midwife or MD?

[Jayla]

For those of you who work with pregnant/laboring women: for a normal, low risk pregnancy, which type of provider do you think is best? Either for you, personally, or your patients?

I have not had a baby yet, but my preference would be a nurse midwife. My reasons:

• a delivery done by a nurse midwife is significantly less costly than an MD
  
• Nurse Midwives generally seem to view labor as a more natural process requiring less medical intervention
  
• a nurse midwive's approach to pregnancy is more holistic

I would not choose a midwife who did not have a nursing background.

What would make you choose one over the other? Sorry, I haven't included DO since I don't know whether or not L&D was within their scope of practice...

[Lovely_RN, MSN]

I had an MD for my first birth and now I have a CNM. At the beginning of this pregnancy I had to see the MD in the practice because I had a C-sec and a premie the first go round so I was considered a bit high risk. Luckily, once my records came from the hospital I gave birth at 13 years ago I was allowed to stick with my CNM. If I have more children I will never go back to an MD if I can help it. I find that CNM are more sympathetic then MDs, more willing to take the time to answer your questions, and they don't talk down to you. My CNM has an RN background and a masters degree. I don't think I would go the lay-midwife route.

[faye2272]

Must be me, or at least the culture here in england, but I find a discussion about whether to have a midwife or a doctor in attendance for a delivery really strange! If you are having a straight forward pregnancy why on earth would you involve a doctor? Having spoken to many obstetricians it is clear that many of them consider childbirth to be a "condition" that need to be managed, rather than a natural event that women have been doing since the dawn of time. In 4 weeks time i will be completing my 3 years of midwifery training. I did not train as a nurse first, and do not consider this a disadvantage in any way. I have worked with midwives who were previously nurses and many of them insist on treating the women like patients making me want to scream "they're not sick!!!!" In england nurses have to complete a 3 year course and in most places only 2 days practice are in obstetrics, then an 18 month course in midwifery. I (and all other direct entry midwives) have to complete a 3 year midwifery course with 3 months in general placement. For people who dont want to be general nurses and who are only interested in midwifery, why would you want to train as a nurse first when on direct entry you have far more training in midwifery. So why oh why would someone say that they would only want to be attended by a midwife who has nursing training? I know i have little or no understanding of systems outside the UK, but please, give specialist midwives a chance, after all thats what they are, specialists.

[CEG]

For people who dont want to be general nurses and who are only interested in midwifery, why would you want to train as a nurse first when on direct entry you have far more training in midwifery. So why oh why would someone say that they would only want to be attended by a midwife who has nursing training? I know i have little or no understanding of systems outside the UK, but please, give specialist midwives a chance, after all thats what they are, specialists.

In the US midwifery (certified nurse midwives) training is built upon the foundation of nursing experience. Most schools require a minimum of a year experience in labor and delivery to apply. So those who go to direct-entry programs lack the experience of those who spent years as nurses prior to going to get their masters degree. I am in a direct entry program but plan to work as a L & D nurse prior to finishing my degree and becoming certified. Just a possible explanation.

[HHW2006]

I had my first baby with a doc and my second with a CNM and if I ever have a third it will definetely be with a midwife. My experience the second time was so much better - due in large part to my midwife. I just can't say enough about how wonderful I think midwives are - in fact I still see one for my yearly exams!

[Jayla]

So why oh why would someone say that they would only want to be attended by a midwife who has nursing training? I know i have little or no understanding of systems outside the UK, but please, give specialist midwives a chance, after all thats what they are, specialists.[/quote

Here in the US, unlike most if not all of Europe, most pregnant women are managed by physicians (mainly OB/GYN). However, most people I've talked to who are open to midwifery seem to prefer a CNM.

Most CNM programs (not all however) require at least a year of L&D or NICU nursing experience in addition to the midwifery training. I personally would prefer the person who delivers my baby to have experience working in an acute setting. Not all deliveries go smoothly or are without complications (some of which are extremely life threatening)--so while I do believe that pregnancy and birth are natural and not "medical" events, there is no guarantee that they will not become medical events.

My personal comfort would be to have a practitioner who has a experience working not only with uncomplicated, straight forward deliveries, but also deliveries where mom and/or baby's health go south and sometimes very quickly. Perhaps training in Europe is different than the US, but I don't feel that lay midwives have the same level of training/experience as a CNM. Just my opinion.

[Lovely_RN, MSN]

I prefer a CNM over a lay mid-wife because in New York State anyone with a bachelor's degree in any discipline (and no previous healthcare experience) can become a lay mid-wife with one year of training full time. I would rather have a RN with L&D experience and a MS degree in midwifery.

ETA: I know other states have different requirements but I live in New York so I am using that as an example.

[fergus51]

Must be me, or at least the culture here in england, but I find a discussion about whether to have a midwife or a doctor in attendance for a delivery really strange! If you are having a straight forward pregnancy why on earth would you involve a doctor? Having spoken to many obstetricians it is clear that many of them consider childbirth to be a "condition" that need to be managed, rather than a natural event that women have been doing since the dawn of time. In 4 weeks time i will be completing my 3 years of midwifery training. I did not train as a nurse first, and do not consider this a disadvantage in any way. I have worked with midwives who were previously nurses and many of them insist on treating the women like patients making me want to scream "they're not sick!!!!" In england nurses have to complete a 3 year course and in most places only 2 days practice are in obstetrics, then an 18 month course in midwifery. I (and all other direct entry midwives) have to complete a 3 year midwifery course with 3 months in general placement. For people who dont want to be general nurses and who are only interested in midwifery, why would you want to train as a nurse first when on direct entry you have far more training in midwifery. So why oh why would someone say that they would only want to be attended by a midwife who has nursing training? I know i have little or no understanding of systems outside the UK, but please, give specialist midwives a chance, after all thats what they are, specialists.

It's very different in the US and Canada. I would prefer a CNM because I know the educational requirements and I'm comfortable with them. Pretty much all CNMs have L&D experience before doing their course and there is really no substitute for that. Direct entry midwives here often have less practical experience than CNMs when they finish school. I wouldn't mind having a doctor attending me either. It can be reassuring to know that they can manage everything that arises.

Like I said though, it's been largely because of my experience working with UK midwives that I am so pro-midwifery and would use either type of midwife there (direct entry or nurse first). I might feel more comfortable with a nurse first midwife if I had any chronic health issues, which a lot of mothers have.

ps

Congrats on finishing school!

[FrumDoula]

Perhaps training in Europe is different than the US, but I don't feel that lay midwives have the same level of training/experience as a CNM. Just my opinion.

I have had a variety of experiences. For my first child, I began with a midwife who was a CNM. She should have simply called herself a mini-OB. It would have been more honest. I changed practitioners at 32 weeks to a wonderful family practice doctor (a male, no less!) and had a fabulous birth, even with its attendant complications. If I had had a choice, I would have homebirthed.

With my daughter, 6 years later, my husband (a DO medical student) and I chose to have a homebirth with a CPM. It is not supported in the research that nurse midwives have safer outcomes than certified professional midwives. My midwife has certainly had her share of unexpected outcomes, including hemmorhage, shoulder dystocia, decels, etc, some of which required transport and some which did not. Given the fact that she has caught something on the order of 1500 babies, I felt pretty safe with her.

What concerns me about the differences between even CNM's and CPM's is not the birth per se, but the prenatal care. My CNM had 15 minute appointments, 30 at the most. She never asked me about nutrition, never suggested anything which could have improved my health. It was bizarre. My CPM came to my home, stayed for over an hour and ascertained what my eating habits were, as well as my general health. Appropriate tests were done, including urine dipsticks, blood tests, etc. In this way, she was able to make sure I continued to be low risk, thereby lowering the chance of poor outcome at the birth itself.

It's a fallacy that CNM's are more prepared for birth than CPM's. The lay midwives I know study and apprentice for years. Sure, there are yahoo's out there, but we've all seen OB's who we wouldn't sent our PETS to, let alone entrust with our bodies and wee babes. The CPM track is rigorous and demanding. Different states have different laws which make it easier or harder on midwives, but this does not reflect on the inherent safety of direct entry midwives.

Still, when it comes to the recommendations I give to my clients, I simply tell them to go to a practitioner they feel comfortable with, and who gives them good, evidence-based information. Not every woman is comfortable in every kind of birth situation.

Alison

[nurseglad]

In the US midwifery (certified nurse midwives) training is built upon the foundation of nursing experience. Most schools require a minimum of a year experience in labor and delivery to apply. So those who go to direct-entry programs lack the experience of those who spent years as nurses prior to going to get their masters degree. I am in a direct entry program but plan to work as a L & D nurse prior to finishing my degree and becoming certified. Just a possible explanation.

Hi I'm in the UK where I trained as a direct entry midwife on the three year course. I have 6 years experience on labour and delivery, and have experience of high risk obstetrics, including scrubbing for caesarian

sections and resuscitation of the newborn. This encompasses many pre existing medical conditions women have, aswell as those which arise or are exacerbated during pregnancy. I am currently in the process of applying to the Florida School of Traditional midwifery (University of Florida) so that I may qualify as a CPM and gain Licensure . I am hoping to do this as midwifery practice in the UK seems to be progressing (or regressing....) to a medicalized approach to what is in the majority of cases a normal physiological event! In any event I feel that the line between what I am qualified to do... to be a midwife is becoming blurred, and in fact I am increasingly required to behave and practice as though I am an obstetric nurse. Is there anyone out there who has made the leap of faith and gone to the US to practice, or are thinking of doing so?

Kind regards to everyone

[BlueEyedRN]

I ended up having to have an emergency C-section with my first baby so I was glad that I had been going to an MD and I knew both him and the other OB who assisted. I felt comfortable (as far as possible in the circumstances) because I knew from experience that they were both excellent doctors and would take good care of us.

However, I had a terrible experience with my second delivery because the doctor would not listen to me at all. I mean, it turned out fine and everything went well and I was able to have a VBAC. But I felt I had to fight for everything. It was in a military facility in Virginia which may have a lot to do with it. The doctor was there on the floor the whole time so I thought it would be a good situation. But it took me hours to convince him that I was in labor (another OB in the group had insisted that I come in as soon as I knew that it was real since I was VBAC). I was dilated to 4, but my contractions were irregular (they never got regular btw), and he sent me home and told me to come back in a week. I sat in the parking lot and labored for an hour in the car and then went back in and insisted that they assess me again. I was at 5 1/2 by then so they decided I was right after all. So the doctor wanders in at some point and tells me that he is going to break my water, and then leaves again. Twenty minutes later, my water broke on its own and then the nurse didn't believe me when I told her. When I was fully dilated, the doctor came in and assessed me, told me to start pushing with the nurse, and then left again. I pushed for fifteen minutes, then he calls up to the floor and sends someone in to tell the nurse to have me stop because he decided to attend a meeting. Thirty minutes later he finally decides to grace us with his presence and I was finally able to finish giving birth. And then when he was sewing me up (I tore pretty bad), he starts telling dirty jokes to the nurse who thought he was just hysterical. I wanted to kick him in the head. After it is all over, he looks at my IV and notices that I don't have pitocin up there. "Wow, did you go into labor naturally? Oh, wait, aren't you that girl I sent home this morning?"

Anyway, the point of this ridiculously long venting story is to say that there are some amazing MDs and some really annoying ones and my friends all said that midwives are much more personable and caring, but sometimes they are annoying too. So who knows. :)

[PegRNBSN]

There are so many generalizations and stereotypes being thrown about in this thread!

I have been an OB nurse for 24 years. In that time I have worked with wonderful OBs, FPs and midwives. I have also worked with horrible ones in each category. My only experience with lay midwives are from home births that have to come to the hospital. Some of these midwives are scary in their lack of knowledge especially in regards to the usually high risk situations that their pateints are presenting with. Others are very knowledgeable.

I guess when it comes down to it, you need to figure out what is the most important things you are looking for in your provider and then find one that you gel with. I like to tell women to talk to nurses for recommendations about hospital based providers. They are the ones who see everything and really have an understanding of the practice and beliefs of each practiotioner.

I have a little list of questions that I ask the woman to help get an idea of what she is looking for.

[lovemyjob]

I agree, Peg, there are good and bad in all categories. There are some really great MD's out there as wll as some really great midwifes.