Choices in Maternity Care

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[This content is also available in audio form as episode 8 of my Transition to Parenthood podcast, which you can find on any major podcasting service.]

Let’s talk about all the choices you make in your maternity care, from choosing a care provider and birthplace and developing a birth plan to what happens if unexpected complications arise and you have to make choices about interventions you were hoping to avoid.

Values Clarification

Before beginning to research your options, take time for self-reflection, considering the big picture of your hopes and goals for your birth. If you will be parenting with a partner, this should be a mutual discussion. [Here’s a values clarification worksheet you can complete together to aid the discussion.]

  • How important do you think the birth experience is? To some, birth is a means to an end – one day in a life, and they just want to get through smoothly and safely. On the other hand, some people view birth as a profound life event, with lifelong effects on the family. They may want to put more time and thought into this decision making process.
  • There’s a continuum between natural and technological – viewing birth as a natural process which should unfold with few interventions versus being willing to use any medical interventions that might make childbirth quicker, easier, and less painful. Where you stand on that continuum will guide your choices.
  • What are your attitudes toward pain medication? Some people can’t understand why anyone would choose to birth without it. Others look forward to the experience of an un-medicated labor, believing that making it through that challenge will empower them to find new inner strengths. Many people are seeking a balance and want to have all options open.
  • The last consideration is to think about what a satisfying birth experience would look like for you, and what choices would help to move you toward that vision.

Choices to Make During Pregnancy

We’ll first consider your options for birthplace, caregiver, and labor support. Note, if you’ve already made these choices and just want to learn about interventions proposed for labor, skip halfway down this page. If you want information on pain meds, check out my podcast episode on medication.

Before examining options, let’s define what I mean when I talk about someone with a low risk pregnancy. It is up to a trained care provider to assess risk on a case-by-case basis, but generally a woman would be considered low risk if she was in good health without pre-existing disease (like heart disease or type 1 diabetes), has not had significant issues arise during pregnancy (like gestational hypertension or placenta previa), and is having an uncomplicated pregnancy with a single baby.

A person with a high risk pregnancy typically sees an OB and gives birth in a hospital. Someone with a low risk pregnancy has the whole range of options available.

Choosing a Birthplace

Hospital

98% of American babies are born in hospitals. The advantages of hospitals are that pain medication is available, and all potential interventions, including cesarean delivery, are available on short notice. They are the safest alternative for high risk pregnancies.

The disadvantages are that policies may place restrictions on choices that laboring women can make; such as movement and positions, eating and drinking while in labor. Even for low risk people, many interventions are routine, such as IV’s and electronic fetal monitoring. The nursing staff may change throughout the labor and are typically strangers to the family. Birth is viewed as a medical event, managed with medical interventions to prevent possible complications.

If you choose a hospital birth, and have multiple hospitals to choose from, know that hospitals range hugely in their policies, philosophies and intervention rates. Learn about your options. Don’t feel like the choice needs to be based solely on which hospital is the fastest drive from your home. Unlike on TV, the average first time labor is 14 hours, so you’ll have time to get there.

Out of hospital birth

Advantages: Lower cost. Fewer restrictive policies and more personalized care – the midwife knows the parents well and there aren’t unfamiliar people at the birth. People giving birth outside a hospital typically have significantly fewer interventions than those birthing in hospital. Birth is viewed as a natural event, and part of the on-going life experience of the family.

A disadvantage is that it’s not covered by insurance in some states, and not available in all states.

The expectant parent should be in good health and experiencing a low risk pregnancy. The choice of a well-trained and competent caregiver is essential; as is a clear plan for hospital transfer if needed.

For first time mothers, about 23% end up transferring to the hospital – mostly for non-emergency situations, such as prolonged labor, exhaustion, meconium in amniotic fluid, prolonged ruptured membranes, or a desire for epidural pain medication, which is not available outside the hospital.

For Home Births, the parents may feel relaxed and safe in their own territory and appreciate not having to go somewhere during labor and being able to just relax and setting in after birth.

Out of hospital birth centers provide a ‘home-like’ setting for active labor, birth, and the first few hours after birth. They may be a better out-of-hospital option than home birth for some parents if their home is far from a hospital or is otherwise not a good setting for a birth.

Some of my clients who planned birth center births haven’t liked the anxiety and uncertainty of having to decide when it was time to go to the birth center or haven’t like the fact that they have to leave the birth center a few hours after birth and chose home birth for subsequent births.

Choosing between Hospital and Out of Hospital

For a low risk pregnancy, the question of whether hospital or out-of-hospital birth is right for you depends a lot on your personal goals and priorities, as we discussed above.

In several surveys (Fleming, MartinDurham, Fleming2), when new parents were asked to rate their satisfaction with their birth place, consistently the highest rates of satisfaction were for those who planned and had an out of hospital birth, those who had a planned hospital birth were the mid-range of satisfaction, and the lowest satisfaction was for those who planned a home or birth center birth and transferred to the hospital.

I do encourage those planning out of hospital birth to think a lot about the possibility of a transfer and make a transfer plan which helps increase the chance they’ll have a positive experience even if it wasn’t what they had originally planned.

Choosing a Caregiver

The choice of birthplace and caregiver go hand in hand, so let’s also explore options for caregivers, which include OB’s, family practice docs, nurse midwives and direct entry midwives.

Doctors

OB’s, or obstetricians, are doctors with additional training in pregnancy and childbirth. They are trained surgeons and can perform cesarean deliveries. Their prenatal appointments are usually very brief. During labor, they consult with the nurses by phone and are typically with their client only for second and third stage.

In rural areas family practice doctors often attend births, but that is less common in urban areas. Nationwide, only 6% of family practice docs attend births.

Midwives

Midwives attend about 10% of the births in the U.S.

Certified Nurse-Midwives have at least a bachelor’s degree in nursing, are registered nurses, and have completed additional training in midwifery. Their focus is on normal health care during the childbearing year and prevention of and screening for problems. Prenatal care appointments are around 20 – 30 minutes. During labor, they check in with a client off and on during first stage, then attend birth and initial recovery. They take insurance, they can write prescriptions and provide all needed care for most pregnant people. 94% of nurse-midwifery clients birth in hospitals, but some nurse midwives attend home births or birth center births.

Direct entry midwives are professional midwives. That is the full focus of their training. They care for women prenatally, during labor and birth, and postpartum. They also provide newborn care. They attend home births and birth centers. They serve low risk clients. Prenatal appointments may be an hour long. The midwife attends the client through active labor, transition, 2nd and 3rd stage. The legal and financial status varies state to state as does insurance and medicaid coverage. Go to www.mana.org to learn about your state.

Midwives can provide all needed care for clients with low risk pregnancies. If their clients develop complications or require a cesarean, they refer care to an OB.

Choosing between Doctors and Midwives

Physicians tend to practice the medical model. Their focus is on monitoring for possible variations from the norm, and intervening quickly with the most effective tools to prevent or manage complications.

Midwives tend to practice the midwifery model: The role of the caregiver is to monitor the client’s physical, psychological, and social well-being, and provide education and support. If problems arise, caregivers may start with gentle interventions, and only escalate up to higher impact interventions if needed.

Because of these philosophical differences, a low risk client who sees a midwife will typically experience fewer interventions than a similar client seeing an obstetrician. So, less continuous monitoring, fewer episiotomies, vacuum extractions or cesarean deliveries. Health outcomes for mothers and babies are similar between hospital births and planned home births.

Doulas

Some people confuse midwives and doulas, so I want to clarify the difference. A midwife is a medical care provider, who supervises a patient’s care, similar to a doctor. A doula does not provide medical care. A doula is an additional support person you may choose to hire to provide emotional support, hands-on help with comfort techniques, information about your options, and ideas for helping your labor to progress. In my podcast episode on labor support, I describe all the things a labor support person can do during labor – doulas are trained professionals in this field.

Doulas do cost money and are typically not covered by insurance.

Parents who hire doulas have lower rates of cesarean, forceps, and Pitocin to speed labor. They are less likely to use pain medication (although if they choose pain meds, the doula supports that). They have increased rates of breastfeeding, and report higher satisfaction with their birth experience.

More information on doulas: www.dona.org, or info on choosing a doula.

Also be sure to read about making a birth plan during pregnancy to help clarify what all your priorities are for the birth, and how you are hoping your labor will unfold.

But, sometimes things don’t go as planned, and interventions may be proposed which were not in your original plans. So, let’s talk now about…

Choices to Make in Labor

Whenever an intervention is proposed, the first thing you’ll want to do is ask your care provider about Timing – how urgent is this decision? Do you have time to ask questions and to think about it?

When an intervention is proposed that we weren’t expecting, that often feels like an emergency to us. But there is usually plenty of time to explore the options.

If there is time for questions, here are the:

Key Questions to Ask

  • Benefits: Why do it? What is the problem we’re trying to identify, prevent, or fix? How is the test or procedure done? Will it work?
  • Risks: Why not do it? What are the possible tradeoffs, side effects, or risks for my baby or me? How are they handled?
  • Alternatives: What else could we do? What other options are available? What if I wait? What if we do nothing?

Making the Decision

Your care provider is a wealth of information and expertise. They can give you all the medical information about why they made the recommendation they did. They have already done a benefit-risk analysis and proposed to you the thing they believe to be the best solution – the best compromise between effectiveness (benefit) and potential risks. It’s based on all their medical expertise. But it may not fully take into account your personal goals and priorities – only you know those best.

When they make a recommendation, there were usually other options on the table. Imagine that there were 5 things on the list of possibilities. #1 was way too risky to start with. And #5 was really low risk but the care provider also doubted that it would be effective. So they’re not really options. The care provider chose to recommend option #3. But, you could ask them – are there other options that are almost as good? Maybe #2 is slightly higher risk, but really likely to work quickly. If you’re exhausted, or if you’re really concerned about the possible problem you’re trying to prevent, you might say that #2 seems better to you. Or, if under your values clarification, you said that you generally lean toward the natural approach (aka the midwifery model) or low intervention, you might ask whether #4 is a viable option. It may not be effective, and you may have to escalate up to a stronger intervention, but is it possible to start gradually?

Let’s look at some possible interventions that might be recommended and think about how your decision-making might play out.

Induction

Near the end of your pregnancy, your care provider may recommend that you consider induction. That’s using medical interventions to start a labor that hasn’t started on its own. So, let’s look at benefits – why would they recommend inducing? Basically there’s some reason it might be better to get labor moving than keep baby inside for longer. For example, if the pregnant parent has blood pressure that’s increasing, or the baby is not growing well, or the bag of waters has broken but labor has not started.

Regarding risks of induction – the tradeoffs that we know will come with induction are an IV and continuous monitoring. There is an increased chance of vacuum or forceps delivery. With contractions coming on faster and stronger than they would otherwise have done, the pain may be worse and more parents will choose pain medication. For the baby, they may have been not quite ready for birth, so they may have lower Apgar scores at birth or may be more likely to be admitted to special care nursery.

In deciding on any intervention, we need to ask ourselves: do the benefits outweigh the risks?

This can be a little tricky with induction, because most reasons to induce fall on a continuum where if it’s a mild problem we probably don’t need to induce yet. If it’s a big problem, we may wish we had induced sooner before it got bad. Deciding when to intervene vs. when to let pregnancy continue is a medical judgment call.

So, when you ask a care provider about alternatives, a big question is about timing: do we do it now? Or tomorrow? Or in the next week? What happens if we wait? To learn more about the induction decision, read the Lamaze Healthy Birth Practice on letting labor begin on its own.

Sometimes labor is induced not for medical problems, but because of the dates on the calendar – a few years ago, obstetrical recommendations were that pregnancy should continue to 41 weeks unless there was a medical reason to induce. A recent study suggested that obstetricians could offer elective induction at 39 weeks, so we may soon an increase in recommendations to induce because of dates. Again, explore whether the benefits outweigh the risks for your pregnancy.

If you decide that induction makes sense, then the next set of alternatives to ask about is which method to choose – there’s natural induction methods such as orgasm, nipple stimulation or taking herbs or castor oil, or there’s medical methods from acupuncture to balloon catheters to Pitocin. To learn more about these alternatives, read Pregnancy, Childbirth, and the Newborn or look at the blog Evidence Based Birth.

Routine Interventions

Depending on what part of the country you live in, and which hospital you are giving birth at, you may be offered a number of routine interventions – these are interventions that are typically used for all people in labor regardless of whether they are low-risk or high risk. They could include having an IV or a heplock, having intermittent or continuous monitoring, limits on whether you can eat or drink in labor, and limits on how long labor can be before they augment with Pitocin or recommend cesarean.

Before you go into labor, learn about each of these interventions and their benefits and risks by reading Pregnancy, Childbirth, and the Newborn, the blog Evidence Based Birth or the Lamaze Healthy Birth Practice on Avoiding Interventions unless they are medically necessary.

Then talk to your care provider, or take a hospital tour, to learn which of these practices are routine at your hospital, and whether you have options about them. For example, your care provider may be able to write special orders for you to make exceptions to standard hospital protocols. If there are interventions that you have strong preferences about, you could also contact other hospitals to see what their protocols are, but typically if you were to choose a different hospital to give birth in, you would also need to change to a different care provider.

Cesarean Birth

In the United States, 32% of babies are born by cesarean. Every pregnant parent should be fully informed about this common intervention.

In general, vaginal birth is safer for the birthing parent and for the baby than cesarean birth is. Cesarean sections are a very common surgery, and pretty safe as surgery goes. But, it is major surgery, and does carry with it an increased risk of bleeding, increased risk of infection, more postpartum pain, and has potential impact on your future fertility and pregnancies. Thus, a cesarean should only be done when the benefits outweigh those risks.

The benefits of cesarean depend on what problem they’re attempting to prevent or to fix. I separate indications for cesarean into three categories. There’s planned cesareans – one of the most common reasons someone would plan a cesarean is if they had one with a previous baby; however, vaginal birth after cesarean (also called VBAC) is an option for most of these parents and is lower risk for the mother than a repeat cesarean, and similar risk for the baby.

Other reasons for a planned cesarean include pregnant with triplets (or more), placenta previa where the placenta implanted over the cervix, a baby in the breech position (bottom down instead of head down), or other health conditions in the pregnant parent or baby where the risks of a vaginal birth are higher than the risks of a cesarean. Another reason would be a big baby – different care providers have different opinions on when and if this would be an indication for a planned cesarean.

If your care provider recommends scheduling a planned cesarean, you generally have plenty of time to ask questions, and learn more so you can make an informed decision.

The next category is emergency cesarean. These could be due to emergencies like cord prolapse, placental abruption, uterine rupture, or other urgent health issues with the pregnant parent or baby. True emergency cesareans are rare – around 1% of births. The time from decision to surgery beginning can be minutes – there is not usually time for a lot of questions and decision-making.

The final category is unplanned cesareans, and this accounts for the vast majority of [primary] cesareans. Now, I can tell you from personal experience that many unplanned cesareans may feel like an emergency to the parent. With my first birth, we had expected a normal vaginal birth, and when my doctor said “we need to start thinking about cesarean”, I freaked out, because it wasn’t what I expected. I blurted out “but I haven’t read that chapter in the book yet.” He said “well, if you want time to read, that would be fine.” That clearly told me that this wasn’t an emergency, and I was able to slow down and say “so I have time for questions and time to think about it?” You almost always do.

Most unplanned cesareans are for one or both of these reasons: “failure to progress” which means a labor that is taking longer than expected and doesn’t seem to be progressing as we would expect, or “non-reassuring fetal heart rate.” Before baby is born, we don’t have a lot of information about how they’re doing, but one of our key indicators of well-being is their heart rate. If it looks good, that’s reassuring. If the baby’s heart rate is unusual – it’s faster than normal, slower than normal, or not responding to contractions in the way we expect, that’s non-reassuring. It’s really important to understand that this doesn’t mean something IS wrong with baby, it just means we wonder whether something is wrong with the baby. If the concern is high enough, a cesarean will be recommended.

For both these indications, there is absolutely a point they can reach where a cesarean is the best answer. But where along the way do we draw the line… when is it a minor problem we’re monitoring but don’t need to intervene with, and when have we reached the point where cesarean is essential. This is another judgment call by your provider. You can ask them what your alternatives are: is there anything else you could try first? Could you wait an hour and take steps to help labor progress, and then in an hour if there’s no progress, re-visit the conversation?

I encourage you to learn more about cesareans before the end of pregnancy – learn how the procedure is done and what the recovery is like. If cesarean is likely for you, you may may also ask your care provider about family centered cesarean,  which can include your care providers taking steps like low lighting, calming music, lowering the surgical drapes so you can see the delivery, delayed cord clamping, early skin to skin contact – placing the baby on the birthing parent’s chest even as surgery is completed, and initiation of breastfeeding in the first hour.

Whether you’re making a decision about cesarean or any other intervention, it’s important to ask the questions you need to in order to make a decision that feels good to you. It’s also OK to ask for a few moments alone to process the emotions about this decision – it may not be what you had hoped or planned, but you understand why it’s the right decision in the moment, and later on, you won’t regret making it. No matter the specific details of your birth, you can have a positive experience with compassionate labor support and informed decision making.

To learn more about medical interventions and choices in childbirth, check out www.ChildbirthConnection.org or go to https://www.lamaze.org/healthybirthpractices. To learn more about pregnancy, labor and babies, check out my book, Pregnancy, Childbirth, and the Newborn.