Many women automatically seek an obstetrician for their prenatal care. But why not consider a midwife? In this article, the authors tell you what midwives do and conquer some common myths and misperceptions regarding Certified Nurse-Midwives (CNMs). How much do you know?
Dana Eltringham, Carmen Gore, Cathy Malo, Shelagh Roberts and Amorette Stiles

A different brand of care
You suspect you might be pregnant. What's the first thing you do? Buy a pregnancy test. If the test is positive, you call your OB-GYN and schedule an appointment, right?

Wait a minute...

Why not call a certified nurse-midwife (CNM) instead? A growing percentage of American women are doing just that - they are seeking a CNM to provide comprehensive care from the very beginning of pregnancy through several weeks after they deliver their baby. As defined by the American College of Nurse Midwives (ACNM), CNMs are licensed health care practitioners educated in the two disciplines of nursing and midwifery who have completed accredited nurse-midwifery education programs and passed a national certification examination.

Numerous studies indicate that births attended by CNMs produce similar, and in many cases, superior birth outcomes than births attended solely by obstetricians. Impressive measurable results of CNM-attended births include lower infant mortality rates, higher birthweights, and cesarean section rates almost half that of the national average. So why are most American women reluctant to use CNMs? Part of the reason seems to be that midwives suffer from an unfortunate negative image in this country.

A historical perspective
Today's CNM is constantly struggling to establish her role in American childbirthing practices. This was not always the case, however. Until approximately the mid-1800s, midwives were the predominant birth attendants in the United States, and doctors were called upon only for emergency cases. With the rise of professional medicine and corresponding medical advancements such as anesthesia, medical doctors began offering specialized health care for pregnant women to expand their practices.

Some American physicians actively opposed midwives in the mid-1800s and early 1900s because they saw midwives as a threat to their profession. At the same time, American women sought physician care more frequently, despite the fact that midwife-attended births were no less hazardous than doctor-attended births.

During the early 1900s, doctors increased their focus on the pathological implications of pregnancy rather than treating it as a natural process. Judith Pence Rooks, former president of the ACNM, discusses the work of Dr Joseph DeLee, a leading obstetrician of the early 20th century, in her book Midwifery and Childbirth in America. "In 1920," Rooks states, "Dr DeLee proposed a sequence of medical interventions?[that] consisted of sedating women at the onset of labor, performing episiotomies, administering medicine to make the uterus contract, and using forceps to deliver the baby... All of the interventions from Dr DeLee became routine medical procedures for women during labor and delivery." From induced labors to the electronic monitoring of the fetus, the American model of pregnancy care has come to emphasize the systematic use of precautionary interventions to address potential complications of pregnancy and birth.

According to Alice Bailes, a CNM who practices in Virginia, "Perceptions [of midwives] are all over the map." Bailes contends, "Some people think that CNMs are substandard providers of care. Other people think that CNMs are providers of care who help women to optimize health in birth and gynecology. Others don't even know CNMs exist."

For example, Marcie Taylor*, a 28-year-old married female with no children, says that the first thing that comes to her mind when she thinks of a midwife "is an older woman (mid-40s or -50s) with graying hair, wearing a dingy white bonnet and a black knitted shawl, sending all the men out for hot water and blankets so they won't hear the screaming." Charlotte and Jim Hanahan*, parents of a two-year-old who are expecting their second child, think of "home births" when they think of midwives. Jim maintains that midwives are "quacks -- not medical professionals" and therefore feels uncomfortable with his wife using one. Sean McInnis, an unmarried 26-year-old male, says, "To be honest, I thought the practice [of midwifery] had ended in the United States and Western world. I believed midwifery was only present in third-world countries."

Midwife certification
These convictions reflect general misconceptions many Americans hold about midwifery in the United States today. In reality, CNMs are registered nurses who have completed a program accredited by the ACNM and have passed the national American Certification Council (ACC) exam. According to the ACNM, 65 percent of practicing CNMs have a master's degree, and many have completed CNM programs at such prestigious educational institutions as Columbia University, Yale University, and Georgetown University. Furthermore, National Vital Health Statistics Report data indicate that in 1997, 96 percent of CNM-attended births occurred in hospitals, 2.4 percent occurred in freestanding birthing centers, and only 1 percent of CNM-attended births took place in the home. Despite these facts, the general perception is that midwives are marginal health care providers who are not qualified to independently manage births.

"Everything is more a disease model instead of health promotion in this country," says Claudia Ravin, RN, MSN, CNM. "In this country, we focus on interventions, pharmacology, and

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