The Difference Between Midwives and Doulas: International Midwives Day
For many expectant parents in the US especially, the term “midwife” seems old fashioned and the term “doula” seems trendy. Neither is the case. And too often, the two professions are conflated into one and presumed to be lesser than the medical standard of American obstetrics. Also, not true.?
So here’s a bit of a breakdown around the roles of both, their similarities and important differences, and why our culture sees one as backwards and the other as a luxury.?
Let’s start with midwives.?
Midwives are clinical professionals and specialists in pregnancy, birth, and postpartum care. Many too are able to provide services around fertility, conception, breastfeeding, and well person care. There are three types of midwifery trainings and certification — Certified Professional Midwife (CPM), Certified Nurse Midwife (CNM), and Licensed Midwife (LM). There also exists a cadre of midwives who are trained through an apprenticeship and do not seek licensure, sometimes called “lay” midwives, though that can be misleading as to the level of training they undergo, and often work within smaller communities organized around common religion or ethnicity. There are national organizations which oversee credentials and certifications, but licensure is depended on exclusive state requirements that vary widely across the country. All midwives must pass the same difficult written exam in order to be considered for certification.?
Midwives work with all birthing persons.
Midwives can work in a variety of settings including attending home births, birth center births, and in some cases hospital births, too, depending on the state requirements and type of certification. Most often, only nurse midwives are able to practice in clinic or hospital settings, which is different than how midwives are able to practice in most other countries.?
All types of midwives are trained extensively in supporting physiological birth (what you might think of as “natural” or “normal” birth), preventative care, clinical testing and protocol in pregnancy and birth, infant health and monitoring, postpartum clinical care and educational support including feeding preferences, and emergency care. If pregnancy or birth is shifting away from physiological in a way that needs more intensive medial support (typically under 25% of pregnancies), midwives will transfer care to an obstetrician and/or specialist. American midwives, unfortunately, in most cases need to give full transfer of care to an obstetrician in these circumstances, where sharing care is the norm in most other similarly industrialized countries. That model of care is proven to be safer than the American model and hopefully we will shift more to that model in the future, with continued advocacy for it.?
In almost all states, midwives are required to have “doctor supervision” in order to practice and maintain licensure and restricts most midwifery practice to those with a nursing degree. Rather than this being a system that ensures more safety, as it may appear to be, it is effectively used to suppress the expansion of midwifery care since it leaves it up to the doctor’s and regional hospital’s discretion as to whether or not they will support any or all midwives trying to practice in their area. It has been shown that U.S. states with the most restrictions to midwifery care have the worst maternal and fetal outcomes in the nation. It is one of the contributors to the overall poor obstetrical outcomes here. The industrialized countries around the world with the highest percentage of midwife attended birth (in all settings) have the best birth and infant outcomes across all indicators. Though the U.S. pushes the idea that the only acceptable form of midwifery is nurse midwifery, there is no evidence to suggest that is true — globally or here.?
The variation in types of midwives (nurse or direct entry) is also atypical. Most midwives in other nations are trained in a variety of settings, including in the hospital, and are able to practice where they choose under one federally sanctioned certification and without restrictive and largely bureaucratic doctor oversight.? That isn’t to say there is a perfect system anywhere, but countries like New Zealand where midwives see the majority of pregnant persons, can practice in any setting, transfer to any setting based on need or parent preference, and are paid well for it, the outcomes are hugely improved, even for more traditionally high risk groups. In the UK, the National Health Services (NHS) has in the past several years actually paid families to transfer care to home birthing with midwives in order to improve outcomes, lower cesarean rates, and keep public healthcare costs in check.?
The Pope has declared 2020 the Year of the Midwife and Nurse. The WHO and other UN bodies have published reporting stating that midwives are able to provide care to folks in the childbearing year at least as good as, if not better, than obstetricians in most situations in most countries around the world. There are many countries actively trying to increase the number of midwives in training and practice while seeking to raise the standard of maternal and fetal care. ?
The U.S. stands apart it it’s continued reluctance to accept the profession of midwife more broadly, though it shares much of the history of other countries for why midwifery was suppressed for a number of centuries and midwives actively targeted for harm. It is a long and complex story combining some of America’s longest standing horrors of racism, class divides, and misogyny. There are some chilling, but well explained explanations of how this triple threat has caused midwives to attend less than 10% of American births that are worth reading by any pregnant person :
We have one of the highest rates of interventions like inductions and cesarean surgeries in the world, as well as the fastest rising rate of maternal deaths amongst similar countries. We have some of the highest rates of preterm births, poor infant health outcomes including mortality, lower than usual rates of breastfeeding, and higher than usual rates of SIDs.?
Over 700 pregnant people die in or just after childbirth a year in this country, the majority of them Black women under the care of hospital-based obstetricians. Roughly 85% of obstetricians are sued for malpractice in this country before they turn 65. Most of the cases are settled out of court with gag orders (this is why you don’t know this statistic unless you look for it) and only 5% of cases are won in favor of the injured family, including in instances of maternal death. Countries with the best outcomes in these areas all have the vast majority of births attended by midwives at home, birth centers, and in hospitals. The United States has to make significant changes to it’s maternal health system if we are to do better by pregnant persons and their families.
How are midwives and doulas different?
The most significant difference between a doula and a midwife is that a midwife is a primary clinical care provider and a doula is not. This means that the training for either is significantly different.?
As noted, midwives, regardless of where they get their training, go through between 3-10 years of specialized training in the full spectrum of reproductive care, including hands-on clinical training, apprenticeship, and some form of academic training. They must keep up with their trainings every year in order to maintain licensure and certification.?
Doulas are trained in either a weekend intensive or over several weeks of trainings. There are two primary types of doula — birth or postpartum — though doulas exist for full spectrum care and even for assisting folks through the transitions of death or gender transitions. Some doulas practice multiple modes of care.?
There is no one type of person drawn to be a doula and doulas set up their practices in a wide variety of ways. You may find you’re drawn to your chosen doula because of their experience or because you just have a gut feeling about them that’s more nuanced and emotional. Ultimately, it is your choice which doula you bring onto your team, and so it is up to you how make the determination of “right fit” and not some other ideal.
Doulas do not have access or the training to utilize the medications and equipment that can make complicated birthing situations safe. Midwives, however, are able to provide all preventative and emergency care and medical procedures in any setting, with the exception of the less than 10% of births needing interventions such as induction, forceps, vacuum, pain medications, medication for preeclampsia or hypertension, and cesarean surgery. In most cases, those likely to need that care will have been transferred to obstetrical care prior to labor. Most homebirth transfers are for non-emergency care like in very long labors where pain medication and extra oversight can be particularly beneficial to parent and baby.?
In their trainings, doulas are taught about the physiological processes of birth and postpartum — for parent and baby — and how they can assist families through non-clinical means like education, emotional support, physical comfort, and advocating for themselves through informed consent. It’s way less crunchy and crystals than you might imagine. Often doulas are given extensive education in the hormonal process of birth, newborn care, lactation and feeding support, how to spot complications (but not diagnose or treat) to be able to quickly refer parents to the necessary care provider, and are trained in emotional counseling including (hopefully) practicing trauma-informed care. Some trainings are more in-depth than others, so it is appropriate to ask potential doulas about their trainings in an interview.?
Unlike midwives who are able to provide complete care from conception through the childbearing year, doulas always work in tandem with a primary care provider. Though in some birth centers and midwifery practices there are in house doulas or there are volunteer doula programs at some birthing locations, most families will hire their doula independently. Doulas are able to practice wherever families give birth, though some might not be open to attending births with certain providers or birthing places for a number of reasons. You should be transparent about where you intend to give birth and with which provider.?
Doulas can be a great resource in understanding more about the provider you choose, since they tend to have worked across a wide range of providers and care styles and locations. They don’t have any financial incentive in where you choose to give birth and so are also a good way to gauge what you’re in for in a particular location. Postpartum doulas are typically very familiar with the pediatricians in your area, as well as the range of complementary care providers in the medical field and otherwise.?
If you are considering working with a midwife at home, hospital, or birthing center, a birth doula can be a great compliment to your birthing team.?
In hospital setting, it is not commonly guaranteed that you will see a midwife for care over a doctor, even if that is your preference, due to the shift-style scheduling common in most U.S. hospitals. You are also less likely to have met a hospital-based midwife routinely for your prenatal care than with a case-load and independent midwife attending births outside of the hospital. A birth doula can then be an excellent bridge, offering a continuity of care, which is the gold standard for health outcomes for birth parent and baby.?
For those choosing birth outside of the hospital with a midwife practice, a birth doula can help you individualize your education and care. They are often included in “team” meetings later on in your pregnancy appointments to offer cohesion in care and make sure there is a good stream of communication with everyone who will be present for the birth. This is almost never offered to families in OB or midwife practices within the hospital system, unfortunately, though you may request one from any provider. Homebirth and birth center midwives often like working with birth doulas because doulas are able to support birthing people early in labor when clinical care is often not needed so midwives can rest longer so they are alert when they need to be later on in birth and just after. Midwives and doulas also share a common shorthand and so can communicate updates and details readily to one another so the parents can focus on labor as it’s occurring.?
At home and birth center births, you will have two qualified midwives assisting you and baby once you are in active labor. In the hospital, you will primarily be seen by a nurse or series of nurses that will rotate with shift changes and you will occasionally see the doctors or midwives on shift. Your doula, however, will likely remain with you for most of labor and birth and for a few hours after. In some cases, a birth doula may leave to rest and shower or may call in their backup, but that is reserved often for very long births and inductions.?
The greatest benefit — in terms of safety as well as peace of mind — to hiring an independent doula or midwife is building a relationship with that birth attendant in advance and knowing they will be at your side for all of labor and into checkups during the fourth trimester.?
A postpartum doula may or may not be a birth doula and vice versa. Postpartum doulas are trained in the ins and outs of physiological birth recovery and early newborn care. They have varying levels of expertise with lactation support, but all postpartum doulas get a good overview of breastfeeding support and education. They are similarly capable of spotting possible complications, but can not diagnose or treat. Still, they can be a great initial contact if you have questions or concerns about your recovery and/or what’s going on with baby.?
Some postpartum doulas offer overnight support and some daytime or both. Daytime support is largely for education and guidance around all things postpartum recovery whereas overnight support is more for parents to get some extra sleep (on average, about 30-45 mins around each feed).?
I could go on about the differences between midwives and doulas as well as the differences between types of doulas and types of midwives, but I’ll save that. If you have more specific questions, please feel free to write them in the comments below or to email me through my Contacts page.?
I also highly encourage you to take some time, no matter how early or how far along you are in pregnancy or postpartum, to spend at least 4 hours interviewing at least 4 types of care providers. Most American families spend more time researching flat screen TVs than OBs and our standard of maternal care is far too poor to leave it to trust. You have a right to spend at least one hour with any potential provider — doctor, midwife, doula — to ensure you feel comfortable being cared for by them. If they resist your request to sit with you this long, that should be a red flag in itself.?
Here’s some important further reading about why care provider choice is so important, and keep an eye out for my upcoming videos, workshops, and handouts on how to choose the best care provider for you.?
What is homebirth? from Evidence-Based Birth
The Evidence for Birth Centers from Evidence-Based Birth
*Article originally published on Rosewood Reproductive Health Consultation website. Reposted with permission.
Educator, Birthworker, Consultant, Writer
2 年I love (the link you included) Dr. Neel Shah's allyship and his work on facility designs' impact on outcomes. We need more interprofessional voices boosting these modality/system distinctions and the benefits of appropriate midwifery care!