A doula holds a baby
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With Caesarean section surgeries occurring in nearly one in three pregnancies and traditional hospital births by obstetricians costing an average of $8,000 to $10,000, some pregnant women are exploring other options. And the future of childbirth in America might start looking more like the past.

Who: Midwives and Doulas

For thousands of years, women have been giving birth with the help of midwives and doulas. In some countries—both rich and developing—almost every pregnant woman sees one for her prenatal, delivery and postnatal care.

In the United States, most pregnant women see an ob-gyn for their prenatal care and delivery. Yet evidence shows use of midwives here is increasing.

There are two broad classifications of midwives in the United States. A certified nurse midwife (CNM) has completed traditional nursing school and then gone on to complete midwifery training. A certified professional midwife (CPM) has training in midwifery but is not a nurse. Generally, CNMs have clearance to deliver in hospitals and CPMs do out-of-hospital births—either at home or in nonhospital birthing centers.

According to Miriam Perez—a volunteer doula, activist, creator of RadicalDoula.com and editor at Feministing.com—while a midwife attends to the medical needs of a labor, a doula's mission is different. "A doula is only really worried about the emotional needs of the mom," she says. "She's there to coach and support the mom and kind of help her get what she needs from her birth experience. That's what makes [the doula] unique from everybody involved—from the partner to the doctor to the nurses to the midwives. The doula is the only person who is there just really focused on the needs of the mom."

A newborn
Photo: © 2009 Jupiterimages Corporation
Where: At-Home or in a Birthing Center

In all 50 states, CNMs, midwives who deliver in hospitals, can get a license to work. But laws regarding CPMs, who are trained for nonhospital births, vary from state to state. In some states, CPMs are required to be licensed. In others, they are regulated but not required to be licensed. In still others, they are banned outright. The Midwives Alliance of North America keeps an updated list of state-by-state rules on CPMs.

Though about half of states allow at-home birth, it remains uncommon in the United States—just 1 percent of births occur in nonhospital settings including home births and birthing centers. Washington was one of the first states to license CPMs, and they now have double the national average of mothers who elect for nonhospital births. For a point of reference, in the Netherlands, about 34 percent of women give birth at home.

In many states that do not license CPMs, an underground, extralegal system of home births exists. This black market leaves CPMs open to the threat of prosecution for practicing medicine without a license. An organization called The Big Push for Midwives is engaged in fights in states to change legislation to legalize CPMs.

According to the American College of Nurse-Midwives, a midwife actually can lead to better birthing outcomes. The organization cites an independent 1998 study that shows reduced infant and newborn deaths associated with midwife-assisted births in the United States.

There aren't requirements about who can and cannot see a midwife in a hospital, but most CPMs will only attend to an out-of-hospital birth if the mother is not in an at-risk category. This usually means mothers cannot be very young or old or have conditions like high blood pressure, autoimmune diseases, cancer, obesity and diabetes. However, "at risk" is not a definite term. "There's a lot of debate in the birth world about what things should be ['at risk']," Perez says. "The only reason you couldn't have a midwife at all, even in a hospital, is if you had to have a Caesarean section, because midwives are not surgeons. That's what obstetricians are—they're trained as surgeons. You're not going to have a midwife doing C-section, but pretty much anything else can be done by midwives."

A pregnant woman uses acupuncture
Photo: © 2009 Jupiterimages Corporation
What: Acupuncture, Acupressure and Water Birth

Once a pregnant woman goes past her due date, she can find herself pressured to medically induce labor. Just as there are good reasons to treat a due date as more of a suggestion than a rule, there are also good reasons for wanting to jump-start a slow or overdue labor.

While a few unproven, nonmedical ways to start labor include walking, spicy food and sex, some pregnant women swear by acupuncture or acupressure. In fact, acupressure has such a reputation for inducing birth that prenatal massage specifically avoids areas—such as on the hands and feet—that could accidentally trigger labor. Just as midwifery has been the means of delivering babies through most of human history, acupuncture has been a method of inducing labor in overdue pregnancies for thousands of years.

As a reminder, it's always a good idea to consult a doctor or midwife before starting any new activity during pregnancy.

Once labor actually begins, one way to alleviate some pressure and pain of contractions is through use of a water tub. Some pregnant women even deliver in water. A common misconception about water birth is that the newborn baby will drown in the water. "Because babies are floating in an amniotic sac of fluid in the belly, they're already in water. That's not an issue," Perez says. "And they're not breathing through their noses until the umbilical cord is cut. They get all their oxygen through the cord."

Perez adds that some water birth advocates even believe it's the best option for everyone. "Some people argue that it's less shocking for the child to born into the water rather than to be born straight into a shocking, bright environment," she says.

The biggest hurdle with water births is finding a facility that offers them. Most traditional hospitals do not. As with an out-of-hospital birth, being "at risk" could complicate plans for a water birth. Additionally, if the mother tests positive for Group B streptococcus, convincing a midwife or obstetrician to allow a water birth may prove difficult. If having a water birth is important to you, make sure your facility not only offers but encourages it and that your doctor or midwife is enthusiastic about your decision.

Would you consider using any of these nonhospital options? Share your thoughts in the comments area below.

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