Understanding the Difference: Midwifery Care and Medical Care, for Pregnancy and Birth

by Stephanie Larson,

You recently discovered that you’re pregnant, and along with your new baby-bump in progress, comes a plethora of decisions you need to make. One of the first decisions to put your attention towards is what type of care you want during your pregnancy, birth and postpartum. By default you might simply assume that you’ll be with an obstetrician (OB), but did you know you have other choices?

The choice of care during pregnancy and childbirth is an important one, and there are two main models of care to consider: the midwifery model of care, and the medical model of care. Each is different, and it’s important to understand the differences between the two in order to make an informed decision about which is your best fit.

The Midwifery Model of Care

The midwifery model of care is centered around the idea that pregnancy and childbirth are natural, normal, physiologic processes that generally don't require intervention. Care providers who practice the midwifery model of care see birth as a healthy life event, not as an illness. They consider your needs as a whole person, including your unique circumstances and family needs. 

You can choose a midwife as your care provider, even before you become pregnant. Midwives are trained professionals who provide care throughout pregnancy, childbirth, and the postpartum period. They also provide gynecological care, and family planning care. They focus on your physical, emotional, and social well-being, providing holistic care. This approach emphasizes the importance of informed choice, shared decision-making, and continuity of care.

One of the benefits of the midwifery model of care is that it leads to fewer medical interventions, such as inductions, cesareans, and episiotomies. It allows for a natural, holistic birth experience. Interventions carry risks, and can lead to more interventions and more risks. Care providers who are educated in this model are trained to understand and support the natural process of birth, including the emotions and behaviors that accompany birth. They understand the importance of not disrupting the natural flow of hormones which help birth proceed safely and smoothly. They provide low-intervention care. This can result in a more satisfying, safe, and empowering birth experience for you and your baby.

Midwives spend a great deal of time with you. You’ll see your midwife about every four to six weeks during pregnancy (or more often as you near your estimated due date), and nearly as often after you give birth. Some midwives come to you for your appointments, and they’ll stay about an hour, giving you plenty of time to talk about how you’re feeling, and ask questions. When it comes time for your birth, they’ll typically be there with you during your whole active labor if you want them to be. They’re also ready to step back if you want them to take a more hands-off role. The midwifery model of care lends itself well to personalized care that is tailored to your unique needs and preferences.

Another benefit of the midwifery model of care is the continuity of care provided by having the same midwife throughout pregnancy, childbirth, and the postpartum period. This allows for the development of a strong relationship between you and your care provider, which can lead to better communication and trust. Check with your midwife to find out if there are other midwives they work with who might be present at your birth. If so, you will usually have the opportunity to meet them beforehand, so you will get to know them and feel comfortable with them.

In the midwifery model of care, practitioners are ready to accommodate any position you decide to be in during birth, such as standing up. They also know how to catch babies in any position they decide to be in, such as breech, or posterior.

Some midwives can prescribe drugs, like epidurals, depending on the type of midwifery credentials they hold. You can find out when you’re interviewing potential care providers. While midwives don’t perform cesareans, they will recommend it to you for your consideration if they feel it is needed, and can arrange transfer of care to a surgeon if necessary.

The midwifery model of care may be a good fit for you if:

• You view pregnancy and birth as healthy life events, not illnesses
• You want to avoid unnecessary interventions and their risks
• You like personalized care and a close relationship with your provider
• You had a prior cesarean and you want a vaginal birth this time (VBAC)
• Your baby is in a breech position

The Medical Model of Care

The medical model of care, on the other hand, is centered around the idea that pregnancy and childbirth are medical conditions that require close monitoring, management, and intervention by surgeons. Obstetricians are the primary care providers in this model. Their expertise and the bulk of their training is in performing cesarean surgery. This approach emphasizes the routine use of medical interventions and technology. Due to the current prevalence of the medical model of birth in the US, 32% of births are by cesarean, compared to only 5% in 1970.

One of the benefits of the medical model of care is the ability to provide care in high-risk pregnancies and during complicated births. Obstetricians can perform cesarean birth (surgical birth), vacuum-assisted birth, or birth with forceps. Additionally, the medical model of care is able to provide access to advanced technology, such as ultrasound and fetal monitoring, which may provide valuable information. 

However, something to consider with this model of care is that it can actually be the cause of complications or even false emergencies. For example, electronic fetal monitoring has been shown to increase cesarean births without improving the risk of stillbirth. As another example, the routine intervention of inducing labor (forcing it to start), can lead to fetal distress, which can lead to emergency cesarean birth. Upon having an emergency cesarean you may think it was lucky you were in the hospital with an OB, because you needed an emergency cesarean. But without the medical intervention of the induction in the first place, the cesarean could have been avoided. This is called iatrogenesis, which is when a medical activity causes a harmful complication.

Another benefit of the medical model of care is the availability of pharmacologic pain management options (drugs), such as epidurals, which can provide significant pain relief during labor and birth. 

However, the medical model of care also has its drawbacks. There will be many medical protocols and interventions which are routine, and you’ll have to advocate for yourself if you want to reject these. This can lead to a more tense and less satisfying birth experience. You may feel like you’re just another pregnant person on a birth conveyor belt, instead of an individual. Additionally, the continuity of care may not be as strong in the medical model, since you may see multiple care providers throughout your pregnancy and birth. You’ll typically see your provider less often than in the midwifery model, and only for about ten minutes each visit, which is not enough time for them to get to know you fully, or for you to ask all of your questions. Additionally, in the medical model your care provider may not be present during your labor and usually doesn’t come in until your baby is crowning, right in time to catch and then leave.

Obstetric violence, (coercion, humiliation, acting without consent, withholding care, taking baby away, not letting you push because the doctor isn’t there yet, etc…) is more likely to occur with the medical model of care. The emphasis is often on the provider making the decisions and expecting your compliance, instead of on informed consent (explaining the risks and benefits of all the options and giving you time to think it through and decide for yourself).

Another drawback of the medical model of care is that the providers are often unwilling or don’t know how to support you in any position you decide to labor and birth in. They usually prefer for you to be in bed, and on your back. If your baby is breech they may want to do a cesarean because they haven’t had training in catching a breech baby.

The medical model of care may be a good fit for you if:

• You view pregnancy and birth as medical events
• You have a planned cesarean
• You prefer extensive monitoring and interventions
• You only need ten minutes with your provider during visits

Titles Won’t Tell You Which is Which

Now you understand the difference between the two models of care, and can decide which one suits you best. But you need to know this important caveat. Titles won't tell you who practices which model of care. It's not as straightforward as you might think. There are some obstetricians who practice the midwifery model, and there are some midwives who practice the medical model. It depends more on the way they were educated than on their title. If they got most of their training in a hospital setting, then they learned that birth is a medical event that requires medical management. If they got most of their training in home or birth center births, then they learned that birth is a natural process that shouldn’t be interfered with unless absolutely necessary. The only way to know which model of care a provider practices is to ask them a lot of questions about how they practice, and their attitudes towards birth. 

Ultimately, the choice between the midwifery model of care and the medical model of care is a highly personal one that should be based on your preferences and needs. Ask lots of questions so you can determine which care provider is best for you. You can always change providers at any point if you’re not happy with your care.

Sources:

Jansen L, Gibson M, Bowles BC, Leach J. First do no harm: interventions during childbirth. J Perinat Educ. 2013 Spring;22(2):83-92. doi: 10.1891/1058-1243.22.2.83. PMID: 24421601; PMCID: PMC3647734. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647734/ 

American College of Nurse Midwives ‘Comparison of Midwifery Credentials in the US’ https://www.midwife.org/acnm/files/ccLibraryFiles/FILENAME/000000006807/FINAL-ComparisonChart-Oct2017.pdf 

King T, The Effectiveness of Midwifery Care in the World Health Organization Year of the Nurse and the Midwife: Reducing the Cesarean Birth Rate. Journal of Midwifery and Women’s Health. 31 January 2020 https://doi.org/10.1111/jmwh.13089 https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.13089