All About Midwives

Ann Ledbetter:

That’s a hard question, because I don’t want to stereotype. I think there’s a lot of overlap. I will say that as midwives, we’re really trained to appreciate the physiological aspects of labor. On average, you’re going to see midwives doing more things like different positions for labor and birth. Midwives are big supporters of hydrotherapy and alternative pain control methods during birth. I would say fewer of our patients choose to get an epidural. We’re big supporters of vaginal birth after Cesarean, in general. Over the years, I think that midwives have really been pushing the envelope, in hospital birth, about what options are given to women. Skin-to-skin and delayed cord clamping are really common in midwifery care. Now they’re even becoming more common in obstetric care, in part because midwives have really pushed for policies like that.

Emily Oster:

We talked recently, and I had sent you something I wrote about midwives, and I used the phrase “delivered.” You wrote back and said, “We don’t say ‘delivered’; we say ‘attending birth.’ The midwife attends the birth.” I thought that was such an interesting linguistic term, but underlying such a different attitude to what your job is.

Ann:

I am not going to say I never accidentally slip up and use the word “delivered,” but as midwives, we really do prefer to say “attended birth.” In fact, I submitted an article to a journal and they responded. It was a midwifery journal, and they were like, “Go back, and every time you said ‘delivery,’ change it to ‘birth.’ ” So it’s not just me. It is parlance, in midwifery-speak, that we don’t like to use the word “delivered” because I think it gives a little too much credit to the provider and not enough to the mom — because this baby’s here because this mom did a ton of work. Gestating a baby, pushing out a baby, it’s no joke. So for me to show up at the last minute and say, “I deliver unto you your baby…” So when you’re speaking about it officially, [midwives] like to say, “I attended a birth,” not “I delivered a baby.”

Ann:

Labor support is key. Birth is really freaking painful, and if you don’t have supportive people in that room helping you through it, it’s nearly impossible. I am not against epidurals. I think they can be a really useful intervention. I even have times that I recommend them to people — people who’ve been in labor for days, people who are at their wits’ end. I don’t think it’s a bad choice. I think there are very good reasons to get an epidural sometimes, but I also think that women are inherently capable of childbirth. For women who don’t want an epidural — and there are really good reasons to not want an epidural — it’s my job to support them.

Emily Oster:

Midwives are having a bit of a moment. Of course, that moment is not at all new. For a very, very long time, hundreds, possibly thousands of years, midwives or people who were effectively midwives were delivering all babies. In my mind, they wear little white caps and ride their bicycles to the hospital, but that is based entirely on Call The Midwife.

Emily Oster:

Ann Ledbetter, thank you so much for joining me.

Ann Ledbetter:

Hi, Emily. Thanks for having me.

Emily:

I’d love to start by just having you tell people who you are and what you do.

Ann:

My name is Ann Ledbetter. I’m a Certified Nurse-Midwife in Milwaukee, Wisconsin. I work at a federally qualified health care center, which is a kind of clinic that’s designed to provide care to an underserved population. The majority of my patients are on Medicaid insurance and they tend to come from the Spanish-speaking immigrant community of Milwaukee.

Emily:

I’d love to talk a little bit about what you do as a midwife, and almost to start by level-setting about what is a midwife and why is it different from an obstetrician. I think many of us have, most of our contacts come from that television show Call The Midwife.

Ann:

That’s a great show.

Emily:

I’m curious if you wear that type of uniform, if you ride a bicycle. Anyway, say more. Seriously, it would be great to just hear a little bit more about midwifery, in general, from you.

Ann:

My job as a midwife is split between two settings. One is the clinic. In the clinic, I’m mostly doing prenatal care. I would say about 80% of my patients are pregnant, but I’m also doing some basic GYN care, pap smears, contraceptive care, procedures like Implanons, Nexplanons, and IUDs, that kind of thing. In the hospital, it’s a different approach, but basically, when I’m on-call, it’s a twelve-hour shift and I am providing care during birth to anyone who comes in, I’m attending that labor and that birth, I do postpartum rounds, OB triage. My practice, we even do circumcisions.

Emily:

In terms of what you do… And let’s talk about the birth part specifically. How is what you do different from what an OB would do, if it is?

Ann:

That’s a hard question because I don’t want to stereotype. I think there’s a lot of overlap. I will say that as midwives, we’re really trained to appreciate the physiological aspects of labor. On average, you’re going to see midwives doing more things like different positions for labor and birth. Midwives are big supporters of hydrotherapy and alternative pain control methods during birth. I would say fewer of our patients choose to get an epidural. We’re big supporters of vaginal birth after Cesarean, in general. Over the years, I think that midwives have really been pushing the envelope, in hospital birth, about what options are given to women. I think about a coworker of mine who, about 20 years ago, spearheaded this effort to change the unit policy so that all babies were handed directly to their moms after birth rather than being separated. Skin-to-skin and delayed cord clamping are really common in midwifery care. Now, they’re even becoming more common in obstetric care, in part because midwives have really pushed for policies like that.

Emily:

Yeah, you guys were out ahead on both of those things, which have quite good evidence behind them. I want to talk about, from an individual standpoint, how people would think about choosing a midwife versus an obstetrician for their individual birth. Because this is a question that comes up for many people. You have to choose a provider. These are different kinds of providers, and my sense is that for a lot of people, their perception is “A midwife is appropriate if I want to have a baby at home or if I’m committed to no pain medication.” Let’s just start with the question of are those stereotypes accurate?

Ann:

I do feel that people who want to have an unmedicated birth are really great candidates for midwifery care, and I think they’re likely to get the support that they want during their birth. But I do not think they’re the only candidates for midwifery care. Personally, I work with a patient population that really isn’t seeking midwifery care per se, but they do great with us. I think most of my patients come to my clinic because it’s a bilingual clinic that accepts Medicaid insurance, not because they’re seeking some certain kind of birth experience. But because they’re mostly receiving care from midwives, they do have lower epidural rates. I think that there’s a whole lot of women who probably fall into this category of somewhere in between someone who wants a lot of medical intervention and someone who wants none. I think midwives are really great providers for those people as well.

Emily:

One of the things a lot of people talk about is the idea of midwives as appropriate for low-risk births. What does that mean? Is that true?

Ann:

Yeah, good question. Good question. I really don’t love the high-risk/low-risk dichotomy because in my experience, so few women fit neatly into one or the other. There’s probably a small percentage of women that have zero risk factors whatsoever. They’re very low risk. Then there’s women who are obviously very high risk. But I would say most people fall into what I would call a medium-risk category, and I take care of a lot of those patients. For example, as a midwife, I take care of women of all different body sizes, all different ages. I’ve had patients as young as 13 and as old as 47. I take care of patients who have risk factors like complications in a prior pregnancy, people who’ve had a preterm birth, preeclampsia, who had a C-section for their last birth. That’s a really common patient for me to care for.

Emily:

Can we talk about that time, because one of the biggest… Complaints might be a little strong, but concerns that women expressed to me about their prenatal care and birth experience is a lack of time. “I was in the doctor’s office. I didn’t get a chance to ask my questions. I forgot something. The appointment was very short.” This comes up all the time, and you talk now, and you and I have talked in the past, about the value of time and the fact that in midwifery care there is more of that time.

Ann:

It probably varies, again, based on physicians, and I don’t want to stereotype or say that everyone practices a certain way, but I do know from talking to obstetrician colleagues that they’re often seeing many patients in a day, let’s say 25 to 35. In contrast, the midwives that I’ve talked to and myself, it’s more common for us to see maybe between 15 and 20 patients a day, so there’s just more time.

Emily:

Why is it useful to have… It’s such an ambiguous question because I think we can talk a little bit about the data and we can talk about the data on birth outcomes. You’ve talked about the data on epidurals. I think this is a place where the share of people who are having epidurals, even if you’re pulling in a population who is not particularly coming and intending not to have an epidural, you are going to have a lower epidural rate with midwifery care than obstetrics. I think that shows up in the data, but do you have a sense of why? What are you doing?

Ann:

Oh, that’s such a good question. I’m going to say it. Labor support is key. Birth is really freaking painful, and if you don’t have supportive people in that room helping you through it, it’s nearly impossible. I am not against epidurals. I think they can be a really useful intervention. I even have times that I recommend them to people, people who’ve been in labor for days, people who are at their wits end. I don’t think it’s a bad choice. I think there are very good reasons to get an epidural sometimes, but I also think that women are inherently capable of childbirth. For women that don’t want an epidural, and there are really good reasons to not want an epidural, it’s my job to support them.

Emily:

Unfortunately, it is possible. We talked recently, and I had sent you something I wrote, it was about midwives, and I used the phrase “delivered.” “The midwife who delivered your baby.” You wrote back and you said, “Here are some comments on this piece. One thing is we don’t say ‘delivered,’ we say ‘attending birth.’ The midwife attends the birth.” I thought that was such an interesting linguistic term, but underlying such a different attitude to what is your job.

Ann:

Yeah, that’s a really good point. I am not going to say I never accidentally slip up and use the word delivered, but as midwives, we really do prefer to say “attended birth.” In fact, I submitted an article to a journal and they responded. It was a midwifery journal, and they were like, “Go back, and every time you said delivery, change it to birth.” So it’s not just me. It is parlance, in midwifery speak, that we don’t like to use the word delivered because I think it gives a little too much credit to the provider and not enough to the mom, because this baby’s here because this mom did a ton of work. Gestating a baby, pushing out a baby, it’s no joke. So for me to show up at the last minute and say, “I deliver onto you your baby…”

Emily:

It’s like Amazon. It’s like same day Prime delivery.

Ann:

I feel like it devalues everything she did, which is most of the work. I think of myself sometimes, almost like the coxswain of a boat. As a midwife, I’m not the one rowing the boat. I can’t make the boat go faster, but I do have a pretty clear view of the finish line and a pretty good view of the conditions. I can tell if the waves are getting choppy. It’s definitely teamwork. I’m not going to say that I don’t have an important role, but I would not give myself the credit by saying, “I delivered this baby.” That’s why you’ll hear a lot of midwives… We’ll talk colloquially, “I caught babies.” “How many babies did you catch this weekend?” That’s how we talk to each other. When you’re speaking about it officially, we’d like to say, “I attended a birth,” not “I delivered a baby.”

Emily:

I want to talk about data because there is some data on the impact of midwifery care on birth outcomes, and I think you and I differ a little bit in what kinds of data we would want to rely on there. I want to set the stage a little bit and then we can talk about where we agree and where we disagree.

Ann:

Sure.

Emily:

One thing one might imagine doing is comparing women who have a midwife to women who have an obstetrician, and that, as a general approach, if you don’t do any other adjustments, doesn’t really work because the kind of women who are selecting into midwifery care are going to be different on average.

Ann:

True.

Emily:

There is then a version of studies like that that tries to hold more things constant across women, tries to compare more comparable women with different kinds of care. Then there are randomized trials in which people are randomized into midwifery care or not. I am generally of the position, let’s say. Always maybe a little strong. I’m generally of the position that I want to rely on the randomized trials. When you look at the randomized trials, there definitely are some benefits to midwifery care. They are real, but in magnitude, relatively small. Something like a reduction in Ceasarean section, but 1 or 2%. An increase in the chance of a spontaneous vaginal birth, so vaginal birth without forceps or epidural, but maybe a 5% increase. Real numbers, and certainly there’s nothing that would suggest that midwifery care was less good, but if you asked, “Is this a little bit better, a lot better?” The numbers are relatively small.

Ann:

I’m not opposed to the idea of an RCT. In fact, I think it’s kind of crazy that that’s not been done in the United States. That would be a fascinating result to see in the US, if we randomize women to either obstetric or midwifery care, what kind of outcomes are we going to get? But I really wouldn’t hang my hat on that result because I think people behave differently when they’re being watched and in an RCT…

Emily:

Yeah. Tell me more about what you mean by that.

Ann:

Supposing we had this hypothetical RCT where people are either being cared for by obstetricians or midwives. Those care providers are both going to be working really hard. They know they’re competing. They’re going to be trying to get the best outcomes possible. I think that both groups will probably have really good outcomes, and in the end, there may not be a very big difference. But I think, “How do we translate those results to the real world then?” Just because the circumstances are this way during an RCT, that doesn’t mean that’s how they are in the real world. In the real world, the pressures on obstetricians and midwives are different, so I think we can expect something different from our RCT than what happens in the real world, which is why I think the retrospective data is really valuable to us because that’s showing us what actually happens in the real world.

Emily:

In a sense, I think what you’re arguing for, maybe we could both agree, is that we need better, almost natural experiments. Cases in which people show up at your clinic and they show up not because they’re seeking out a particular kind of care, but because that’s available and what Medicaid will pay for. Because that kind of data is almost more what you want than either a very controlled RCT or a retrospective study in which you’re comparing people who are selecting one thing to another, which is potentially quite biased.

Ann:

That’s the experiment I would love to see, the study, because I think that’s more common than people even realize. I think midwives have this reputation as caring for the most easy patients, like, “Your patients are all well-educated. They’re mostly not women of color,” but that’s not my population. I see patients who really span the gamut of different life experiences, and I wouldn’t say at all that my patients are “low risk.” Being at a federally-qualified health care center, we’re seeing the patients with the most difficult socioeconomic circumstances, and yet my practice… I don’t want to brag, but we get midwifery outcomes, the same outcomes that you’re seeing with people who are choosing midwifery care for other reasons. I think there’s plenty of opportunity for a natural experiment. There are also some health care systems that are starting to send low-risk patients to midwifery care, and this is how it’s done in many parts of the world.

Emily:

Every place… Exactly. It’s an interesting case in which in the US, the share of births with midwives has grown over, it’s about 12% now, and most of those are in hospitals, but in most of Europe, it’s like enormously large share. That’s the default, as opposed to it being a weird choice.

Ann:

Yeah, which is another thing. I think some of those RCTs that you were looking at, Emily, they’re from countries where a midwifery is more normative. I wouldn’t expect there to be a huge difference in the Netherlands between OB care and midwifery care, because I think that midwifery care is the norm there. Even a Dutch obstetrician is probably intervening less than an American midwife because we’re all attending births in certain cultures, and I think the culture of a labor and delivery unit is this factor that we’re not really able to parse out, but I think it makes a huge difference in birth outcomes.

Emily:

This morning, I was reading an email from one of the people who works on a different podcast that I work on who had just had her baby in the Netherlands, and she had a baby at home with a midwife, even though she was two weeks overdue. She said it was great, very fast, the third baby, so it just popped right out.

Ann:

Oh, that’s cool.

Emily:

She was writing to tell me how great postpartum support is in the Netherlands, which I thought was… It was a little troll-y, but that’s for perhaps a different podcast.

Ann:

Well, hopefully not. Hopefully, it’s not a chaotic scene. As a midwife attending hospital births and caring for a patient population that can be fairly higher risk, I find that I’m consulting an OB and maybe half of the cases, and when there’s time, which hopefully is most of the time, the obstetrician will come in the room and meet the patient and say, “I’m here just in case there are any complications.”

Emily:

Yeah, healthy mom, healthy baby.

Ann:

Yeah, yeah.

Emily:

Can I ask why you got into this?

Ann:

Oh, good question. I grew up in rural Iowa, so I don’t even think I knew what a midwife was, growing up. I went to college and I was following a pre-med track, but I happened to get in an anthropology one-on-one class where I learned about midwifery for the first time. I learned that not only is it a thing, it’s something that’s very common in other parts of the world. Then I ended up majoring in anthropology, and I took a lot of classes in reproductive anthropology, and I read a really good book called Birth in Four Cultures, where that was what tipped me off to the fact that a lot of birth, it’s tradition.

Emily:

You’re trained as a nurse, you’re a Certified Nurse-Midwife, right?

Ann:

Yeah.

Emily:

Can you say a little bit about what that involves and why that’s different?

Ann:

Yeah. In the US, the most common track to become a midwife is the CNM route. I was not a nursing undergraduate major, so I had to do a program that caught me up on the BSN portion, so I had a slightly longer master’s degree program, where I first became a BSN and then became an MSN, master’s of science and nursing. It’s sort of the same degree that a nurse practitioner would have.

Emily:

Then you trained as a midwife?

Ann:

Yeah. The master’s program I did, I became a nurse, and then I did the midwifery portion, which was two years. During that time, I actually also worked as a labor and delivery nurse, and that was a really interesting comparison and experience for me between getting to see what birth was like on both sides, the obstetric side, and then also learning about midwifery and also attending births with midwife preceptors, and comparing the differences.

Emily:

What is the most significant difference?

Ann:

Oh, gosh. I don’t know. As midwives, we have this really strong belief that the female body is capable of vaginal birth. I think that applies to people of all different races and ages and body sizes. So I feel like as midwives, we come at it with a respect for birth. I would use the term physiologic birth. I think we have a strong bias towards allowing labor to come on its own and progress normally. We don’t tend to intervene unless we think there’s something wrong. Time spent with patients is definitely a difference. I’m a midwife, I’m not a doula, and I think it’s really important that people understand the difference between midwives, who are health care providers, and doulas, who are not. But I do think that a big part of my job is being a doula, supporting people in labor.

Emily:

That’s interesting. Do you do home births?

Ann:

I do not, no.

Emily:

What do you think about…

Ann:

It’s ok. You can ask.

Emily:

What is your orientation towards home birth? Let me ask it in that light there.

Ann:

I would say another feature of midwifery care is that we do believe that home birth is a good option for some people, and I am very supportive. I’ve had friends and neighbors who chose home birth, and I thought that was a great decision for them. That being said, I don’t feel that home birth can ever take the place of hospital birth. We really need to offer women options in the hospital, as well. I think that home birth can never take the place of hospital birth on a large scale because there’s too many people that either want an epidural that’s, like we talked about, a very reasonable choice. I would say at least 50% of moms want that, or will want that while they’re in labor. That’s obviously an option that’s only available in the hospital.

Emily:

I really share this frustration because I think so much of the pull, almost, of a home birth is just, “I don’t want to be pushed into the following…”

Ann:

Interventions.

Emily:

Interventions that I might… When I had my first kid in the hospital with… I had both of my kids in the hospital, they’re pretty different experiences, but with the first one, I said, “I don’t want an epidural. I’m not going to…” They were like, “Okay, as soon as you get in, we’ll hook you up to an IV.” I was like, “Why? I have no risk factors. There’s no reason to do this.” They’re like, “That’s the policy.” It was like, then I will not be able to move around. I’m not going to be able to shower. All of these things meant, basically, we ended up being like, “Let’s wait as long as possible to get to the hospital because you’re going to make me do all this stuff, and when I show up, I’m going to have to wait in triage for an hour while they…”

Ann:

I think it’s unfortunate, and depending on where you live, you might have more options. I was the support person for my sister when she had a water birth at a hospital in New Jersey, and that was a really awesome experience. Again, midwives are really pushing the envelope in what’s possible in hospital birth. Even in Milwaukee, a hospital recently opened a water birth suite, and it’s attracting a lot of attention because some women really want that experience, and the room is beautiful, and it will be a great place to have a low-intervention birth, which is what a lot of women are seeking.

Emily:

It seems like with many things, something in the middle, some kind of middle ground, would be helpful. It’s hard. I’m an economist, so I’m always looking for what’s the economics and what is the reason for this? But this is actually a bit of a confusing one, because midwifery care tends to be less expensive than obstetric care for a bunch of different reimbursement reasons. It’s part of why Medicaid, I think, has sometimes started to have this be a good option because there are many reasons why it costs less. The economic incentives are a bit more complicated than just, “Of course we don’t have this because it’s expensive.” It’s actually not necessarily more expensive.

Ann:

Right. It is a little complicated because it’s also true that in certain states, midwifery care is reimbursed at a lower rate. When that’s the case, of course, it doesn’t make any sense for health care companies to invest in midwives because they can only bill a certain percentage less than if they had an obstetrician deliver the same baby. I think there’s various ways we could incentivize midwifery, but unfortunately, our country, our health care system, as I’m sure you know, Emily, it’s really not a consumer-driven health care system. I think if it were, we’d see midwifery really take off because women’s interest in midwifery has really spiked over the last decade. Yet, there are hospitals who won’t give midwives admitting privileges. Midwives often aren’t included on hospital staffs, and they don’t have voting rights about decisions. Then there’s the Medicaid reimbursement problem. There’s a lot of unfavorable laws that make midwifery difficult to practice in many states, including my own. Yeah, it’s going to be a long road, but I am hopeful, too.

Emily:

We could all be hopeful, and it is true that the trends… We can end on a hopeful note, which is that the trends have moved very much in this direction. In the past maybe 10 or 15 years, actually, the share of births attended by midwives has gone up quite a lot in the US.

Ann:

Yeah.

Emily:

See, it’s like a positive note.

Ann:

Yeah.

Emily:

Before you go, let me ask you. You attend a lot of births. What is your favorite moment in a birth?

Ann:

Oh, I love this question. Oh, I love this question. Nothing compares to passing the baby to the mom for the first time. There’s usually so much relief in that moment. I also think one really beautiful thing I get to witness all the time is… I don’t know, I call it the postpartum kiss. Usually, if a partner’s been with his partner for this labor, and he’s seen this really hard thing take place, often, his respect for his partner has gone up a ton. Usually, there’s this moment where they kiss. I would say it’s like two minutes after the birth, once we’re totally sure that everything is fine, and the baby’s breathing and crying and on the mom’s chest, that’s a really beautiful moment for me, and I feel really blessed that I get to witness that all the time.

Emily:

That is amazing. Tamar, don’t cry. Ann, thank you so much for being here. This was really a treat.

Ann:

Yeah, thanks for having me. I appreciate it.