College of Western Idaho
Emotional Support of Certified or Licensed Midwives versus Obstetric Gynecologists and Certified Nurse Midwives
Sondra Jones
English 102 034W
Leslie Jewkes
10 October 2011
Abstract
The differences between Obstetric Gynecologists, Certified Nurse Midwifes, and Certified/Licensed Midwifes are often misunderstood and misjudged. The obstetrician and Certified Nurse Midwife are often seen as the more reliable healthcare professionals because they work in hospital settings. Yet, can a cold hospital room be compared to the comfort of a home? Or a doctor and nurse yelling push as opposed to a woman’s body naturally contracting as it is ready? Certified/Licensed Midwives come to the family’s home and make the mother the center of care. These healthcare professionals see that each family member is emotionally cared for not just physically. Certified/Licensed Midwives do indeed grow closer to their clients because of the one on one attention. Midwifes use a model of care that encompasses not only the physical attributes of pregnancy but the emotional health and well being of the mother. The care of the Obstetric Gynecologist or Certified Nurse Midwife often does not meet the emotional need.
Pregnancy comes with many feelings and emotions. With any circumstances there is anxiety and joy. Each woman has expectations, hopes, dreams, and fears about bringing a new life into the world. A healthcare provider can bring comfort and support to the mothers and families that are experiencing so many changes. Both an Obstetric Gynecologist’s and a midwife’s goal is to deliver a child safely into the world while providing optimum care to the mother. The emotional health of the mother impacts the pregnancy, birth and life of the newborn. A healthcare provider must offer emotional support to the mother and family and a midwife can often do this best.
Prenatal care of a woman starts when she becomes pregnant and contacts a healthcare provider such as a midwife or an obstetrician. The individual chosen to be the healthcare provider for a family can be influenced by many things: primary care doctors, family members, friends, culture and personal opinions. When a mother chooses to give birth with a midwife she generally prefers limited medical intervention. A family will choose a Certified Nurse Midwife (CNM) who generally delivers in a hospital setting or, a Certified/Licensed Midwife (CN/LM) who generally delivers in a birthing center or home setting. In 2006 it was reported by Vital Statistics that only 0.90 percent of births were outside a hospital and that 61 percent of home births were attended by midwifes (MacDorman 4). An OB/GYN and CNM has less influence and observation time because they are not frequently around families nor do they see clients as often during their pregnancy. CN/LM’s see their clients quite often, conducting home appointments and request to meet with partners and other children. A midwife is able to better emotionally support a women because of the more intimate relationship.
Some healthcare professionals feel that midwifery is not safe when practiced outside a hospital. Jeffery Kluger from Time Health reported, “It's this fact that has always been responsible for the fault line between obstetricians — who are trained to view birth as a medical procedure — and midwives, who see it as that but as something less clinical too." Midwives see birth as an experience, from conception until a family is in a new routine with the new baby. An OB/GYN sees it as a secluded event that must be dealt with and handled. Not all obstetricians feel this way; however, it is hard to get that optimum care when they have so many patients to care for.
In 2006, Idaho had 47,246 births, 45,932 being in a hospital setting and 1,301 being outside of a hospital. (MacDorman, 11) As you can see, home birth is still not generally accepted but is becoming more and more common. Throughout the country, midwifery is becoming more popular as well. MSNBC wrote an article about a family, the Teeples, delivering with local midwife stating, “The Teeples are a part of a small but growing contingent of people choosing to give birth with midwives, caregivers who view birth as a natural, rather than medical, experience and one that should be tailored to a mother’s needs” (More mothers choose midwives for delivery: Number of women giving birth without doctor has doubled since 1990) This article attests to the fact that many families are discovering the joys of giving birth with a midwife.
Generally a midwife will be able to give more time and attention to each one of her clients as she often has a fewer number of clients than an OB/GYN would. Kelley Vandersys is a proud mother of four children who has delivered once in a hospital setting with an OB/GYN, once in a hospital setting with a CNM; and twice at home with two different LM’s. In an interview conducted on the 17th of September 2011, Mrs. Vandersys, when asked about the emotional support received during and after her individual pregnancies, stated that there was “None offered from the OB/GYN or Midwife in the hospital” however, in her first home birth “some, but there was still a chasm because of spiritual beliefs” and with her final birth the LM “stepped into my home and offered support in ways I did not know I needed.”
Generally a midwife will be able to give more time and attention to each one of her clients as she often has a fewer number of clients than an OB/GYN would. Kelley Vandersys is a proud mother of four children who has delivered once in a hospital setting with an OB/GYN, once in a hospital setting with a CNM; and twice at home with two different LM’s. In an interview conducted on the 17th of September 2011, Mrs. Vandersys, when asked about the emotional support received during and after her individual pregnancies, stated that there was “None offered from the OB/GYN or Midwife in the hospital” however, in her first home birth “some, but there was still a chasm because of spiritual beliefs” and with her final birth the LM “stepped into my home and offered support in ways I did not know I needed.”
When a woman becomes pregnant her body begins to change. Hormones inside her body must adjust to provide an acceptable environment for the fetus to develop. The hormone, human chorionic gonadotrophin (hCG) developed by the placenta, notify the woman’s body that ovulation no longer needs to take place (Nilsson, Lars, 84); hCG is also the hormone that is measured on a pregnancy test. (Puryerar, 36) Progesterone, a mussel soothing hormone, (Brown, Struck, 20) and estrogen, which increases the amount of protein production that is essential for fetal growth, will also increase throughout your pregnancy. The fluctuation in these hormones can cause discomfort, sickness, fatigue or moodiness. Having these hormone changes explained in a comprehensive way will aid both mother and father in dealing with these symptoms. Midwifes are often more personable than a doctor and easier to talk to. Many people experience the feeling of walking into the doctor’s office; waiting for 20 minuets; and then not remembering any of the intended questions to ask. The doctor proceeds to talk at the client as opposed to with them. Being open, honest and curious is much easier when the healthcare provider has time to sit and go over the things you are wondering about as well as get to know you as a midwife would.
A mother’s appearance can also affect her emotional state of mind. Some mothers are happy with the way that her body is changing and love the expanding of the stomach as the child grows. Yet others are very self-conscious about the weight that is gained, as well as sexuality, appetite, energy levels, and ones general appearance. Midwifes can continually remind the mother that these changes are normal in pregnancy, giving a woman comfort through the rough days. Suggestions of new ways to sleep, positions to try to reduce pressure, home remedies or nonmedical ways to reduce discomfort can be shared with the mother. While an obstetrician or CNM may offer some of the same ideas, more medical terminology and possibly more intervention would be suggested.
Since a midwife has more communication with the woman’s family, they can make more of an investment in the daily lives of the mother she can make suggestions based on the woman’s situation. If the woman is a first time mother the midwife may suggest a taking a stroll with the partner or a friend daily or if the mother has other children going to the park and walking around or watching the children play may be encouraged. The midwife will be able to determine the correct level of exercise for each individual mother. Eliminating foods that contain allergens and making healthier food choices is always a good option. Diets and exercise if used correctly in pregnancy can greatly benefit both the mother and child. Two Medical Doctors, Dr. Michael F. Roizen M.D. and Dr Mehmet C. Oz M.D., give ideas on a diet plan in their book You Having A Baby. (82-87) Both obstetricians and midwifes can give specialized instructions to the expecting mother on how to handle food allergies and incorporate foods her whole family can eat. Since a CM or LM interaction with not only the mother but the family is so much more intimate and personal that the CM/LM may have a better idea of what is going on and get a better response.
A midwife can offer a great deal of emotional support by offering as much information as possible to the expecting family. Giving the family reasonable expectations about pregnancy, childbirth and postpartum care is critically important to the parents feeling prepared and excited for the birth. Kelly Vandersys stated, “there was an honesty” in referring to the second midwife experience. Setting up friends to bring meals, having a birth plan, making arrangements for children if they need to be cared for during the birth should all be part of a midwifes prenatal visits. This personal care can not always be given by CNM or OB/GYN’s because they have a greater volume of clients.
Screening for problems in pregnancy, as well as possible depression both during and post childbirth is highly recommended to all healthcare providers. Both midwives and obstetricians can reduce fears and frustrations by offering suggestions to mothers struggling with their pregnancy. Giving a woman medical reasons for why she is feeling the way she is as well as offering emotional comfort can aid in reducing stress and anxiety. However, sometimes all a midwife will do is sit and hold the expecting mothers hand and reassure these symptoms will go away and until they do she will be right with her which is something more difficult to do when you have a larger clientele.
A hospital setting offers some peace of mind in that there is emergency medical attention that can be given if anything goes wrong at anytime, however the majority of births that have limited to no medical intervention are completely normal.
After delivery the job does not come to an end for a healthcare provider. The mother still needs a great deal of emotional support and training. She will have questions on how to breastfeed her child if that is her choice. The midwife can teach the mother how to position the baby; how often the newborn must be feed, and how to deal with any complications. If problems arise beyond the knowledge and instruction of the midwife, a lactation consultant may be contacted but generally the encouragement and advice to solve any problems that arise can be provided. In a hospital setting instruction could be offered but not as conveniently or comfortably as in the family home or birthing center.
The mother will also have questions about what happened during childbirth. Kelley Vandersys stated that after each delivery she had no debrief in the hospital; with her first home birth the midwife spoke about the actual birth and worked though questions and concerns, and with her final birth “I was not debriefed as well… partially because my dad died the week after.” Circumstances prevented a formal debrief but the midwife kept in contact to answer any questions Mrs. Vandersys might have had. Mrs. Vandersys stated that she wished she could have had a more complete debriefing. It would seem that talking about the events of ones birth extensively would have a constructive effect on decreasing postpartum anxiety and depression, however, a study conducted by Selkirk, et al and published in the Journal of Reproduction and Infant Physiology concluded that a debriefing session with a midwife dose not decrease post pregnancy depression. (145)
Having several follow up sessions after birth is critically important; not only for screening of physical problems of the mother and infant, but also for physiological and emotional disorders. Shaila Misri, MD, et al states in a study published in the Canadian Journal of Psychology, “Our study suggests that antenatal depression and anxiety contribute to increased maternal postpartum parenting stress. Parenting stress should be included routinely in clinical assessment of women at risk.” (227) A midwife or OB/GYN should be invested in their client to the point that the professional would know what are normal behaviors for the woman, how she interacts with her children, her husband and her family. This is not always possible when you have so few visits with an OB/GYN or CNM. A midwife should be encouraging family members to help the mother care for the baby and the household. Meals should be prepared so that a husband or older child can then put in the oven themselves. Family bonding should be promoted so that each member of the family has a special connection to the new infant.
The midwife often acts as a mother figure when things are going wrong in pregnancy. She is seen as someone trustworthy and dependable. This enables the midwife to be able to more easily identify and remedy problems before they grow to extremes.
Depression; both during and after pregnancy is a serious condition that affects about 12.7 (Palladino, 953) percent of women and is not to be taken lightly by the healthcare provider. If the woman has had a problem with depression in the past or is on an antidepressant while pregnant this should be identified right away; action should be taken to determine if the medication should be continued, modified or safer drugs considered. Discontinuing all medications, when becoming pregnant, has been shown to lead to adverse maternal side affects such as serious postpartum depression or mood disorders. (Bennett, Idman, 37)
The causes of depression during and after pregnancy are many. Hormone changes, lifestyle changes, fears and apprehensions of having a child, outside stressors such as moving, financial trouble, marital problems are all stressors that could affect the mother’s moral. Diana Lynn Barns Psy. D states in her article from “Midwifery Today”, “Besides the myriad feelings that surface, the tremendous chemical changes that occur around the time of delivery and in the months following predispose women to a variety of reactions. During pregnancy, hormonal levels elevate dramatically, particularly levels of progesterone and estrogen. They drop just as dramatically, often within hours to days of childbirth. In addition, the amount of endorphins (those substances responsible for feelings of well-being) produced by the placenta during pregnancy drop significantly after delivery”
A healthcare provider must be conscious to ask questions and get personal with the mother. Once trust is gained a midwife can more easily be a supporter in whatever the mother is going through at the current time. If this emotional support is not enough it is possible that a professional physiologist may be needed to help cope with this depression.
Current studies have shown that depression during and before pregnancies have also been shown to lead to extended hospital stays (Palladino, et al 953-962) if the parents choose a hospital setting. Since CM and LM’s practice outside a hospital this cause of depression is taken out completely unless complications arise.
What is known as the “Baby Blues” is a time shortly after childbirth where the mother is slightly depressed. This could include; sadness, fatigue, anxiety, mood swings, disappointment in herself, her birth, and her baby, an emotional letdown, as well as feelings of being overwhelmed and insufficient. (Bennett, Indman, 38-39) These “Blues” as they are commonly referred to occur in seventy to eighty percent of women (Brown, Struck, 210-215; Bennett, Indman, 38-39) and is not determined to be unusual or a mood disorder. A midwife can be physically present or a spoken with immediately if these symptoms start becoming overwhelming for the mother. It is much harder to explain anxieties in a hospital and often the woman will end up talking with nurses.
More serious depression and mood disorders can occur after childbirth and the midwife must be actively looking for signs and symptoms of these destructive and dangerous behaviors. These behaviors include; depression or anxiety disorders, obsessive compulsive disorders, panic disorders, post traumatic stress disorders and psychosis. (Bennett, Indman, 39-48) The symptoms can range from extreme mood swings and feelings of hopelessness to thoughts of physically injuring the baby or themselves. If these symptoms develop the woman should be referred to a psychologist who has experience with postpartum depression. Midwifes generally do not deal with these issues. Physiologists and Medical Doctors must take the lead with the midwife as a support and point of reference.
Through each of the forms of post partum depression a woman should be assured by the midwife that she is not alone and that the feelings she is having are not her fault. A midwife can give a woman hope by reveling that others have succeeded in overcoming these illnesses and she will too. The midwife can also give personal references to the woman. A healthcare provider associated with a hospital can easily find support groups and specialists for the mother if need be. It is at times easier for the obstetrician or CNM to transfer the mother quickly to other providers in their group or network; however, a midwife will generally give more options and attempt to find someone who the mother connects with not just in a network.
A midwife can offer much knowledge and is involved in every part of the birth process. She makes suggestions, holds the mothers hand, and is a shoulder to cry on. Kelly Vandersys describes it as, “A common bond… an intimacy.” The midwife will be alert and responsive to warning signs of depression and should be involved and have gained enough trust that the mother would be willing to take her suggestions to heart. Though an obstetrician may be the more traditional route, a midwife can not only be the one to welcome your newborn baby into the world, but the guiding strength to lead you through pregnancy and beyond.
Works Cited
Barnes, Diana Lynn Psy. D. “What Midwives Need to Know about Postpartum Depression”. Midwifery Today. Spring 2002. Web. 15 September 2011.
Bennett, Shoshana S. Ph.D, Pec Indman, Ed.D., MFT. Beyond the Blues. San Jose: Moodswings Press, 2003. Print
Brown, Sylvia, Mary Dowd Struck, R.N. M.S. C.N.M. The Post-pregnancy Handbook. New York: St. Martins Press, 2002. Print
Kluger, Jeffrey. “Doctors Versus Midwifes: The Birth Wars Rage On.” Time Health. 16 May 2009. Web. 6 October 2011.
MacDorman, Marian F Ph.D, and Fay Menaker, Dr. P.H. C.P.N.P. "Trends and Chareteristics of Home and Other Out-ofHospital Births in the United States, 1990-2006". National Vital Statistics Report. 3 March 2010. Web. 2 October 2011.
Misri, Shaila MD, FRCPC, Kristin Kendrick, BA, Tim F. Oberlander MD, FRCPC, Sandhaya Norris MD, FRCPC, Lianne Tomfohr BA, Hongbin Zhang, MSc MEng, Ruth E Grunau, PhD, RPsych “Antenatal Depression and Anxiety Affect Postpartum Parenting Stress: A Longitudinal, Prospective Study” Canadian Journal of Psychiatry. 55.4 (April 2010): 222-228. EBSCOhost. Web. 15 September 2011.
“More mothers choose midwives for delivery: Number of women giving birth without doctor has doubled since 1990”. MSNBC.com. 28 October 2006. Web. 5 October 2011
Nilsson, Lennart, Lars Hamberger. A Child Is Born. New York: Random House Inc., 2004. Print
Palladino, Christie Lancaster M.D, M.Sc., Heather A. Flynn, Ph.D., Caroline Richardson, M.D., Sheila M. Marcus M.D., Timothy R.B. Johnson, M.D., and Matthew M. Davis M.D. MAPP. “Lengthened Predelivery Stay and Antepartum Complications in Women with Depressive Symptoms During Pregnancy.” Journal of Womens Health 20.6 (2011): 953-962. EBSCOhost. Web. 16 September 2011.
Puryear, Lucy J. M.D. Understanding Your Moods When You’re Expecting. Boston, New York: Houghton Mifflin Company, 2007. Print
Roizen, Michael F. M.D., Mehmet C. Oz M.D. YOU Having a Baby. New York, London, Toronto, Sydney. Free Press. 2009. Print
Selkirk, Rosemary, Suzanne McLaren, Alison Ollerennshaw, Angus J. McLachlan, Julie Moten. “The longitude effects of midwife-lead postnatal debriefing on the psychological health of mothers” Journal of Reproductive and Infant Psychology, 24.2. (May 2006) 133-147. EBSCOhost. Web. 16 September 2011.
Vandersys, Kelly. Personal Interview. 17 September 2011. 
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