Choosing a care provider is one of the most difficult decisions a pregnant mom has to make, and definitely the one with the most far-reaching consequences for her birth experience.
In South Africa, where gynaecologists are the default care providers, most moms find it daunting to go against the stream and choose midwife care, despite the fact that the World Health Organization identifies a midwife as the medical professional most suited to caring for a normal, low risk pregnancy. One of the reasons moms find this a difficult decision, is because there is a very poor general understanding of what midwife care means, and definitely endless misconceptions.
There are in fact, a great many similarities between midwife care and gynaecologist care, which may put a mom at ease, and there are also several differences, which may encourage a mom to pursue the birth she desires. Although there are infinite variations of these scenarios, we take a look here at a midwife-led birth in an active birth unit inside a hospital, compared to a gynaecologist-led birth in a standard labour ward.
- The medical team
A great, common misconception is that a midwife works in isolation. This is simply not true. Just as the gynaecologist works in a team consisting of midwives, anaesthetists and paediatricians, with the gynaecologist being the main care provider, similarly the midwife is part of an established network of hospitals, gynaecologists, anaesthetists, paediatricians, sonographers, paramedics and ambulance services, all working together under the midwife’s lead to care for the mother and baby.
- Care during pregnancy
The frequency of appointments and what checks are performed, is nearly identical. Midwives, like gynaecologists, do monthly check ups, measuring the baby’s growth and heart rate, mom’s blood pressure, urine values and blood values when required. While gynaecologists do a scan at every check-up, the midwife sends the mom for sonars at either a gynaecologist or sonographer only at clinically important points in the pregnancy (12 weeks, 20 weeks and 36 weeks) with more sonars requested only if needed.
A major difference in this regard however, is that the midwife places much more additional emphasis on the mom’s holistic health and wellbeing, birth preparations and expectations, and consultations last an average of 45 minutes, compared to the average of 15 minutes that a gyne visit takes. This means that a much deeper relationship is established with the midwife.
Very few gynaecologists in South Africa is willing to let a mother go past 40 weeks and would rather schedule an induction. Midwives, however, are very comfortable with mothers going up to 42 weeks, as long as mom and baby’s conditions allow, and will conduct all the necessary checks to make sure it is safe to continue the pregnancy.
- Early labour
When birthing with a gynaecologist, a mom is typically at home on her own during early labour, and has to take the decision of when to go to the hospital largely on her own, which can be a daunting decision and she may end up being either sent back home, being admitted very early, or arriving too late. Once she is admitted and under care, she is usually “on the clock” and a time limit is often placed on how long she then has to deliver the baby.
The midwife, on the other hand, is available per telephone or whatsapp from the first contraction, monitoring the mom’s progress and advising the mom on comfort measures, how to help establish progress, and when to meet at the birth venue. Often the midwife will conduct a home visit to establish progress before moving the mom to the birth venue.
Upon arrival at the hospital, the mom birthing with a gynaecologist will generally enter through the main reception, and mom will be taken for evaluation while the dad stays behind to complete admittance administration. The midwife, however, will meet the mom outside in the parking lot and assist her with going straight to the birthing room which is already prepared with a hot bath, candles and soft lights. Once the mom is settled, the midwife will assist the dad with admittance administration right there in the birthing room.
- The birth
The conditions a mom labours under is generally very different in the two scenarios. Most hospitals will allow a mom to walk around during labour, some provide a birthing ball, and a very few will allow the mom’s choice of music or dimming of lights. In most cases, standard hospital atmosphere and bright hospital lights are the norm, with various nursing personal coming and going as shift changes take place and the hospital midwives see to various patients. Only a few hospitals allow mom to eat during her labour. For the greatest part of her labour, the mom will be attended to by a hospital midwife that she has never met before, who will monitor her progress and decide when it is time to call the gynaecologist, who would typically be there in 10-15 minutes.
When birthing with a midwife, the atmosphere in the birthing room is entirely up to the mom – lights are low, she can burn candles or oils, play her own music, put up motivational posters and is encouraged to take in fluids and light snacks. The mom will be allowed to labour while walking around, on a birthing ball, in the shower, in a hot tub or on a birthing stool. The midwife, who has a well-established relationship with the mother, is in attendance right through the birth, giving the mother undivided attention. This places her in the unique position to identify a developing emergency very quickly and act swiftly – either to intervene herself, or to call in the back-up gynaecologist, who would typically be there in 10-15 minutes.
When birthing with a gynaecologist, the doctor usually determines the position a mom gives birth in. This is mostly on her back, with legs pulled up or a foot against the doctor’s chest. A midwife, however, will allow the mom to choose the position she is most comfortable in, which makes a massive difference to pain management and ease of labour. This could be squatting, on all fours, on a birthing stool, on a bed or in a bath.
While a gynaecologist will often instruct a mom when and how to push, and allow about 15-30 minutes for this before intervening, a midwife will allow spontaneous pushing with rest periods in between, and up to two hours may be allowed if mom is coping.
In both scenarios, if a c-section is required, mom will be attended to by an anaesthetist and paediatrician, and will be transferred to theatre within a few minutes. However, the midwife will stay by the mom’s side through out the procedure, will help facilitate skin to skin as soon as possible after delivery and ensure that baby stays with mom while she is stitched and then transferred to the ward, if it is safe for both of them. She will then help mom settle in the ward and assist with getting baby to latch. This differs from standard hospital protocol, where a new set of midwives will attend to mom in theatre, and after a short period of holding, baby will be taken via incubator to the baby room while the procedure is completed. Once mom is also transferred to the ward, a new nurse will settle mom in and help with breastfeeding.
- After the birth
Once baby is born, the midwife will immediately place baby skin to skin on mom’s chest and leave baby there for the golden hour of skin to skin while allowing for delayed cord clamping, and only do checks and measurements after this. The midwife will stay by the mom’s side until she is well settled, and mom is usually given a lie-in period of 3-4 hours in the birthing room before transferring her to the ward or preparing her to return home.
Depending on the hospital and the gynaecologist’s protocol, delayed cord clamping may be allowed, and baby may be placed on mother’s chest for a short period before being taken away to measure, but this is not always the case. Some hospitals weigh, measure and warm baby first before giving baby to mom. Most hospitals transfer mom to the ward within an hour after the birth, and the gynaecologist usually leaves soon after baby is born, leaving mother in the care of the hospital midwives, who will assist with latching and getting mom settled.
While the gynaecologist will visit mom during her stay in hospital, once she is discharged she will only have a follow up appointment at 6 weeks. The midwife, however, will visit mom during her hospital stay or if she goes home the same day, will visit her at home, and will follow up with two to three additional home visits over the course of the fist two weeks, and also check up on mom telephonically or over whatsapp. Many moms maintain communication with their midwife for months after the birth to ask for advice or recommendations, and the relationship that develops is a truly special and unique one.
To summarize – the mom who chooses to birth with a midwife, is not in any way compromising the safety or medical care of her baby or herself, but is choosing a birth where she will be respected, encouraged and supported in a way that is not possible in the standard hospital environment.
Midwife care is evidence based, safe, integrated with other medical professions and personal, and offers a mom the chance to have the truly special and unique birth experience she desires.
By Mia Verster (VBAC mom and Pretoria based Architect)