Choosing a Caregiver

There are several different professionals who can attend births, and deliver babies. There is a range of philosophy and practice amongst individual practitioners, but they fall at varying points along a continuum of beliefs about birth. These are often referred to as the “medical model” and the “midwifery model,” although that’s a generalization.

Medical model believes: There are potential dangers and risks inherent in pregnancy, labor, and birth. The role of the caregiver is to attempt to prevent problems, to remain aware of possible complications and variations that may arise, monitor and test for issues, and intervene quickly with the most effective tools in order to prevent further complications.

Midwifery model believes: Birth is a natural and normal physiological process which varies from woman to woman. The role of the midwife is to monitor the mother’s physical, psychological, and social well-being; and provide education and assistance. If problems do arise, they explore alternatives for coping with the issue, generally attempting to minimize technical interventions. When needed, midwives refer women who need advanced medical care to an obstetrician. For more on the midwifery model, see http://cfmidwifery.org/PDF/mmoc_brochure.pdf.

Obstetrician:

Training: OB/GYN doctors have graduated from medical school, and had three or more years of additional training in obstetrics (pregnancy and childbirth) and gynecology (health and disease of the female reproductive system). OB/GYN are trained surgeons, and can perform cesarean deliveries.

Philosophy/Focus: Physicians are primarily focused on preventing complications, detecting potential problems, and providing early intervention to prevent worsening of the situation.

Patient Interaction: Average prenatal visits: less than minutes. During labor: consults with your nurse by phone, or may come to the hospital to briefly check on patients’ labor progress. Typically arrive at the hospital shortly before delivery, and stay through third stage, and early recovery.

Note: many OB’s are part of a group practice, or use other physicians as backup at various times. This may mean that the doctor you saw during pregnancy is not the one who will attend your birth. (In one survey, 71% of women were attended by their primary provider, 9% by someone they had met briefly beforehand, and 9% by someone they had never met.

Family Practice Doctor:

Training: Family physicians have completed medical school, and completed three years of additional training in family medicine, including maternity care. Education focuses on the health care needs of the family from birth through death. They care primarily for low risk women, and refer to obstetricians if complications arise. Only about 25% of family physicians in the U.S. attend births.

Philosophy /Focus: Similar to OB/GYN, but may have more of a focus on health, wellness, and preventative measures than on treating advanced disease.

Patient Interaction: Similar to OB/GYN, but may arrive a little earlier in labor.

Certified Nurse-Midwife. (Licensed in Washington State as ARNP’s)

Training: CNM’s have graduated from a school of nursing (at least a bachelor’s degree), become registered nurses, and completed one or more years of additional training in midwifery. Their educational focus was on normal health care during the childbearing year, parent education, prevention and screening for possible problems, and newborn care. They typically have a working relationship with an obstetrician for consultation and referral.

Philosophy / Focus: Specialize in the care of women with uncomplicated pregnancies and births. They tend to view labor as a natural process, and use minimal medical interventions. (Due to their training within the “medical model” they may have a more medicalized view than a direct entry midwife.) They support the parents’ goals, and provide emotional support as well as physical care in labor.

Patient Interaction: Average CNM sees 140 clients a month and attends 10 births a month. Typically spend 40 minutes on a new client visit; 20 minutes on return visits. They check in with the mother through most of her labor, then attend birth and initial recovery stage.

Many CNM’s are part of group practices, where 4 – 8 midwives share a client load. Often in these practices, the midwives share call duty. So, if you went into labor on a Monday, midwife A is on duty. On Tuesday, it’s midwife B. You generally would have met all the midwives during your pregnancy.

How commonly are CNM’s used? In 2012, CNM’s attended 7.9% of all births in the United States, 11.8% of all vaginal births. 94.9% of CNM-attended births were in hospitals; 2.6% in birth centers; 2.5% in the home.

Legal / financial. Nurse-midwifery is legal in all 50 states. They have prescription writing authority. Most states mandate private insurance coverage, Medicaid covers in all 50 states.

Licensed Midwife / Direct Entry Midwife / Certified Professional Midwife:

Training: Licensed midwives have completed 3 years of midwifery training, which includes all the information required to care for women prenatally, during labor and birth and postpartum. It also covers newborn care, newborn procedures, and breastfeeding. Generally, licensed midwives attend home births and births in birth centers. Midwives serve low-risk women. They should ideally have a collaborative relationship with physicians for consultation and referral.

Philosophy / Focus: Similar to Certified Nurse Midwives, but with an even stronger belief in pregnancy as a normal, healthy life event rather than a medical condition. Intervention levels tend to be even lower than CNM’s due to this non-medical-establishment approach.

Patient Interaction: Case load is typically smaller than CNM’s. Prenatal care appointments may be 30 – 60 minutes long. The midwife is usually with the mother continuously from active labor through birth and the baby’s first few hours of life. Many practice independently or with one or two partners, so you may be more likely to have your preferred caregiver at your birth.

Legal / Financial status: Varies widely from state to state. (See www.mana.org) In Washington, there are over 100 licensed midwives. Their care is covered by Medicaid, and by several insurance companies. Generally, a licensed midwife can: do pap smears and other routine gynecological checkups, conduct prenatal exams, attend labor and birth. The only anesthesia a licensed midwife can use is a local block on the perineum. If a patient develops any condition that is defined as high-risk, if a patient desires pain medication during labor, or requires pitocin, c-section, or other medical interventions, the midwife will transfer the patient’s care to a physician.

Lay midwives

Lay midwives practice in some communities. Training and experience can range widely. Not all lay midwives are adequately trained If you consider using an unlicensed midwife, it’s important to be cautious and ask questions about their backgrounds.

Risk Status

If you are a “low-risk” mother with a “low-risk” pregnancy, you can choose any caregiver. If you are at higher risk, you will be best served by an obstetrician or a perinatologist (an OB who specializes in especially high risk cases.)

It is up to a trained care provider to assess risk levels, but generally a woman would be considered low risk if she was in general good health without pre-existing disease (including heart disease or type 1 diabetes), has not had significant disease arise during pregnancy (gestational hypertension, gestational diabetes, placenta previa), and is pregnant with one baby.

Intervention Rates / Safety of Midwifery Care

In general, for comparable low-risk women: if they have a home birth, they are likely to have the least interventions, hospital birth attended by a nurse-midwife has a lower rate of interventions than hospital birth attended by a physician. Studies that have looked at maternal satisfaction generally find that those with a midwife had a more satisfying birth experience than those with a physician.

The statistics below are from one study of 12,000+ births for low-risk women in Canada (Janssen, 2009), and compare intervention rates based on where the woman had planned to give birth. (Note: of those who planned home birth, 21% actually gave birth in a hospital, often due to a transfer for a needed intervention, such as cesarean. These women are still in the “planned home birth” category.)

 

Planned home birth with midwife Planned hospital birth with midwife Planned hospital birth with physician
Augmentation (with Pitocin or amniotomy) 23.7% 39.9% 50.4%
Epidural 7.7% 19.0% 27.9%
Episiotomy 3.1% 6.8% 16.9%
Cesarean 7.2% 10.5% 11%
Perinatal death (baby) .35 per 1000 births .57 per 1000 .64 per 1000

 

The women who gave birth at home had fewer complications, and so did their babies: less chance of low Apgar scores and reduced need for resuscitation at birth.

Other studies of births with midwives have shown similar results: lower intervention rates, as good of outcomes, and higher satisfaction.

Finding a Caregiver:

Check what caregivers and birthplaces are covered by your insurance. Think about what kind of care you wish to receive during labor and birth, and which caregiver and birthplace is most likely to provide that. Ask your friends, family and co-workers who they used, and whether they had a good experience.

To find a physician: Ask current doctor for referrals; ask for referrals from your chosen hospital (most hospitals have bios of their providers on their websites). Schedule an initial consultation with the physician you are considering; they might charge for this. You can also search for obstetricians at www.acog.org/About_ACOG/Find_an_Ob-Gyn For family physicians, look for online referral sites.

To find a midwife: For a nurse-midwife, search at http://ourmomentoftruth.midwife.org/OMOT-FIND-A-MIDWIFE . To find a licensed midwife, or certified professional midwife, search at http://mothersnaturally.org/midwives/findAMidwife.php and http://cfmidwifery.org/find. Ask birth centers, doulas, or childbirth educators for referrals. Schedule an initial consultation to make sure it’s the right match. Most midwives will offer an initial interview free of charge.

For consumer reviews of local caregivers and information about local intervention rates, see www.thebirthsurvey.com

Questions to ask potential caregivers

Where were you trained? How long ago?

How many births have you attended? How many labors attended from start to finish?

Will you expect to be at my birth, or is there a chance someone else will attend? Who?

For midwives: who is their backup physician? What conditions lead to a physician referral?

What are their intervention rates? What do you consider routine interventions for labor?

Who can be with me during labor and birth? What are the roles of support people?

Can I move around during labor? Can I eat? What positions do you recommend for birth?

What things do you normally do for a woman during labor?

Besides drugs, what do you recommend for relieving pain during labor?

How do you help mothers who want to breastfeed?

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