- John H. Kennell, MD
This is another one of those questions that we doulas get a lot, particularly from people who may not have known that midwives still deliver babies in the U.S. It doesn’t seem as if two different practitioners who both deliver babies could be that different, does it? But they are–in training, in philosophy, and in health outcomes for mothers and babies.
Midwives are nurse-practitioners with specialized training in well-woman care and the care of women in low-risk pregnancy and birth, as I explained in the previous post, “What’s the Difference between a Doula and a Midwife?” They have eight years of training and multiple degrees in nursing and midwifery, and are licensed and governed by the Board of Nursing. They can diagnose medical conditions, write prescriptions, provide prenatal care, and manage labor and birth for low-risk women, as well as co-managing higher-risk births. OBs–or, more properly, Obstetrician/Gynecologists–are medical doctors who have completed their four years of medical school plus five years of residency in a hospital where they specialized in women’s health during pregnancy and birth. They also diagnose medical conditions, write prescriptions, provide prenatal care, and may provide instructions for nurses managing a woman’s care during labor, but are typically present only for the second stage of labor, when the baby is pushed out. They are also trained to perform surgical procedures such as episiotomy and cesarean.
Those are these two providers’ official scopes of practice, but what really distinguishes them is their philosophy and approach to prenatal care and birth. Most midwives take a very holistic view of pregnancy and birth, seeing the emotional, psychological, and spiritual side of the woman’s experience as a key part of her pregnancy and birth. They therefore address all of these components along with the physical ones in a typical prenatal appointment. To midwives, pregnancy and birth is not a medical condition, but a normal life stage, one that the woman will remember forever and that has great power to affect every other aspect of her life. Midwives, like doulas, view it as key that a pregnant and laboring woman be treated with respect and compassion, and that her own knowledge and instincts about her body and its processes be respected as well.
While midwives are trained to recognize complications that may develop during pregnancy and birth, they assume that a pregnancy is normal and healthy if a mother shows no symptoms. This philosophy leads them to conduct fewer invasive tests and recommend fewer medical procedures than OBs. Because midwives see the mother’s due date as just an estimate, they tend to support the natural onset of labor rather than inducing labor at 39, 40, or 41 weeks. Their holistic model of care means that, barring some emergency, a midwife commits to help the woman she has cared for give birth and generally tries to stay with the laboring woman the entire time she’s in labor. Because of their lower rates of induction and the use of evidence-based labor support, midwives generally see shorter labors, fewer complications in birth, fewer injuries to the mother and baby during birth, and fewer NICU stays for the newborns they help to deliver. Midwives generally make themselves available to the mother by phone or in person for the immediate post-partum period, to support her transition into her new role and/or family life.
OBs generally have received little training in the psychological and emotional components of pregnancy and birth, but lots of training in the medical diagnosis and treatment of various complications that may develop. For this reason, they are more likely to favor invasive tests and procedures aimed at identifying complications even when there are no symptoms present. Doctors also generally spend less time with the pregnant woman in each appointment, since their main focus is on the woman’s physical well-being rather than encompassing also any social or emotional factors that may be affecting her pregnancy.
Many, but not all, OBs treat the due date as a deadline for the baby’s birth, and will start suggesting or even recommending artificial induction of labor as the due date approaches. Some even have policies that dictate how long a pregnant woman may go past her due date without being induced. The most conservative OBs want a mother to agree to induce labor the day after her due date; this practice is not supported by evidence-based medicine, since studies show that the average length of a healthy first-time pregnancy is actually 41 weeks and 3-5 days.
OBs try to keep to regular business hours unless they are on call overnight for their practice, so even if a pregnant woman goes into labor while her own doctor is on duty, it is very possible that her baby will be delivered by another doctor. Once a mother is in labor, by whatever method, the OB generally will only see her one to three times during labor: once at the beginning to check her cervix, once in the middle of the day if no one has called the doctor to tell her that dilation and effacement are complete, and then at the very end, when the woman has already started pushing and nurses believe that birth is imminent. After the birth, the doctor may or may not have the responsibility of checking on her within the first few days (this is done by whatever partner from the practice is on call), and generally will not see or speak to the mother for six weeks after the birth, unless a complication arises.
Although there are doctors who believe in a more holistic approach to pregnancy and birth, the constraints of their practice and insurance requirements often pressure them to practice in the manner I’ve outlined above. It is important to understand the differences between midwives and OBs, because your choice of care provider will affect not only your pregnancy and birth, but also your experience of new motherhood and your memories of these events for the rest of your life. Either choice is fine, as long as it is the one that’s right for you.
Heather McLees-Frazier is a doula, writer, and the mother of (almost) three children. This article is reposted from her website, heathermcleesfrazier.com.
“You are constructing your own reality with the choices you make…or don’t make. If you really want a healthy pregnancy and a joyful birth and you truly understand that you are the one in control, then you must examine what you have or haven’t done so far to create the outcome you want.”
~Kim Wildner-Mother’s Intention: How Belief Shapes Birth
To find out more information on a specific doula you can click on either her web-site or doulamatch profile below, call or email her. Or if you prefer you may contact Richmond Doulas here. You can also search doulamatch directly.
Inactive doulas who remain active members of Richmond Doulas are listed at the very bottom of this page.
Elaine Troy Allen
Masa Doula Services
Joy Outland-Brock, LCSW
Eden Springs Professional Childbirth Doula
Emily Little Bruno
Rosehips Professional Childbirth Doula
ALACE 2007, toLabor 2011
Mother Nature Doula Services
Blooming Birth Doula & Belly Casting Services
Jenny Fisher, Birth Doula
Barefoot Birth Services
Jacki Glattfelder, Birth Doula
Melanie Headley CBE, CLC
The Supported Birth
DONA and toLabor
Ashley Larsen Kovalik
Support the Mama Professional Birth Services
Mary Jo Lowery
In Bloom Doula Services, LLC
DONA and toLabor
Maris Wurdeman Mendez
Jenny Morand, Birth & Postpartum Doula
A Mother is Born RVA
Katherine P., The Smiling Doula
Cat Ennis Sears, MT, MFA
Momma Work Doula Services
Jacqueline Sears, AAHCC
Alison Spillane, MSW
Baby Love Doula Services
A Sweet New Life Doula Services
Abigail Winter-Lewis, Massage and Doula Services
DONA and toLabor
Linda Zaffram, MSW, LCSW
Mother Nature Doula Services
Doulas go “inactive” (stop taking clients) periodically for a variety of reasons–perhaps they are on maternity leave, returning to graduate school, or just having trouble finding appropriate childcare for their own children during particularly long labors. The following doulas are currently inactive, but planning to return to birth work when their situation changes. They remain active members of Richmond Doulas.
Rebecca Flanagan, Birth Doula (inactive)
Janna Heizer Fuentes
First Steps Doula Services
The Healthy Birth ~ Childbirth Education and Doula Services
Melissa Yeager, birth doula
Miesha Vargas, birth doula
Baby Love Doula Services
Editor’s Note: April had her baby with the midwives at VCU Medical Center. This choice made it possible for April to have two doulas as well as a close friend at her birth; some hospitals have policies limiting the number of people who can attend a woman in labor. If you want more than one birth attendant present at your birth, be sure to discuss this ahead of time with your medical care provider. You can find doulas who are currently available on our “Find a Doula” page, or by emailing firstname.lastname@example.org.
My due date, April 5th, came and went without incident. I was beyond ready to meet our little one, to see if we were having a boy or a girl, and to no longer be pregnant.
I tried all the wives’ tales I could remember: I bounced on my yoga ball, I walked miles and miles–you name it, I tried it! I had my 41 week appointment with the midwife, and per her suggestion I decided to try castor oil. She told me to mix it with peanut butter or greek yogurt–protein apparently helps keep the intestinal distress to a minimum. I made a smoothie with the yogurt, castor oil, and some strawberries and a banana to help mask the taste. It wasn’t too bad! It wasn’t too great either, though.
I did have some intestinal discomfort, and had mild contractions throughout the day. They were not intense, but became a little stronger and more regular as the day progressed. I decided to go to bed around midnight to get my rest since I was pretty sure the next day would FINALLY be THE DAY.
I woke up on Saturday, April 13th, around 3:30am with contractions strong enough that I could no longer sleep through them. They were still very manageable, and I decided to take a shower. The contractions picked up a little more, and I decided to wake my husband and make breakfast around 5:30am. I got a call from the midwife to check on me, and we decided I would labor at home a few more hours and wait to go to the hospital (unless my water broke- which it did not).
We headed to the hospital around 8am, at which point my contractions were about every 2-3 minutes and more intense, but still manageable. I had to vocalize through most of them, but was still using long, slow, deep breaths to handle each wave. We got to the hospital & I called my doulas and a dear friend I also wanted present to support me during the birth process. I checked in, got a room, and began to walk and use the birthing ball. The midwife checked me and unfortunately I was only 1cm dilated. She decided to ‘stay in there’ a moment and check me during a contraction, after which I was magically dilated to 4! This was a really uncomfortable process, as I was not interested in laboring on my back at ALL and had to be reclined during a cervical check. The midwife was gentle and efficient, but it was still really painful.
I continued to use different positions during contractions, such as leaning over the elevated back of the bed, bouncing on the ball, swaying with my husband, squatting, and walking. Around 12:30ish, the midwife suggested we take the birthing ball into the shower and labor in there a while. This was the point my contractions picked up even more intensity. I was being more vocal, I was unable to talk through them at all, and I started humming/grunting/moaning in a lower register. The midwife peeked in and suggested that it was time for another cervical check since I was sounding very different during my contractions.
We headed back to the bed where she said I was a solid 5cm, and wanted to check through a contraction again. Let me tell you- THAT em-effing HURT! It was the first time I whimpered and cried in pain. My husband later told me that it was during this moment he began to get a little panicky, as he was upset to see me in pain. As soon as she was finished checking me, my water broke. I didn’t notice it at all; I felt no pop, no gush, nothing. The next contraction knocked my socks off though! I felt fluid gush out at this point, and the contractions were one after the other with no break. One doula was rubbing my lower back, the other was applying pressure to my hips, my friend was rubbing my feet and calves, and my husband was holding my hand, reciting some of my positive birth affirmations to me. The midwife continued to encourage me and help me vocalize in such a way that I could relax my jaw. I threw up.
At this point, I asked to get into the tub. It was about 2pm. I got into the tub and immediately the contractions, while still intense, were manageable again. The doulas continued to massage me, and my husband continued to support and encourage me. I threw up again. I felt like I needed to poop. I knew I was only dilated to 5cm just a few moments ago, so I assumed that I actually had to use the bathroom. When the midwife did a quick check she was surprised to find a head in the birth canal!
I had really hoped to be able to deliver in the tub, unfortunately the hospital did not allow it as they were being renovated at the time. So, out of the pool with me and into the bed. The midwife suggested that I get on all fours and try a few pushes. The doulas continued to massage and apply counter pressure, and my husband never left my side. The midwife had a squat bar to put on the bed, and I assumed a squatting position for pushing. I was very vocal, trying to make the low “oh” noise but it was getting harder to maintain my long & slow yoga breathing pattern. I pushed. I pushed. I screamed. I pushed. It felt like an eternity. My eyes were closed. I don’t know who was massaging what. I don’t know who was talking to me or what they said. I gave one last BIG PUSH and the next thing I knew I was reaching down and picking up my baby! I leaned back on the bed holding onto a very slippery, very alert baby GIRL! She was wide-eyed with wonder! My husband had tears in his eyes. It was the most beautiful, magical moment of my life so far. It was only 2:34pm. Just a half an hour before, I was only 5cm dilated. I was in shock!
Eleanor Joanne (Ellie) was perfectly content to wait a full 8 days past her due date, but when she was ready, she was ready right now!!!
She was a 9 on the APGAR scale, and weighed 8lbs4oz, and was 21 inches long.