Elizabeth Osborne's experience of her first childbirth was typical. "It was hard work," she recalls, "but much less painful than I had anticipated." What was surprising about the smooth delivery, though, was her baby boy's size-a whopping 10 pounds 7 ounces-and the fact that she opted to abstain from painkilling drugs, even when delivering such a large baby. "I never once thought about drugs," Osborne says, "and I had no tearing or episiotomy or stitches." She credits this outcome to the care of her primary birth attendant-a certified nurse-midwife (CNM). "I really felt I was in good hands."

Like Osborne, a growing number of American women are placing their trust and their births in the capable hands of midwives. Certified nurse-midwives attended more than 300,000 of the nation's births in 2002. Only a tiny fraction of these were home births. Like Osborne's, most took place in a hospital, in the care of a CNM. CNMs are registered nurses, graduates of a midwifery education program accredited by the American College of Nurse-Midwives (ACNM), and have passed a national certification exam. ("Direct entry" midwives, practitioners who do not hold a nursing degree, represent a much smaller group.) Certified Midwives (CMs) also graduate from ACNM-accredited education programs and must pass the same national exam.

Midwives can be found in private practices, hospitals, clinics, physician's offices, and birthing centers. The actual scope of services a particular midwife offers is determined by such factors as state and local regulations, insurance, hospital policies, and her relationship with her collaborating physician, who provides consultation and assistance when needed. Generally speaking, however, CNMs and CMs are authorized to provide primary care to women and to manage pregnancies and vaginal deliveries. "I never saw any of the doctors for prenatal care or during delivery," Nara Hojvat-Gallin says. With a degree in public health, specializing in women's, maternal, and child health, Hojvat-Gallin calls her choice of a midwife-attended birth "a no-brainer."

Good outcomes, fewer interventions. Surprisingly, many women are not aware that for a low-risk pregnancy (which most are), a midwife might be the best choice. An independent 1998 study determined that infant and newborn deaths were significantly lower following midwife assisted births. Other research has consistently confirmed equal or better outcomes for midwife versus physician-assisted low-risk births, citing significantly lower rates of interventions such as induction of labor, rupture of membranes, episiotomies and cesareans.

These results reflect a fundamental difference in perspectives. Physicians are trained to look at pregnancy in terms of what might go wrong, and to intervene at the first sign of trouble. Midwives "approach birth as a normal, natural, healthy life event," says Cindy Kaiser, a Butte, Montana, CNM, recently retired from active practice.

Different quality of care. When telling their birth stories, women who experience pregnancy and labor with midwives frequently use words such as empowering, wonderful, and unforgettable. What elicits such language? It might be a feeling of confidence inspired by a relationship of deep trust built over many months. "Personalized care, where you feel like someone is actually listening to what you say," is the hallmark of traditional midwifery, notes Jessica Jordan, a Richmond, Virginia, CNM. The midwifery philosophy stresses respect for the woman as an active participant in her own healthcare and birth. Fran Wilson, a CNM in Washington State, says that midwives "develop a communication base wherein women can express themselves comfortably." Consultations provide ample time for the mother-to-be to talk about her desires and concerns. "Our midwife saw me as an individual," confirms Becky Laczkowski of Arlington, Texas, who had her second baby with a midwife. "She always had time for any questions."

"Midwife means 'with woman,' and that means while she is laboring," CNM Cindy Kaiser says, "We're the support, the cheering section-nurturing, guiding, protecting."

Many women cite that support as one of the most important reasons they chose a midwife. Nancy Rynex Cochran, whose third child was born with a midwife, remembers: "The best thing about having a midwife was the comfort and care she gave me. She didn't just show up to 'catch' the baby."

Because they are often more experienced in low-intervention births, midwives are usually willing to be more patient than physicians, recognizing that few women labor according to textbook guidelines. They know, of course, when it's time to call for a physician's consultation or step in with more aggressive measures, but they also know when to suggest a simple change of position, and when to let time do its work. Finally, perhaps the greatest service a midwife can offer is to help make labor what many women might never have imagined: a joyful experience. "My last two deliveries were so much fun!" laughs Robin Pearsall, a realtor and mother of four whose two cesarean births with an obstetrician were followed by two midwife assisted vaginal births. "I learned how good it could be."

Choosing a midwife. No provider can guarantee a perfect birth. However, "what you're buying from that person is their expertise and judgment," says Henci Goer, author of The Thinking Woman's Guide to a Better Birth (Perigee, 1999). "The key," she says, "is to make sure that person is worthy of your trust." Choose someone who respects and addresses your concerns and whose philosophy on birth is compatible with yours. Interview more than one caregiver, ask open-ended questions, and keep in mind that "it's never too late to switch." Inflexible policies can be a red flag; caregivers should treat each labor as unique. Click here to Find a Midwife. Things to consider:

For All Caregivers

• What is the likelihood that you will be the one attending my birth? (In group practices,
  you could end up with whomever is "on call" when you go into labor.)
  
• During labor and delivery, what are your policies on IVs, continuous or intermittent monitoring of fetal heart rate, eating and drinking, moving around or changing position, and use of a warm shower or bath?
  
• Under what circumstances would you recommend inducing labor? Augmenting a slow labor? Ordering an epidural? A cesarean? Other interventions?

Midwives or Birthing Centers

• What is your educational background and experience?
  
• What is your relationship with consulting physicians, and will I meet him or her?

A Birthing Center or a Home Birth

• What pregnancy conditions would preclude a birth center or a home birth? Under what labor circumstances would I be transferred to a hospital?
  
• Will you stay with me if I'm transferred?

A word from the doctor. "What's really a shame is that more women aren't afforded the opportunity to deliver with a midwife," says Dr.Terry L. Cole, a California obstetrician. In his 21 years of practice, Cole says, he has "virtually always been associated with midwives."

In his Ventura and Oxnard, California, offices, Cole and two CNMs-Anne Chezar
Garnett and Denise Ellison-serve women from all walks of life. When a low-risk woman comes to Cole, he will meet with her once during her pregnancy, but otherwise she will receive all her prenatal care with the CNMs. Garnett and Ellison share call duties; most women will see both midwives during the prenatal period, so they will be comfortable with either one for the birth. Deliveries take place at one of two nearby hospitals supportive of the midwifery approach. "When a woman goes into labor, she calls the midwife," Cole says. "I'm just called if I'm needed. I'm there for consultation."

Most of the women delivering with his midwives are classified as low-risk. Cole says that he, Garnett, and Ellison can co-manage women with moderately elevated risk, such as those with mild toxemia. And in cases where Cole needs to manage the delivery, one midwife might still be there to offer emotional support.

Cole's confidence in midwives is evident, but the most telling endorsement he offers? "My wife was delivered by midwives. If you are a low-risk patient, you really want a midwife delivering your baby," Cole says. "Anyone who has ever seen a midwife with a woman in labor or been delivered by a midwife would never go back to a doctor."

*taken from "Up Close and personal" by Caroline Kettlewell, Every Baby magazine, Issue Four.