth community has revealed that the general public is unclear about the important distinctions and differences of these essential birth workers-their training, and the services they provide. Knowing the scope of practice of the birth professional you are about to hire for your birth is critical in order for you to be informed and have realistic expectations about your care and upcoming birth.
My name is Maria Chowdhury. As an Arkansas State Licensed Midwife, I've served the homebirth community since 2004. I first started attending births as a student midwife- an apprentice in 2001 when I attended Arkansas Midwives School and Services, a MEAC accredited midwifery school. It was a 2-year academic program and a 3-year apprenticeship program. I had the privilege of academic learning structure in the classroom and hands-on practice directly with clients immediately upon enrolling in the program.
Let's Compare the Definitions of Midwife- Obstetrician-Doula
The word midwife means "with woman." Her role is to be with the woman as a guardian and a guide to help women pregnant make informed decisions about their bodies, babies, and births. Midwives provide professional services like prenatal care, childbirth education, labor and birth support, postpartum and newborn care, and breastfeeding support. Many midwives also provide well-woman and gynecological care.
A midwife is an expert in "normal." She supports healthy, low-risk women to have natural births. She recognizes when things go outside the normal parameters and seeks medical care when a pregnancy or birth becomes high risk.
The word Obstetrician OB- means, "Standing by waiting." An OB is a medical doctor who specializes in pregnancy, childbirth, and women's reproductive systems. OB's work with nurses, nurse midwives, physician assistants, and other health professionals. OB's work in hospitals and are experts in all types of birth, especially high risk, and medicalized births. They are trained as surgeons.
I want to highlight the words "standing by and waiting." Their role is to literally stand by and wait. That is why the nurse will help you push your baby down until you can see the head, and then the OB comes rushing into the room at the last minute to finish the job. They are fulfilling the definition of their name. They stand by until the absolute moment you need them.
A doula is a professional support person that can help you think through your birth preferences and desires. They can help you write your birth plan and support you in labor and after birth. Doulas are great at helping you find your own voice so you can speak up for yourself in labor when you have to.
A doula is not a medical professional like a midwife or OB; however, she is a knowledgeable and compassionate person who helps prepare you and your partner for the birth and postpartum. They are often well connected in the birth community and can serve as a resource for other parenting and birth-related situations.
I want to spotlight and highlight doulas here. They are front line workers. They thrive on the front lines! They are essential for women who are wanting natural births in a hospital setting. Maybe the client doesn't want a natural birth, but they want to feel supported and prepared for the smoothest possible birth in the hospital.
Doulas are also incredibly helpful in birth center births because, in a busy birth center practice, just like in the hospital, you might not know who your midwife will be on the day you give birth. And if you need to transport from the birth center to the hospital, your midwife might not stay with you depending on what else is happing at the birth center. So, by having a doula as your primary support person, you will have that consistency and trusting relationship matter where you give birth or who takes care of you in labor.
Doulas are helpful in home birth as well. But, in my small practice of 1-4 births a month, I had plenty of time to establish a personal relationship with my clients. Rarely did I have two people in labor or needed to leave anyone at the hospital alone because I had apprentices that wanted to fill those roles. Every homebirth midwife practice is different, and maybe doulas more essential in different situations.
Different Types of Midwives
One of the challenges midwives face is that there are several types of midwives with different training and scope of practice. Yet all of us want to keep the title "midwife."
For example, If I introduced myself as a Labor and Delivery Nurse (which I am not!) You would know what I do for a living. If I said a Neonatologist, you would know what I do. You might have a few questions about my practice, but the title is fairly clear.
However, this is not the case for midwives. Let me explain in more detail:
Different Types of Midwives and Their Training
This is not a hierarchy. Each midwife has a role to play in the birth community. We need all of them to serve women and families. Just because the CNM -generally speaking, has the most education, and from an external perspective, she works in the hospital, so may appear to some as more professional. This is a value judgment. From my perspective, we need the full spectrum of midwives to care for the full spectrum of women and families. One type of midwife is not more important than the other.
Certified Nurse Midwife CNM's-Attend births in hospitals, birth centers, and at home. They have a master's degree in midwifery and work under the supervision of an OB. They attend births of healthy, low-risk women. They are at the mercy of the hospital policy.
Certified Professional Midwife CPM's- Attend homebirths and birth center births. There are many paths to become CPM. Lots attend midwifery programs and utilize the apprenticeship model. Others are solely apprentice trained. All work autonomously. Meaning, they do not need to have OB supervision to make decisions and care for their clients. They attend the birth of healthy, low-risk women.
Licensed Midwives LM- Typically, they have the same scope of practice as CPM. At least in Arkansas, an LM has the same rules and regulations as CPM. In Arkansas, though, we have to say and write LLM, which means Licensed Lay Midwife. By its very definition, that does not make any sense. You can not be a layperson and be licensed and certified at the same time.
One little side note about Arkansas- In Arkansas, as of writing this, we have no Black midwives or Latina or Native American, none in the hospitals, birth centers, or attending homebirths. -there are Latin and black apprentices that seem committed to becoming midwives.
Here's the important crux of the matter. Not every state is legal. There are many states where midwifery is illegal or a legal. An a legal state is known as a "grey state." In these states, it is not illegal for you to have a home birth. It is unlawful for you to pay for professional midwifery services. It is unlawful to advertise yourself as a midwife. You, the client, do need to pay your birth keeper. You will have to donate to her cause.
If the birth goes great, then great. End of story. If the birth goes south and there is a demise or a complication that requires transport, that midwife is at risk for getting her door kicked in and being arrested for the felony of practicing medicine without a license.
I want to acknowledge that this is tricky ground for us to navigate. And I want to be respectful of everyone's feelings and skills. At the same time, I need to express myself and expose this situation. Unlicensed midwives have so much value and so many birth keeper skills, and yet they are shrouded in misunderstanding and surrounded by danger.
Unlicensed or Lay Midwives- Attend births at home. Most are primarily apprentice trained and work autonomously. Many have attended midwifery courses. This whole area is grey, and there is not a one size fits all answer.
Many unlicensed midwives simply don't have a license because they live and work in a state where midwifery is not legal. Many of these midwives are CPMs. They have the training, but their state does not legally recognize them.
Others don't have a license because they work for god and not the state and not the law. They do not want to work in a system of limiting rules and protocols, which could also be seen as not working within a framework of safety and peer review. Without this container of safety, it can be seen or interpreted as a lack of integrity or professionalism.
Let's take this a bit further since unlicensed midwives don't have the same rules that the LM's, CPM's and CNM's do. And, they also have the most questionable and variable education. They are so much harder to put into a category. It is hard to say what to expect from their practice.
I bring this up because, LM's, CPM's and CNM's have a clear protocol that says they only work with healthy, low-risk women. That means they transfer or transport for issues like twins, breaches, VBAC, high blood pressure, post dates, diabetes, previous birth history of hemorrhage, shoulder dystocia, etc.
Granted, all of these situations have degrees and variations of normal. Some of these are not such a big deal. The point is, there is a system in place for when a low-risk woman becomes high risk to get the level of care she needs. Generally speaking, an unlicensed midwife does not have this same network in place, so, unfortunately, they are forced to allow complications to brew until the last minute before seeking care because it is so hostile for them and their clients. Versus having a system that allows the midwife to make arrangements for smooth transport before becoming an emergency.
In my state of Arkansas, if there are CNM's in the hospital, there are both LM's and CPM's freely practicing and offering professional home birth services; why would anyone hire an unlicensed midwife?
Well, twins, breeches, and VBAC are considered high risk. I know many a couple that chose to have a home birth in those circumstances. Twins and Breeches do need a skilled care provider with experience attending these births. If non of the LM's, CPM's or CNM's are not allowed to attend them, they are not gaining the experience they need. Unlicensed midwives have the most experience in this situation even though they are high-risk births.
VBAC, in my opinion, is not the same risk level as twins or breeches. Yet there are far more women with VBACs than both twins and breeches combined. And Arkansas has a 27.7% C-section rate. When the WHO states that we should have a 10% c section rate worldwide, that means lots of women had a medically induced c section for issues like failure to progress.
Many of these women want to see what their bodies will do. They want a safe, uninterrupted biological birth, and they cannot have it at home with an LM, CPM, or CNM. They cannot have it in the birth center and many hospitals. These women will, of course, choose the unlicensed midwife.
The problem is not with unlicensed midwives. The problem lies in the system that denies women's legal rights to practice midwifery in all 50 states. The system that railroads women into a surgery that they didn't need and then denies them the right to have a safe home birth. The system needs fixing. It's not that midwives need punishment.
I want to say thank you to all the midwives who show up for women, again and again, despite the dangers. In spite of the risk of being arrested for a felony because she helped a woman give birth with dignity on her terms in the privacy of her own home! Thank you for your courage, your bravery, and commitment to birth.
In order to change the culture of birth and fix the broken system, we must legalize midwifery in all 50 states. We need to lift the VBAC ban for homebirth. And the very least, we need to stop doing so many unnecessary obstetrical interventions that lead to an inflated rate of cesareans! We need to train more midwives. We need the full spectrum of midwives to serve the full spectrum of women.
Here you are watching this video because you are pregnant and need to make decisions about where you will give birth and who will help you. To do that, you need to know the right questions to ask yourself and potential midwife. I want you to know what to do before, during, and after your consultation. So watch or read Hiring the right midwife for your safe and empowering homebirth starts with an effective consultation.
Knowing the right questions to ask your care provider before you hire them is critical. Who you choose to help you give birth matters. Your birth plan matters. Download this list of 50 Questions to ask your midwife and a list of 25 Questions to ask your potential Doula and your Homebirth Birth Plan Template.
If you are contemplating whether homebirth or hospital birth is right for you to watch or read. Why Home is Way Better Than Hospital Birth for Low Risk Women Who Want a Natural Birth.
Yes, in some ways, your birth is just about you and your birth.
But the bigger picture here is that it is about us as a collective of women. It is about us as mothers, daughters, sisters, brothers, fathers, sons, doctors, nurses, doulas, and midwives! We are all needed. If we are going to improve the culture of birth, then we need to make brave birth decisions that are in alignment with our hearts, minds, and with what our babies want.
Please, take your time, deciding who is the right fit for you. How you give birth is very important and should not be taken lightly. Or it will get railroaded in a direction you don't want to go. Your pregnancy and birth are a big deal. Choosing the right or the wrong care provider can make all the difference.