Over the last few years, the practice of birth work has been thrust into greater public consciousness — shining a spotlight on the work performed by doulas and midwives who support birthing individuals through navigating fertility, pregnancy, labor, and postpartum. In fact, from 2003 to 2018, hospital-based midwife-attended births increased by nearly 12%.
So, what exactly are doulas and midwives? How do they differ in the care they provide? And what's the increasing hype around them all about? We're covering it all below, but here's the gist:
- Doulas and midwives are both birth workers who provide what's called "continuous labor support" in hospitals, birthing centers, and at home births.
- Doulas provide non-medical guidance and emotional support, while midwives provide medical care. For this reason, midwives are more comparable to physicians than they are doulas.
- You can work with a doula and a midwife at the same time, and you can also work with a doula alongside a physician. In some cases, midwives might also work in collaboration with physicians.
- Any type of continuous labor support — whether it's from a doula, a midwife, or a partner — has been shown to positively impact birth and postpartum outcomes and experiences. But since midwives are more focused on medical care, like physicians, they don't always offer continuous labor support. Doulas are uniquely valuable because of this.
Read on to learn more about the type of support that might be best for you — and where you can find a doula or midwife to stay by your side throughout your reproductive journey.
How did the birth work profession start?
The models for doula work and midwifery both come from the framework of traditional midwifery, which existed long before modern gynecology was even conceived.
The man known as the “Father of Gynecology,” Dr. J. Marion Sims, began practicing medicine in the US in 1835, soon after graduating medical school. Simms developed his knowledge through the unethical, and anesthesia-free experimentation on Black, enslaved birthing people in the US — knowledge that was further bolstered by midwives who were brought to the US from the continent of Africa as enslaved people, specifically to provide reproductive healthcare to other enslaved individuals.
Traditional midwifery has existed in indigenous cultures around the world, placing a focus on low-intervention, high-touch care for community members. In South Africa, for example, the traditional midwife is still used to this day — a relic from centuries ago when humans in these cultures still lived in tight-knit communities, and the midwife was the most experienced and knowledgeable medical resource in the community.
Until the 19th century, midwives handled the majority of deliveries in the US — before there were efforts to suppress the practice in the early 1900s. Though there was a resurgence of midwives during the women's movement in the '60s and '70s (around the same time the word "doula" was coined), only around 8% of total births in the US are performed by midwives. In contrast, in other developed countries, births have continued to be primarily handled by midwives.
What should you know about doulas?
A doula is a non-medical support person who offers emotional and physical support throughout pregnancy, labor, and postpartum. The word “doula” is of Greek origin and roughly translates to “woman caregiver.”
Doulas provide continuous, uninterrupted support throughout labor whether that labor takes place at home, a birth center, or in a hospital, advocating for the birthing individual and fulfilling their non-medical needs during the process. Throughout pregnancy and postpartum, doulas offer:
- Advocacy: In moments where a birthing individual may be unable to advocate for themselves, doulas ensure the lines of communication remain open between the birthing individual and anyone they may need to communicate with, whether that's a partner, medical provider, or family member.
- Pain relief: During pregnancy and labor, doulas provide support for discomfort and pain by suggesting birthing positions, breathing techniques, relaxation techniques, and even sleeping positions. Doulas can also offer physical support, like counter pressure, in order to ease labor.
- Knowledge: While they aren’t medical providers, doulas may be able to provide evidence-based knowledge around the process of birth, from conception to postpartum. While a doula should never advise you to go against the advice of your medical provider, they can inform you of the options you have around each decision you need to make.
- Calming of nerves: Every pregnancy is different. Sometimes a voice of reassurance or a listening ear from someone who's seen others go through the same process numerous times can provide some mental balance.
The different types of doulas
To help you understand which type of doula may be right for you, these are the differences between the primary specializations within this form of birth work:
- Birth doulas: Birth doulas are trained in offering continuous, uninterrupted support throughout pregnancies and the process of labor at home, in birthing centers, or in hospital settings.
- Postpartum doulas: Postpartum doulas support birthing individuals in the care of their bodies post-labor, and in the care of their new addition. They can provide support around proper latching techniques, how to use a cloth diaper, and a host of other postpartum concerns.
Some doulas are community-based doulas, who work in communities with less access to doula care and are typically members of the communities they serve. Full-spectrum doulas are trained for the full scope of reproductive care. You can also find doulas in different realms, such as fertility doulas, sex doulas, abortion doulas, and death doulas. Overall, doulas serve to offer support and provide access to knowledge.
Doula training and certification
There is no nationally recognized standard for the certification of doulas. This is by design, as doulas provide particular impact in resource-poor communities — requiring certification would establish barriers to entry, limiting access for the communities that need the support most. However, there are some programs that will certify doulas who've successfully completed their training.
How do doulas work alongside physicians?
Dr. Luo explains that she typically interacts with doulas throughout labor and delivery, when her patients have brought doulas along for the process.
"I frankly wish I could interact with doulas more and earlier in the pregnancy journey rather than at the point of birth. This way, we all have more experience on how to work as a team to best support our patients," says Dr. Luo. "What is hard to see as a provider is that doulas are typically out-of-pocket expenses for patients and for some patients who would benefit greatly from having a doula, unfortunately that kind of support is out of reach." (More on insurance a little later.)
What should you know about midwives?
A midwife is a medical care provider who is trained and certified to offer medical support during "low-risk" pregnancy, labor, and postpartum. While some midwives may also be trained as doulas, midwives are the only one of the two qualified to offer medical support. For that reason, midwives are more directly comparable to physicians than they are to doulas.
The word "midwife" comes from Old English, meaning “with woman.” It refers to the person who is with the person giving birth — but you don't have to identify as a woman to be a midwife.
The types of support that midwives provide during pregnancy include:
- Monitoring of the fetus’ health, growth, and position in utero
- Advising on the necessity of additional appointments or tests with an obstetrician
- Providing medical support and advice
- Helping with preparation for labor and birth
During labor, midwives offer support including:
- Information, encouragement, and emotional support
- Monitoring of labor progress, and suggestions to help the process along
- Monitoring of fetal heartbeat and other vital signs
- Administration of pain relief, or coordination with a doctor to facilitate the same
- Calling for extra medical help if needed
According to certified midwife (as well as doula) Dana Cosentino, CNM, midwives can also be involved preconception: They can order and interpret blood tests, prescribe contraceptives, and manage fertility care. In New York, where Cosentino practices, licensed midwives are fully autonomous women's healthcare providers. "Personally, I order mammograms, do Pap smears, STD testing, and even menopause care!" she explains.
When the care of a birthing individual and their baby goes outside of the scope of a midwife’s training, like when a cesarean section is needed, the midwife will refer the patient or client to an obstetrician for more specialized support. This can happen during prenatal care, at the time of delivery, and postpartum.
Midwife training and certification
There are three types of certified midwives recognized in the US:
- Certified Nurse-Midwife (CNM): This is a midwife who has a nursing degree, has completed a graduate level midwifery program, and has passed a certification exam from the American Midwifery Certification Board.
- Certified Midwife (CM): This is a non-nurse midwife who has completed a graduate level midwifery program and has passed a certification exam from the American Midwifery Certification Board.
- Certified Professional Midwife (CPM): This is a midwife who has met the certification requirements of the North American Registry of Midwives after completing training as an apprentice under a qualified midwife or through a midwifery school or program.
How exactly does a certified midwife compare to an OB-GYN?
OB-GYNs must complete a bachelor's degree, four years of medical school (where they’ll receive an MD or DO), and a minimum of four years in an accredited OB-GYN residency program — with rotations on obstetrics, gynecology, gynecological oncology, high-risk obstetrics, urogynecology, ultrasounds, and reproductive endocrinology. Then, to become board-certified, the doctor must pass exams through the American Board of Obstetrics and Gynecology after graduation from an accredited residency program. Midwives are also highly trained, often entering the field with a bachelor's degree in nursing or a related area, a graduate-level education from midwifery programs, thousands of clinic hours under their belts, and successful completion of board exams.
OB-GYNs and midwives are both experts in "low-risk" pregnancies, meaning the perceived risk of complications is low, while OB-GYNs have the training for "high-risk" pregnancies that might require more intensive medical care. "Generally, at any point a patient becomes 'high-risk' either prenatally or during delivery, midwives can escalate care to involve a physician. That threshold can be very different for each midwife," explains OB-GYN and Modern Fertility medical advisor Dr. Eva Luo, MD, MBA. Some midwives may feel comfortable managing "high-risk" complications like preeclampsia, while others may not. "Midwives typically do not perform operative vaginal deliveries or cesarean sections, so if those more complicated delivery modes are required, then typically a physician will perform them," adds Dr. Luo. That said, midwives can be trained to surgically assist on C-sections for continuous labor support.
If you're considering working with a midwife, Dr. Luo recommends asking if there are physicians on-site and how involved they tend to be for midwife deliveries. You can also ask if you can expect continuous support throughout your delivery or if the midwife, like an OB-GYN, would potentially be overseeing multiple births at once.
What are the benefits of using a doula or midwife?
Research shows that continuous labor support during childbirth has a number of benefits. Continuous labor support is defined as the uninterrupted presence of a support person during childbirth, be it a midwife, doula, or partner — though doulas more commonly provide this continuous support and are valued for this very reason. This support works best when the support individual is not employed by the hospital, and is instead present with the express intention of maintaining focus on one single birthing person.
This continuous labor support can improve birth outcomes in the following ways:
- Higher likelihood of spontaneous vaginal delivery
- Fewer interventions during birthing
- Shortened labor times (by an average of 36 minutes)
- Fewer cesarean sections
- Lower likelihood of an epidural
- Lower likelihood of physical instruments to aid birth (e.g., forceps, vacuum)
- More positive feelings around the birthing process
- Higher rates of breastfeeding/chestfeeding
The benefits of doulas and midwives for Black pregnant people
The positive impact of continuous labor support may be of particular importance to Black birthing people, who are three to four times more likely to die of complications from childbirth compared to white people.
In a study of one Brooklyn program that provided pregnant people with doula care in Black and Latinx communities, participants not only had lower rates of both pre-term birth and low birthweight (compared to other pregnant people in the area), but they also reported that they valued the relationship and felt like they had more of a voice in their birth decisions. While these outcomes might not have been solely caused by the continuous labor support of doulas, it's clear that it played some kind of positive role in participants' experiences.
If you're a Black birthing person who's seeking affirming and disparity-informed care from a doula or midwife with knowledge around the intertwined history of Black culture and birthwork, these organizations and databases can help:
The benefits of doulas and midwives for transgender pregnant people
Studies have shown that many transgender individuals experience discrimination in the traditional healthcare system. As progress continues to be made in providing gender-affirming care for pregnant patients in hospitals and clinics, a growing community of doulas, midwives, and transgender activists are working to improve transgender individuals' birthing experiences. (Some of the more well-known birth workers and activists in this space include King Yaa, Moss the Doula, and Kayden X Coleman.)
While there's no research (to our knowledge) that specifically examines the impact of continuous labor support on transgender and nonbinary birthing people, a doula or midwife who's trained or otherwise knowledgeable in the support of transgender birthing individuals can act as your advocate — ensuring you have access to the right information, helping you find providers who can contribute to the affirming experience you’re entitled to, and supporting bodyfeeding and chestfeeding after gender-affirming surgery.
If you're a transgender or nonbinary birthing person looking for a doula or midwife, know that there are dedicated training programs and workshops for educating birth workers in providing gender-affirming care. Here are a few resources to help you find these support people:
Does insurance cover doulas and midwives?
Some employers offer insurance plans with coverage for doulas and doulas are covered by Medicaid in certain states. In 2019 and 2020, five federal bills called for state Medicaid programs to cover doula care throughout the US. In most circumstances, though, doula care is paid for out of pocket — but many doula organizations offer care at a low cost to make access easier.
In terms of midwife care, some insurance plans will cover midwives as well as home births, but others may not.
Whether you're thinking about working with a doula, midwife, and/or an OB-GYN for your pregnancy and delivery, it's important to check with your insurance plan to see what is and isn't covered.
What's it like to work with a doula or midwife?
We spoke with two Modern Community members to find out.
Jill Kerwin, RN, BSN, a certified fertility nurse at Modern Fertility, told us she reached out to a doula because "wanted to incorporate a more 'natural' experience" into her birthing plan with an OB-GYN. Jill was lucky enough to have a prenatal yoga instructor who doubled as a doula: "I really connected with her during my pregnancy, so it was a perfect transition to have her at my birth as well," she says. Through having "an educated, experienced advocate by my side," Jill felt supported during her delivery — and it "gave my partner a break from needing to be 100% on," she explains. For anyone who's considering working with a doula, here's Jill's recommendation: "I would advise doing research and having open communication with the doula and your partner pre-delivery and make sure that you are comfortable with them fully."
When Kate first began thinking about working with a midwife during her first pregnancy, "I was optimistic about the idea of a caretaker who would offer more time during appointments and never make me feel rushed into and out of the office," she says. Like Jill, Kate wanted to "embrace a more 'natural' pregnancy experience" and thought a midwife could help her achieve her low-intervention birth plan. Kate wasn't sure at first that the "earth-mama vibe" she was striving for would be the right call, so she felt relief after finding out that her midwife group was supervised by a traditional medical care team.
In the end, though, Kate completed care with a physician in the same medical group when she learned her baby was in breech position and needed to schedule a C-section. For her second and third pregnancies, Kate stuck with a physician because she "didn't ever want to relive the experience of having to switch care providers in the midst of my final weeks of pregnancy when I already felt so vulnerable."
"The limited scope of a midwife's care ultimately led me to pursue care from traditional medical doctors, since my first pregnancy required more intervention than I ever hoped I would need," Kate explains. The "gentle care" Kate received from her midwife helped her feel supported and calm, but she emphasizes that working with a traditional medical doctor can be just as great. "Every good medical provider wants the best for their patients, so do research into what kind of interactions might make you feel the most confident with your care," Kate says. "Stand up for yourself and find a provider that makes you feel comfortable."
How do you know if a doula or a midwife is right for you? And how can you find one?
Much of the decision-making here comes down to personal preference — and because doulas and midwives provide different types of care, they often work in collaboration. Midwives and physicians may even work together in some practices.
So, how do you know if a doula in particular is right for you? Working with a doula might be a great option for someone who's looking for a feeling of connectedness in the birthing process. "The type of support you provide is unique to each client, but being there to center and reassure a birthing person as they experience such a milestone is grounding," says Nicole Nwaru, MPH, RN, CLC, a full-spectrum doula and labor and delivery nurse. "Having a sense of connectedness while being in such a vulnerable state is something everyone should have access to. Knowing that you have a knowledgeable advocate by your side definitely helps with feelings of safety and support.”
What if you're deciding between a midwife and a physician? Again, a lot of this comes down to personal preference. At some clinics, explains Dr. Luo, they may offer care from both types of providers. "In some practices, in the prenatal setting, physicians and midwives share patients with established care pathways that shuttle low-risk patients to midwives for the majority of prenatal visits and higher-risk patients to physicians," she says.
Due to the plethora of training programs that exist for doulas and midwives, the options are vast when it comes to finding the provider that is the right fit for you. Here are some resources that can be helpful in finding doulas and midwives:
- Your OB-GYN: Many obstetricians are used to working side by side with midwives and doulas during labor, and may have suggestions on who may be a good provider for you. The added bonus of this approach is if you decide to give birth in a hospital setting, your doctor may already have a relationship with your birth worker of choice.
- Online directories: Directories exist for both doulas and midwives, and may put you on the right track. We already mentioned the National Black Doula Association, but two other great ones are DONA International and the American College of Nurse-Midwives.
- Doula training programs: As we talked about earlier, each doula training program has its own philosophy around its approach to birth work. Starting with a training program whose method you identify with can help you narrow down to the types of doulas you’d be interested in working with.
- Social media: Many birth workers share their knowledge online via social media programs like Instagram and TikTok. While we wouldn’t normally advocate heading to social media for medical support, seeing these individuals share information about their craft may give you an idea of if you’re interested in working with them. You can always ask for their credentials if you do decide to move forward.
It's up to you to decide what types of providers best fit your needs during pregnancy and delivery — but we hope this article helps get you a little closer to figuring that out. For a detailed breakdown of the other types of healthcare providers you might encounter on your reproductive journey, we've got you covered right here.
This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.