Midwives are growing in popularity but still largely misunderstood. This three-part series aims to help you answer the question: What’s a midwife and is one right for me?

In her early 20s, Betty-Anne Daviss was a naturopath hitchhiking across Central America. But in 1976, the trajectory of her career changed.

A major earthquake leveled many of the homes in the Guatemalan village she was living in at the time, which caused several pregnant women to go into labor early.

“I had to learn how to pack a horse and go out to the villages and find out what was going on,” she tells Healthline. “Every time I arrived, people would run up to me and ask, ‘Are you a midwife?’ and I’d say no, but I can help.”

Thus, the earliest of her midwifery training began.

Daviss spent four years in Guatemala, working alongside local midwives to learn their practices. From there, she spent some time in rural Alabama assisting low-income pregnant women who couldn’t afford a doctor before she came to Ottawa, Ontario, in the early ’80s.

She eventually started her own midwifery practice, though it would be several years before her profession was recognized and regulated by the Canadian government.

Learn more about midwifery in the United States here.

In the 40 years since she attended her first birth in Central America, Daviss has traveled all over the world — from the Northwest Territories in Canada to Germany to Afghanistan — to study, among other things, childbearing practices.

Aside from her unique journey to becoming a midwife, what sets Daviss apart from many other healthcare providers who specialize in childbirth is her expertise in vaginal breech birth. That means delivering a baby that’s feet- or bottom-first instead of headfirst vaginally instead of by cesarean delivery, commonly known as C-section.

In fact, Daviss has made it her mission to mainstream vaginal breech birth again

In some ways, Daviss, who also teaches in the women and gender studies department at the University of Carleton in Ottawa, might be considered a bit of a radical.

Last year, she helped publish a study that found there were significant benefits to a woman giving birth to a breech baby in an upright position — kneeling, on hands and knees, or standing —compared to lying on her back.

“We know now from the studies we’ve done that the pelvis is dynamic, and the baby winds its way through as the pelvis changes shape. How is it that we ended up with women flat on their backs and people actually thinking that was normal?” Daviss muses. “That’s totally an abnormal way to have a baby.”

When a woman presents with a breech pregnancy, which happens in 3 to 4 percent of full-term births, the American College of Obstetricians and Gynecologists (ACOG) recommends that her healthcare provider attempt to manually turn the baby in utero whenever possible by a process called an external cephalic version. This places the baby’s head down for delivery.

If that doesn’t work, ACOG determined in 2006 that the decision on whether to do a cesarean delivery or vaginal breech delivery should depend on the experience of the provider.

The Society of Obstetricians and Gynecologists of Canada has a similar position on practitioner skills and experience.

ACOG also notes: “Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.”

Or, as the American Pregnancy Association puts it: “Most health care providers do not believe in attempting a vaginal delivery for a breech position.”

For decades, the standard of care for breech babies has been cesarean delivery, commonly known as C-section, thanks in part to the findings of an earlier study known as the Term Breech Trial.

Spearheaded by researchers from the University of Toronto, the randomized controlled trial looked at the outcomes, focusing on maternal and baby death and morbidity, of more than 2,000 women with breech pregnancies in 26 countries between 1997 and 2000.

According to the data, breech babies who were delivered by planned cesarean delivery had a better chance at survival than those delivered by planned vaginal delivery. They reported serious newborn morbidity in 3.8 percent of babies who were delivered vaginally versus 1.4 percent of the infants who were delivered by C-section.

But in the years since that study was fast-tracked to publication, a number of critics, including Daviss, have raised concerns about its validity

“It was one of the major things that put a nail in the coffin of doing breech births around the world,” Daviss says. “It wasn’t just in North America. It was also in South America, Israel, South Africa, Australia, New Zealand — it was terrible.”

One expert wrote in the American Journal of Obstetrics and Gynecology that based on a number of factors, including “serious questions concerning the overall adherence to the inclusion criteria,” the “original term breech trial recommendations should be withdrawn.”

For example, the protocol was only supposed to include mothers pregnant with single fetuses; however, there were two sets of twins in the 16 cases of perinatal death in the study.

One of the concerns with delivering a breech baby is that its head will get trapped as it makes its way down the birth canal. Daviss says breech births tend to be more difficult because they require more maneuvers.

“Because the head is the last thing to come out, there’s a concern that the baby’s going to take their breath on later, and they do, they often do, but it doesn’t mean we have higher mortality rates with vaginal compared to cesarean breech births,” she says. “[Higher mortality rates don’t] seem to be true in places with good protocols and experienced staff… but there continues to be great fear around vaginal breech births.”

In fact, a 2006 study that focused on women in Belgium and France who presented with breech babies found rates of mortality or morbidity “did not differ significantly between the planned vaginal and cesarean delivery groups.”

Daviss says that another flaw with the Term Breech Trial is it didn’t adequately take into consideration the experience of the healthcare provider. It appeared that they were really trying to push the practitioner into doing more breeches than they were normally comfortable with, she says.

Daviss is the only midwife in Canada to be granted hospital privileges to attend breech births without a transfer to obstetrics.

In her 40 years as a midwife, she’s attended more than 150 planned vaginal breech births.

“I came into it at a time when breech wasn’t considered a highly dangerous thing to do,” she says. “It was considered a variation of the norm. It was considered something you really had to know how to do and had to have the skills to do it.”

One of those planned breech deliveries was with Ottawa mom Val Ryan. In a 2016 interview with CBC Radio, Ryan said she was 32 weeks pregnant when she found out her daughter was breech. “I was very nervous and scared because I thought it meant an automatic C-section.”

“Who told you that?” the interviewer asks.

“No one really told me,” she replies. “It was things I had heard from other people… but it was a myth. I did not want a C-section. I did not want major surgery and all of the potential complications from surgery. I wanted a natural birth.”

“Betty-Anne was able to catch my baby, as the lingo goes, deliver my baby,” Ryan continues. “And for me it was awesome because there was no doctor in the room, it was a very beautiful birth. My story’s quite anticlimactic; there’s no drama, no stress, no doctors.”

Every mother has a different take on what the ideal birth experience is, Daviss says. Her goal is to help women become more informed about their options, which means sharing evidence-based information.

After all, a cesarean delivery is major surgery that comes with its own set of risks. It’s not “a trite matter” for women, she says. In 2016, 32 percent of all births were by cesarean delivery in the United States. In Canada, the rate was 28 percent.

In many hospitals, the C-section rate is much higher than the average, and often avoidable. In California, C-section rates for low-risk mothers vary from 12 percent to 70 percent.

Daviss is also working to help physicians become comfortable with breech again. She’s traveled all over the world hosting workshops and presentations on breech birth at hospitals and conferences.

“The breech issue is one that really touches on issues of skill, politics, and hierarchy — not just in hospitals but in society — and consumer demand and mothers’ real wishes,” Daviss says.

“Birth is supposed to be something where you’re welcoming someone into the world that’s going to be your pride and joy. To have that birth taken over in a way where you feel out of control because the practitioners want to be in control because of their fear, it means we’re working uphill. I think if we could all turn around and run down the hill together, it would work better.”

Read about how midwives are growing in popularity. Later this week, the last part in our series will explore how midwives do way more than “catch babies” — they provide essential care to women without children.

Kimberly Lawson is a former altweekly newspaper editor turned freelance writer based in Georgia. Her writing, which covers topics ranging from women’s health to social justice, has been featured in O magazine, Broadly, Rewire.News, The Week, and more. When she’s not taking her toddler on new adventures, she’s writing poetry, practicing yoga, and experimenting in the kitchen. Follow her on Twitter.