For women seeking a more natural childbirth, a nurse-midwife may be the answer.

Gabrielle Giddings gave birth to her son with the help of an ob-gyn, an epidural, and an episiotomy. Three years later, she delivered a baby girl -- without the shot or the incision. Though most would chalk that up to luck and an easy labor, Giddings credits a decision she made early in her pregnancy: replacing her doctor with a midwife.

"I used a group practice with my first pregnancy, and the obstetrician who delivered my son was the doctor I liked least," she says. "I wanted a more personal experience the next time around." Both deliveries took place in Philadelphia-area hospitals, yet they couldn't have been more different. From the time Giddings was admitted, her midwife stayed in the room, sitting by her side as the contractions became intense, rubbing her back, even lying down on the bed to demonstrate positions Giddings might try during delivery. "Not only did my midwife support my decisions every step of the way," Giddings says, "but she also helped my husband feel truly involved in the labor. It really made the experience wonderful for both of us."

Not Just Home Births

Physician-attended births still account for the vast majority of deliveries in the United States, but midwives are gaining ground. In 1998, certified nurse-midwives attended 9 percent of the approximately 4 million births in the U.S. Yet that's nothing compared to Europe, Australia, and Japan, where midwives are considered a standard part of the birthing process. According to a report from the University of California at San Francisco and the Pew Health Professions Commission, the U.S. and Canada are the only two major industrialized countries in which midwives do not play a central role in the care of most pregnant women.

Why? For many people, the word midwife still evokes images of an elderly woman with no formal training delivering babies at home. In fact, 96 percent of births assisted by certified nurse-midwives occur in hospitals, 3 percent in birth centers, and only 1 percent at home. More important, certified nurse-midwives are nurses who have extensive midwifery train-ing as well as a state license. Direct-entry midwives, on the other hand, may have only a high-school diploma and generally perform home births only. Though certified nurse-midwives are legal in all 50 states and can usually write prescriptions, their direct-entry counterparts are banned or work under restrictions in some states.

Another reason for this country's low number of midwife-assisted births is that not all managed-care companies currently cover the service. This is slowly changing, however -- 33 states now mandate that insurance companies reimburse the cost of hiring a nurse-midwife.

A Personal Choice

For most women, the real appeal of midwives is their nurturing, woman-centered approach to childbirth. "We recognize that pregnant women have emotional as well as physical needs," says Deanne Williams, executive director of the American College of Nurse Midwives, in Washington, D.C. "Our goal is to make the atmosphere -- during prenatal care, labor and delivery, and the postpartum period -- as loving and as supportive as we can." Midwives also encourage women to be more in charge of their pregnancy and labor. "I switched to one in my sixth month," says Deborah Wunderman, of Arlington, Virginia. "My obstetrician's attitude was 'I have a certain way I deliver babies, I know best.' I just wasn't comfortable with that."

Avoiding an episiotomy -- the cutting of tissue to widen the opening of the birth canal -- is another reason women look to midwives. Though the number of episiotomies performed by doctors has dropped significantly -- from 64 percent of all vaginal births in 1980 to 35 percent today -- midwives have long believed the procedure to be both unnecessary and harmful. (In recent years, studies have confirmed that episiotomies can lead to an increased risk of tears in the rectum and urinary incontinence later in life).

Jill Fulop had a physician deliver her first two children and underwent an episiotomy for both -- yet she still suffered a severe tear during the second delivery. For her third child, Fulop opted for a midwife and avoided an episiotomy. Though she needed two stitches for a small tear, the Dublin, Ohio, resident was much happier with her experience. "The midwife let me deliver in a fetal position, not on my back," she says. "It kept me from pushing too fast and tearing."

Midwife-attended births are also more likely to be drug-free. But if a midwife's patient wants an epidural and is in the hospital, the midwife can have an anesthesiologist administer one, just as an obstetrician could.

When an OB-GYN Is Best

Although all certified nurse-midwives are trained to provide prenatal care, to recognize conditions such as preeclampsia and maternal diabetes, and to manage labor, delivery, and obstetric emergencies, they are not appropriate for every pregnancy. Women at high-risk for complications -- including those with certain health problems (such as diabetes, kidney transplants, or blood disorders), those with a history of very large babies, and those pregnant with multiples -- need to be cared for by an ob-gyn. Midwives are also not trained to perform C-sections.

Trying to find a midwife or ob/gyn? Our checklist can help you find the right person for the job.

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Copyright © 2001 Sandra Salmans. Reprinted with permission from the December 2001 issue of Parents magazine; 12/01.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.

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