Well, hello there! I'm back into full swing of nursing school- the final 10 months! I'm taking a break from studying about mental illness to talk about something I really love- women's health. (I just don't have any interesting "love" or "camo" topics so I'll bore you with the "other stuff.") I get asked these questions a lot- "What's the difference between an OB and a midwife?" and "What's the difference between a midwife and a doula?" It can be really confusing at first, so I'm gonna break it down for you.
Obstetrician
An obstetrician (OB) is a physician who is inherently a trained pathologist and surgeon. This means OBs are specialists in pregnancy-related diseases, complications, and surgery. An OB first earns a four year degree, then goes to four years of medical school. After those eight years of college, the now MD goes on to more speciality training in his/her field- obstetrics- usually for another four years. (That's a total of 12 years.) They do learn about low-risk, "normal," vaginal birth, but what they are really good at is the high-risk, complicated pregnancies that often necessitate interventions such as medication and surgery. Because OBs have been trained to treat diseases (and fear litigation if they don't act soon enough), care with an OB tends to be very medicalized and full of routine interventions (medications/actions that are done to every woman, whether she needs it or not). Most women in the US see obstetricians for their care even if they are not high-risk. This system is unlike most other countries in the world. Most other industrialized nations have a system in which everyone sees a midwife first, and if her pregnancy is high-risk or complications arise, she is referred to an OB. We have this system for every speciality except obstetrics. For instance, if you have high blood pressure and a heart murmur, your general physician can prescribe medication and monitor your murmur. That may be all the care you need and GPs are generally very good at what they do, even though they are not "specialists" in cardiology. However, if your GP feels that your heart condition is beyond her scope, she will refer you to a cardiologist. Obstetricians see patients for their prenatal and postpartum care usually in an office, and attend births in a hospital.
Midwife
In the US, there are two different kinds of midwives- direct-entry midwives (Certified Professional Midwife) or midwives that were nurses first (Certified Nurse Midwife). Both are master level degrees, however some states do not allow CPMs to practice midwifery. I will be mainly speaking about Nurse Midwives, however midwives who were not nurses first have just as much merit and worth as CNMs.
CNMs first complete approximately two years of college courses to qualify them to enroll into a nursing program where they become Registered Nurses. After completing a bachelor's degree in nursing, an RN then goes on to becoming an advanced practice nurse with a focus in midwifery. This master's degree gives the RN a new title- Certified Nurse Midwife. The scope of practice for CNMs vary throughout each state, but are generally the same. CNMs have the same level of degree as Nurse Practitioners, but have specialized in the care of pregnant women. Midwifery tends to be more hands-off than obstetrics- waiting until there is an actual problem to act and tailoring care to each individual need instead of routines for all women. Appointments with midwives tend to be a bit longer and have a more holistic focus. This means that midwives put an emphasis on nutrition, exercise, emotions, and thoughts, as well as the basic assessments such as blood pressure, weight, uterine growth. Midwifery tends to be more low-tech, relying more on skills than technology. For example, using a measuring tape and feeling the uterus to estimate fetal size rather than using an ultrasound machine. Midwives tend to be more trained in "normal variations" of vaginal birth. For instance, midwives tend get more training in vaginal breech birth (buttocks or feet first instead of head first), whereas an OBs "go to" for breech birth is cesarean section. (I have a friend in medical school. He told me that his training for breech birth was watching a 20 minute video in class. After the video, the instructor said, "Well, you don't really need to know this anyway because you'll just section.") Midwives appreciate the mind-body connection and understand that things like fear and anxiety can stall labor. Midwives also tend to try least invasive alternatives first, such as upright pushing to use gravity, instead of an episiotomy (an incision to the vagina/perineum). CNMs work in hospitals, birth centers, and attend home births. CPMs attend births in out-of-hospital settings, such as birth centers and at home. Ideally, midwives work closely with OBs in the event that transfer of care is necessary. Midwives are trained how to deal with complications that may arise such as neonatal CPR, administration of emergency medication, how to control a hemorrhage, and suturing tears.
*Disclaimer: These are broad generalizations. Every practitioner is different. There are many OBs who are hesitant about routine interventions and do more individualized care. There are many OBs who strongly support natural childbirth, avoiding surgery if possible, and advocate for a woman's right to make her own decisions about birth. You will also find CNMs who are highly medicalized, do not respect autonomy, and perform many routine interventions. It is always important to interview multiple providers to find one who is a good fit for you.
Doula
A doula is a non medical person whose sole purpose is to comfort and support a laboring woman. A doula does not do internal exams, check blood pressure, run tests, clamp the cord, etc. There are lay doulas (one without a certification) and certified doulas. There are various certifying bodies, but the training is about the same. One must read a handful of books about birth and breastfeeding, write a paper about the books, attend a certain number of births with a certified doula, attend a childbirth education class for pregnant women and their partners (such as Lamaze or Bradley), take a test, and pay a fee. Those that are not certified have typically done many of these things as well. A doula does not replace family members/loved ones, but is a birth professional who supports, encourages, and comforts before, during, and after labor. Most hospitals do not include a doula in their "count" of people allowed in the room (if hospital policy states only two people can be in the room, it usually means two family members plus a doula.) Most doulas understand the importance of loved ones being involved in the birth and will encourage them to stay engaged and focused on the laboring mother. Generally, a pregnant woman and her partner will meet with a doula 1-2 times before the birth. These meetings including becoming comfortable with one another, sharing information about possible interventions so a woman can make informed decisions, and making a birth plan- talking about the goals and desires for birth and ways to achieve those goals. For instance, if avoiding pain medication is really important to the woman, she and the doula will talk about other pain management options and establish a code word to use if the mother changes her mind during labor. The doula's goal is to help the woman have the birth she desires, no matter what that looks like for each individual client. Doulas are a source of information and bring to the birth a calmness, assuredness, and peace. Doulas tend to manipulate the environment to make it conducive for a happy, relaxed, and healthy birth. She may do this by dimming the lights, playing soft music, or using aromatherapy. Doulas help manage discomfort by giving massages, suggesting position changes, using therapeutic movement, encouraging hydrotherapy (warm bath or shower), and offering food and drink. Doulas also recognize the mind-body connection and help women to discuss their worries and fears and use supportive, encouraging words. A doula's job is to trust a woman's innate ability to birth her baby and helps a woman to have the same confidence in herself. A doula stays with a mother through early labor, active labor, pushing, birth, and initiation of breastfeeding (she will stay to support a woman usually up to two hours after the birth.) Doulas go wherever their clients labor and deliver. Studies have shown that this continuous support leads to fewer complications and interventions, higher breastfeeding success, and a more satisfying experience. Some hospitals are noticing this effect and are starting to implement their own doula programs. The rates for doulas vary widely depending on the area and actual doula; the range can be between $400-$1,500.
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