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Midwife Melissa Cheyney talks all about midwifery care, the different types of midwives, and their various certifications, so that you can know what your options are and make the best choice. Learn what role of midwives, OBs, perinatologists, and how they work together.
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Hey, mighty one. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy.
Hello, mighty parents and parents to be. As always, thank you so much for listening and for all the love you give the show. My guest today is Missy Cheyney, who among other things currently directs the International Reproductive Health Laboratory at Oregon State University. Missy is here to answer all my questions about midwifery care, and I couldn’t be more excited. Welcome, Missy. It is great to have you here.
Missy Cheyney: Thank you. I’m happy to be here.
Lozada: Why don’t you tell us a little bit about yourself?
Cheyney: Sure. So, I am a clinical medical anthropologist and I study midwifery globally and with a special focus in the United States. I’m also a midwife myself, so I have the credential of CPM or Certified Professional Midwife. I’m also licensed in my state and I have a small home birth practice, and I also provide backup midwifery care in a birth center in my town.
Lozada: And you just went through several of the things that I want to definitely dig deeper into today. You know, like for example, what is that CPM certified professional midwife? How does that differ from other types of midwives? But before we get into that, let’s take one step back and go deeper into what is midwifery care and how is that different from what OBs do?
Cheyney: So, first and foremost, when I think about the midwifery model of care and when I talk about it with my students, one of the things that I think is so important to stress is that we are trained as providers, and really often share a perspective that birth is in itself not inherently dangerous. That healthy women have evolved to be able to give birth over multiple generations and most of what happens around birth can occur without major medical interventions. So, that means that the fundamental place where care begins is with the assumption that most pregnant people, when they’re adequately supported and are overall healthy, that what they really need in pregnancy and in childbirth is support, and nurture, and close monitoring, just to make sure that everything is unfolding safely.
What they don’t need as a matter of course is massive medical intervention and in our country today, we do medically manage the majority of births, and so midwifery sort of holds open this space that questions whether all of those interventions are always or routinely necessary. So, that is not to be confused with a stance that would say those are never needed, and I think part of the midwifery model of care is not saying no to medical intervention in all cases, but only to those where it’s truly clinically indicated. And then trying to find where that distinction lies, so to summarize, it is essentially the fundamental belief that with support, most women’s bodies will birth in a relatively straightforward way, and then in a small number of cases, women can benefit from closer and more medicalized care.
So, that’s the fundamental assumption, and then the other thing that is really important about the midwifery model of care is that this leads our care to be highly individualized. And so, prenatal care and birthing care are really centered on the needs of the family, and we do not focus solely on clinical needs. We tend to see the whole person before us and so we like to take into account the psychosocial, the spiritual, the community, the cultural, as well as the clinical needs of the people that we’re serving.
Lozada: And, which I find is a very important nuance like you were saying of the midwifery model of care versus a more active management model of care, because birth is such a mind-body connection event, like you were all in, it affects all parts of your being, that sort of not taking into account your psyche, your feelings, your emotions, your past experiences, and just looking at your body like kind of a machine with parts, and that health approach that we have here in the U.S. of these are all individual parts that we view through this narrow lens. It does a disservice to the person that’s giving birth.
Cheyney: Yes. Absolutely. Our minds and bodies are deeply integrated and the emotions that we feel when we’re experiencing our labors and our births deeply affect our hormone levels, which affect the way, for example our uterus contracts. So, it’s not possible in this day and age with the amount of research that we have on the mind-body connection to discount the importance of meeting the psychosocial needs of the laboring person. And the way our society has unfolded and the way we’ve come to manage birth over time in the last three or four generations has really become focused on medical management, and what that prevents us from seeing sometimes is the degree to which other social factors play as important if not more important of a role in how the birth unfolds.
And so, the midwifery model of care is really about seeing the whole person and putting back together the mind and the body, and treating the whole person, and when we do that, research really shows that birth unfolds in a much more healthy way. There’s less of a need for intervention. Labors are shorter. The need for cesarean section is reduced when we treat the whole person. Within the midwifery model of care, we really value longer, highly individualized prenatal visits, because we see as care providers that when a person goes into labor, it is a very different situation if she goes into labor feeling strong, and confident, and capable, so providing really intensive prenatal care, our aim is to prepare women to feel strong and capable and ready to face what their labor brings to them. And that can’t be done very well just in labor. That needs to start earlier in the prenatal period.
So, lots of emphasis on nutrition, on self-care, on exercise, on sort of the mental and psychological preparation for what lies ahead, and that simply takes more time.
Lozada: Yeah. And it impacts the outcome of how things unfold, as well. I always like to tell my clients during our prenatals to think of pregnancy as early, early, early, early, early, super early labor, and that the things that they do during that time can have a very direct impact on even the length of how things flow during the birth itself. But I think it’s a good distinction for us to make right now that we’re not trying to knock OB care. I think one of the things that was pivotal to me when I started doing this work was understanding that we’re talking about two very different categories, practices, approaches, doing the same work, because that’s how we do it here in the U.S., and more Westernized culture, whereas if you look to other models in say Europe, where midwives and OBs stand more side by side, but understand that even though they have an overlap in care, they’re purviews are different.
Cheyney: Yes. I think that is so critical and it’s important to really start this conversation by making the point that midwives cannot practice safely without collaboration with medical providers, with obstetricians, with our colleagues who are obstetricians. We have to understand that obstetricians are trained surgical specialists, and that skillset that they bring to birth is absolutely critical and can mean the difference between life and death for mother or baby in a small number of cases. And we can’t in any way disregard the care that they provide.
I think what we’re struggling with in our country is trying to find the appropriate use of various expertises relative to the situation of the pregnant person before us. So, what is so very different about the United States, relative to let’s say the Netherlands, is that normal, healthy, low-risk women, when they get pregnant, they say, “Oh, I need to call my midwife.” Not, “Oh, I need to call my obstetrician.” And it is understood that midwives are the primary maternity care provider and that you certainly may see an obstetrician over the course of your care if a complication develops. You then may be referred back into midwifery care if it resolves, but that kind of fluidity, where low risk, healthy women see midwives and obstetric care is reserved for those women with more medically complicated pregnancies, and then even for with perinatologists for those that are significantly medically complicated, that kind of hierarchy doesn’t exist in quite the same way in the United States.
So, here you can have perfectly healthy low-risk women with no risk factors who receive obstetric care simply because that’s all that’s available in their community. Not because they want more medicalized care or because they need more medicalized care, but simply because we have this really interesting sort of proportion of attendants at births that’s pretty different from other places. So, in the U.S., about 89% of births are attended by obstetricians, and 11% are attended by midwives. In most high resource countries, that would be flipped, and that allows obstetricians in other countries to practice at the top of their license using this expertise, this skill set that is really unique to them, and it allows midwives to practice within their own scope, which is normal physiologic birth.
That is very much disrupted in our country because of a long history of for-profit medicine that has substantially medicalized even low-risk birth.
Lozada: Yes! Absolutely. And I feel that in the past years, few years especially, there’s been more of an interest and paying more attention to how the system is not quite serving us properly, and that’s why we’re having conversations like this one that we’re having, and you do what you do, and I do what I do. So, having said that, what are the things that you would say very specifically that midwives don’t do that OBs do do?
Cheyney: Yeah. So, that’s a great question, and the thing about midwifery care is it’s often more about what we don’t do as a matter of course versus don’t do at all. I think there’s some really clear distinctions. For example, cesarean sections are performed by an obstetrician and so are assisted vaginal births, so that would be with forceps or vacuum extractions. So, midwives will assist in those procedures, but the primary provider if you’re getting to that point are typically going to be obstetricians. However, the overlap in what we do is actually has a little bit more to do with frequency, so whereas some obstetricians or many obstetricians might see multiple interventions as standards of care, so everyone would get an IV, or almost everyone would get an IV. Everyone or almost everyone would have continuous electronic fetal monitoring. Midwives may sometimes need to start an IV. I certainly have in my career, but I don’t do it for every person. The vast majority of women I care for receive their fluids by drinking, by using a straw, and I would not use an IV unless there was significant maternal dehydration, or if I was trying to replace blood volume after a hemorrhage. So, it wouldn’t be a matter of course, though I have that skill.
Midwives also typically will suture less frequently than obstetricians, especially in community settings where with good perinatal support and management of the timing of pushing, we can often help people to deliver over an intact perineum. So, it is not necessarily that we have a completely disparate set of skills. It’s just the frequency with which they are used can be much, much less for midwives. Part of that is that we are typically serving low-risk clientele, and it is very important not to compare apples to oranges. Obstetricians are often caring for a higher risk population, although they also do care for completely normal, low-risk women, as well. And in those instances, there is often much higher levels of intervention.
In fact, when you look at the international literature on outcomes for midwifery care, one of the things that is really consistent cross-culturally is that midwifery care reduces the level of intervention for mothers and babies across the board. So, that is a real important distinction of that model of care.
Lozada: And I think it also speaks to that appropriate use of expertise of if you have a healthy person that has a flowing birth, they’re gonna require less interventions, and if you step back and just let things unfold, then it’s just gonna happen, whereas if you’re looking at it with a magnifying glass of every single thing might be a problem, and if we circle back to considering what we know impacts the hormones and the psyche, if that energy of anxiety comes in because you’re seeing something that might not quite be how you want it to be, and then that energy of anxiety presents itself, it’s gonna be a little contagious to the birthing person.
And if they’re starting to think more and be more anxious, then the hormones they need for birth are not gonna flow that much, and so then there’s a feedback loop that I don’t think is talked about often enough.
Cheyney: Agreed. That is really critical. And in my field as a medical anthropologist, one of the things that informs anthropology is we study birth not only cross culturally, but across species and over evolutionary time, and one of the things that all primates have in common is an evolved strategy to avoid giving birth under predatory danger. And so, it’s impossible for us to labor when we are terrified. The hormones that we experience when we’re scared, cortisol, adrenaline, catecholamines, actually prevent effective uterine contractions, so it is… And this is highly valuable if you’re in the jungle or in a forest. You don’t want to give birth to a highly-vulnerable infant when there’s predatory danger available. And so, for women to or for primates to stop their labor and to move to a safer space, and to wait to birth until their offspring is likely to be safe makes a lot of sense.
This is a lot harder, though, in a hospital, where typically there are some time-based protocols for how long labor could last, and so we really need to find ways to work to reduce sort of the fear, tension, pain cycles that women can get into into labor that can delay labor, and so we may think through one model of care that giving Pitocin, which is a synthetic form of oxytocin, into the vein to speed labor is an option. But another way to speed labor is to help reduce maternal distress and to help her feel safe, and comfortable, in a warm, dark space, where her body can do what it would do if it were not stressed out.
So, those are two different tactics for helping to speed labor and they have different consequences for mothers and babies, because if you give intravenous oxytocin or oxytocin into the bloodstream, you can cause very, very strong contractions that are quite painful, and non-physiologic, and that often leads to women wanting to have an epidural or some kind of other pain management, and then you get into something that we call the snowball effect, where one intervention leads to another intervention. So, in the midwifery model of care what we would like to do first is try a low tech, high touch intervention, to see if that can help with the progress of labor before jumping to something like an intravenous drip of Pitocin.
So, they’re two relatively different approaches that have consequences for both the mother and the baby.
Lozada: So, Missy, now that we’ve talked about how midwives in general approach the birth process, what are the different types and classifications of midwives?
Cheyney: Yes. So, this is a great question. The United States is very much unique cross-culturally in that it has three different credentialing routes to becoming a professional midwife. So, those are the Certified Nurse Midwife, or CNM. The Certified Midwife, or CM. Or the Certified Professional Midwife, which is the CPM. So, these credentials, even though they’re distinct credentials, they have a lot of commonalities in them, and that they all have some combination of didactic course learning as well as more hands-on methods of internship and apprenticeship. So, these different trajectories are really a reflection of the fact that midwifery was deeply suppressed in the United States, and so in the early 1900s, the vast majority of births occurred at home, close to 100%, almost all attended by midwives, and by 1935, that had completely inverted and the vast majority of births were now attended in hospitals by obstetricians.
And so, as midwifery made a comeback, we call it the midwifery renaissance, so Certified Nurse Midwives become nurses first and then go on and do graduate-level work that takes them to the credential of CNM, or Certified Nurse Midwife. And the vast majority of Certified Nurse Midwives in the United States today practice in hospitals with a smaller percentage practicing in birth centers and at home, so in the community setting.
There’s a separate credential called the CM, or the Certified Midwife, that’s only available in a few states on the East Coast, and this is a credential for individuals who want to be midwives but have a bachelor’s degree in something other than nursing, and so they take the same exam and meet the same standards for a CNM, but do not necessarily become nurses first. And then the CPM is the most recent credential and this is a credential that was developed in the early ‘90s to allow what had been called lay or traditional midwives to become professionalized. And so, CPMs, that’s what I am. CPMs either are trained through an accredited midwifery school or many practicing CPMs today, a little over half, were trained more informally through apprenticeship solely. No matter how you acquire your skillset, CPMs must all pass a standardized examination and a practical exam for skills to be able to get their CPM or Certified Professional Midwife.
So, you’ve got those three credentials, and then to make it even more complicated, state to state there are different credentials that are offered by a state. So, in Oregon, for example, where I live, I became a CPM, but my state offers licensure for CPMs. So, I carry a CPM and also something called an LDM, which stands for Licensed Direct-Entry Midwife. And direct entry simply refers to the fact that CPMs do not become nurses first. We go directly into midwifery training and then become certified as midwives without the nurse credential, which is very common cross culturally, especially in Canada and in Europe.
So, those are the categories. I will say there’s one other category that are much less common in the United States, and those are midwives who refer to themselves as traditional, lay, or sometimes plain midwives, and these are essentially uncredentialed midwives who attend typically only home births and they often do so because they prefer the complete autonomy of staying outside the system. It really is important to remember that we can’t overemphasize the effects of these different credentialing routes on outcomes. In fact, they play very little role relative to those other factors I mentioned, which are the risk level of the pregnant person and the degree of systems integration that the midwife is functioning in.
So, that said, part of why things become so muddy is that when we are talking… We’re talking about the credentials, the alphabet soup, the letters that come after midwives’ names, but also the various places of practice, right? Because you’ve got home, birth center, and hospital. CNMs and CMs can practice in the hospitals, but CPMs cannot, and traditional midwives cannot, and then within the community setting of home and birth center, you can have CNMs, CMs, and CPMs all practicing, but traditional midwives typically only practice at home. So, oftentimes the alphabet soup of credentialing also gets confused with this array of birthing places or locations, and so it can become quite confusing.
Lozada: So, Missy, when a person is looking for a midwife for their care, what should they consider?
Cheyney: Yeah, I think that’s a really important question. I’m gonna answer that by telling you what we know from the research people do consider, and then also give you some recommendations. When women are interviewing potential midwives, just as when they’re interviewing doulas, what we know from them is that they certainly may ask questions about education, and about training, but what women are really doing is asking who do I feel safe with? Who do I feel a connection with? Who do I want to be with me to hold my hand, to support me, to keep me safe, to monitor me, through what will be a very significant point in my life?
And so, we don’t want to overestimate the degree to which clinical decision making affects how people choose their practitioner. It’s much more often about bedside manner, and I think this speaks to the really intense psychosocial needs of people who are laboring and giving birth, and we have as a society tended to downplay that or underemphasize that.
Now, I think also when people are thinking about who to hire as a midwife, it is worth asking questions related to probably three areas. One is trying to understand the experience level of the midwife that you’re working with. Where did they go to school? How were they trained? How long have they been practicing? So, getting some sense of their experience level is really important and asking about their credentialing can help you figure that out. Secondly, I think it’s important to ask about what kinds of emergency safety medications and procedures they’re comfortable with and are able to offer.
So, for example, I do births in home birth setting primarily, and people often ask me what happens if I’m bleeding too much? What happens if the baby isn’t breathing at birth? And what I will tell them is that I carry all of the antihemorrhagic drugs that are available to you in the hospital and I’m trained in how to administer them. It’s uncommon that someone will bleed so extensively that they need an intervention in a home birth setting, but it does happen, and if it happens to you, I will manage it. And then secondly, they will ask me, like I said, will ask me about what happens if the baby doesn’t breathe. All Certified Licensed Midwives have the same credentials as hospital practitioners do for resuscitating infants, and again, it’s very rare that we need to resuscitate an infant, but when you do need to, it is critical that your midwife have that skill set. That means that I will carry the equipment that’s needed to do that and that I feel comfortable and I’m competent and up on my certification to provide that care for you or for your baby if you need it. So, I do think it is important to ask about that while keeping in mind that those are rare instances.
And then the third thing that I think is really important to ask about is what is your relationship like with local medical providers? Should I need to transfer to a higher level of care from let’s say midwifery care in the hospital to obstetric care in the hospital, how will that work? What if I go into labor intending to birth at home, but my labor is taking a long time and I’m becoming exhausted and I want to transfer to the hospital? What will that look like?
So, unfortunately in the United States, medical anthropologists like to point out that we have something called the home hospital divide, and that’s a relatively deep chasm in many states between community providers and hospital birth providers, and this means that often if people are choosing a home or a birth center birth, their access to medical backup if they need it is not guaranteed. And it’s not necessarily smooth. There are many places in our country where local midwives and physicians have worked that out and can provide very smooth transitions from home to hospital or birth center to hospital, but it’s not a given, and so it’s very important to ask about that, because about 11% of people who go into labor intending to deliver at home or in a birth center will require a transfer to the hospital sometime during labor, and I don’t believe that that should be treated as a failure, or as a morbidity, or as a complication, or as a problem, but a normal and expected outcome of care.
It is important that we know how to triage births and move them to the place where they can best unfold. And so, sort of taking away the stigma of that a little bit and talking about that really openly with your midwife is very important.
Lozada: What you were just saying reminds me of two different things that I want to comment on and it’s regarding the requiring transfer to the hospital. So, one question is that 11%. That doesn’t necessarily mean that it’s all emergencies happening, because say you have somebody at home that decides, “You know what? This has been really long and I just… I thought I wanted to do it, but I’m really, I just need the pain meds, or I just need to go to the hospital. I just want to go to the hospital.” Is that situation included in that 11%?
Cheyney: Yeah. That 11% of transfers are almost never emergent. Emergent transfers are very, very rare.
Lozada: Right. Missy, before we wrap up, is there anything that you wanted to make sure we got to about midwives that people need to know that we haven’t gotten to yet?
Cheyney: You know, there is. I think it’s hard for us to continue to talk about midwifery versus medical care, or holistic versus technocratic care. I know that there are real and meaningful differences between the way many obstetricians practice and the way many midwives practice, but I think it’s important to focus on the places where we are converging. And in our country, there is a growing awareness that we’re doing, for example, way too many cesareans. And so, in the decades going forward, what I hope to see is more interprofessional collaboration in really creative ways to provide the best possible maternity care to all people in our country. Right now, the vast majority of midwives in our country are white, college educated, middle class women, and we need a more diverse cadre of midwives to be able to provide culturally concordant care to women of color, to Indigenous women, to rural women, and we have got to start putting our energies towards doing that.
And then the second thing I would say is that there is a popular dichotomy in the international literature where we talk about healthcare systems that do too much too soon, and some that do too little too late, and you can imagine after the conversation today that the U.S. is largely categorized as one that does too much, too soon. But because there’s rampant inequality, social inequality in almost all countries, you can actually have countries where too much too soon and too little too late exist side by side. And so, we have that in this country, where we have a very high percentage of women who are un- or underinsured, or who never receive quality prenatal care and show up in the emergency room never having received quality prenatal care, and that is really unacceptable for a country as wealthy as we are.
Lozada: Thank you so, so much for being on the show today. It’s been really wonderful.
Cheyney: Thank you so much. It was a pleasure.
Lozada: You’ve been listening to a Best of Birthful episode and there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast.
Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Listen every week for more ways to inform your intuition.
Lozada, Adriana, host. “Best of Birthful: How to Find the Best Midwife For You.” Birthful, Lantigua Williams & Co., September 30, 2020. Birthful.com.