During Passover, Julie Cristol often finds herself the butt of jokes about Shifra and Puah, the midwives who helped save Hebrew babies in the Exodus story.
But the jokes make her proud.
Cristol is a certified nurse-midwife who works as the clinical director of Lifecycle WomanCare in Bryn Mawr, a center that has provided birth care since 1978. Over the past 40 years, the center has expanded to include gynecological care as well.
“There’s been a lot of recognition within the health care arena that [midwives] have really good outcomes and that we’re lower cost,” Cristol said. “There’s a lot of attention to cost-effectiveness in the health care world, and midwives come out pretty well because everything about us costs less than an obstetrician. There’s more recognition that low-risk women could benefit from low-risk care and that that will reduce the cesarean rate.”
Maternal mortality rates have increased since 1987 in the United States, a trend that goes against tendencies in most of the Western world. In the midst of what is being called a maternal mortality crisis, some have turned to the midwife model, which is more relationship-centered than a traditional physician-attended birth, as a potential solution.
Research has shown that there are benefits to having a midwife attend a low-risk pregnancy and birth.
“[Midwives] have a little more time,” Cristol said. “The midwife is providing care that takes into account your family systems, your belief systems, your culture. It’s not to say that a physician might not do that, but it’s less likely.”
According to the American College of Nurse-Midwives, about 12,000 midwives practice in the United States. In 2014 — the most recent year that data is available from the National Center for Health Statistics — they attended about 8 percent of births in the country, more than 90 percent of which took place in a hospital. Midwives also practice with many of the tools a physician would use, such as blood tests.
The main difference between a midwife and a physician is that midwives have fewer patients, Cristol said. This allows them to develop a stronger relationship to those patients.
Births attended to by midwives also have a lower rate of medical interventions such as cesarean sections. In the United States, more than 30 percent of births occur by C-section, but the World Health Organization considers 10-15 percent an ideal rate.
Overall, midwives tend to take more of an optimistic approach to birth than physicians, Cristol said.
Cristol worked as a nurse-midwife in hospital settings until Lifecycle WomanCare, which provides birthing suites with Jacuzzis, showers, birthing balls and stools plus access to a shared living room and kitchen.
In contrast, Ray Rachlin, a certified professional midwife and founder of Refuge Midwifery in West Philadelphia, specializes in home births. She said that home births are more patient-centric than those in hospitals.
In a hospital, for example, a patient in labor might be told to change positions to convenience a health care provider. At a home birth, Rachlin often contorts herself to allow the patient to be in whatever position is most comfortable.
“They get to do what they want with their body,” she said, “and I’m there to provide safety and guidance for the birth process.”
When she heads to a patient’s home, she brings tools to listen to the baby’s heart rate, medication to control bleeding and oxygen, as well as a birth stool and other natural comfort measures. Pre-labor and postpartum care take place in the home as well.
Home births do not have access to the same amount of interventions that births in hospitals do, including epidurals. Access to pain medication is one reason people choose to give birth in a hospital setting instead.
“Our culture has a lot of fear around birth,” Rachlin said. “Probably the biggest question that comes up is, ‘What if something goes wrong?’ For healthy, low-risk pregnant people, with a single baby that’s head down at term at the beginning of labor, the chance of true emergencies are very low.”
Rachlin began her birth professional career as a doula, a job that provides physical and emotional support during labor and postpartum. Doulas work alongside either midwives or physicians in hospitals, birth centers or at homes.
Hannah Slipakoff works as a doula and is a member of the Philly Doula Co-op and Maternity Care Coalition’s Doula Program. Her work can involve anything from giving clients massages, wiping their foreheads with a washcloth or bringing them food. Doulas also empower their clients through education.
“We need a reproductive health revolution in our world, where people know more about their bodies and know more about their options and feel like birth is an exciting, empowering, nourishing experience to go through,” Slipakoff said.
Slipakoff plans on becoming a nurse-midwife as well. She is taking prerequisite classes at the Community College of Philadelphia and online, and hopes to start nursing school in the spring.
Midwife education generally takes several years.
Slipakoff decided to take this step in her career because, though she said doula work is essential, there’s more she can do as a midwife. More people have access to midwife care as well because health insurance covers them, unlike doulas.
Rachlin made the switch from doula to midwife because she felt more like an interventionist as a doula since physicians were failing to meet people’s needs. As a midwife, she can provide continuity of care. Home births also compete with hospitals, putting pressure on them to make their practices more relationship-oriented.
“Most people give birth in the hospital and will probably continue to do so,” Rachlin said. “[Those] families would also benefit from patient-respectful care.”
Whether they are performing a newborn exam or holding a patient’s hand during labor, tikkun olam and social justice serve as motivations for many of the Jewish women who work in the field.
“I’m not very religious at this point in my life,” Rachlin said, “but there’s no way around it — midwifery is God’s work.”