Before choosing a care provider and place of birth (the two usually go hand in hand), it is helpful to understand the two main paradigms in maternity care education and practice, described as the midwifery model and the medical model. These terms derive from the kinds of care physicians and midwives have historically provided.
The classic midwifery model is based on the assumption that most pregnancies, labors, and births are normal biological processes that result in healthy outcomes for both mothers and babies. It focuses on maximizing the health and wellness of a woman and her baby, identifying and managing medical problems early on, and attending to the emotional, social, and spiritual aspects of pregnancy and birth.
Midwifery care seeks to protect, support, and avoid interfering with the unique rhythm, character, and timing of each woman’s labor. Midwives are trained to be vigilant in identifying women with serious complications. Medical expertise and interventions are sought when necessary but are not used routinely.
A strict medical model of care focuses on preventing, diagnosing, and treating the complications that can occur during pregnancy, labor, and birth. Prevention strategies tend to emphasize the use of testing, coupled with the use of medical or surgical interventions to avert a poor outcome.
Medical expertise and interventions are vital for women and babies with complications. However, routine interventions on women at low risk of problems can actually lead to problems. Training in the medical model does not typically focus on developing skills to support the natural progression of an uncomplicated birth.
Although it is crucial to understand the differing philosophies and training among practitioners, it is also important to note that the letters after someone’s name do not tell you much about her or him as an individual. Some doctors have attitudes, styles, and approaches that fit the midwifery model, and some midwives incorporate the medical model that is more common for doctors. For this reason, some people believe it is more accurate to refer to the different models of care as a physiologic model (that is, care in accord with the normal functioning of a woman’s body) versus an interventionist or pathology-driven model.
The midwifery model and medical model also give rise to two different ways of organizing maternity care systems. In most industrialized countries, midwives coordinate the care for the majority of childbearing women and collaborate with obstetricians or other specialists when a woman has medical complications or risk factors. Healthy women often give birth in midwife-led hospital units or birth centers or at home.
In contrast, in the medical model prevalent in the United States, doctors manage the care of most women, almost all of whom give birth in hospitals. When midwives do provide the care, they are usually supervised by doctors and working under medical rather than midwifery protocols. For more information on problems with the kind of care most women in the United States receive, see Maternity Care Today.
Most communities in the United States fail to promote a midwifery model of care despite powerful evidence in numerous studies that underscore the benefits of midwifery care and the heightened satisfaction of women who use midwives. A 2013 Cochrane systematic review comparing midwife-led to physician-led models of care found that the women attended by midwives were less likely to have an episiotomy or instrumental birth, less likely to have a preterm birth or loss of the fetus before 24 weeks gestation, and more likely to have a spontaneous vaginal birth. The review concluded, “Midwife-led continuity of care was associated with several benefits for mothers and babies, and had no identified adverse effects compared with models of medical-led care and shared care.”