Healthy Pregnancy Series: Options in Maternity Care

When you find out you’re expecting (or are hoping to be shortly), one of the first things you’ll need to do is find some maternity care. Prenatal care is stressed no matter WHAT experience you are looking for because trained maternity personnel can help you determine if everything is progressing normally with your pregnancy — or not, so that you can get help if you need it. I wouldn’t recommend ever that ANYONE not have some type of prenatal care. But where you get it and who provides it can vary widely depending on what is available to you and your preferences.

Obstetricians

The “standard” maternity care in the U.S. is currently to seek an obstetrician, who delivers in a hospital setting.  This comes along with all of the usual tests (including at least 2 blood tests, if not more; frequent urine tests, ultrasounds, etc.).  An obstetrician typically spends 5 – 10 minutes per visit with patients.  This may vary depending on the patient’s insurance and how busy the doctor is. 

It is important to note that obstetricians are medical-model and are highly trained surgeons.  If you feel or know that, for any reason, your pregnancy falls in a high-risk category or believe you will NEED a c-section (for example, I knew of someone who had been in a horrible car accident and shattered her pelvis completely; it had been put back together with rods and screws but attempting vaginal birth was too dangerous for her), an obstetrician is something you will need. 

If you choose an obstetrician, it is best to find one who will be willing to work with both your needs and wants as well as their opinions and training.  There are doctors who treat pregnancy as a joint effort, and there are those who believe “I’m the doctor, so do it my way.”  Find one who matches your beliefs as much as possible and who will take the time to talk to you and answer your questions.

Be aware though, that most obstetricians treat pregnancy as a disease or at least a delicate condition that requires managing and testing to make sure all is well.  They do not trust the body to handle things naturally.  They also do not believe in out-of-hospital birthing (as a rule) and are often partial to “moving things along” (i.e. breaking your water, administering pitocin, scheduling inductions, etc.).  If you are low-risk and looking for a rather hands-off approach, an obstetrician may not be for you.  As 75% of women are low-risk, don’t automatically assume you will NEED to have an obstetrician as your primary caregiver.

Certified Nurse-Midwives

A CNM is a nurse who has graduate-level training in midwifery.  She (or he) has gone to school to obtain her RN, usually practiced in the field for awhile, then gone on to graduate school to obtain midwifery training so she can deliver babies.  She is directly supervised by an OB and only delivers low-risk babies.  If a woman in her care becomes high-risk, or she suspects a problem, she refers the woman to her OB for further care.  She delivers babies only in hospitals (in most states) and sometimes birthing centers associated with hospitals.  She is still medical-model in most cases, but is more inclined towards natural birthing than an OB.

If you are nervous about birth and are definitely looking for a hospital or birthing center experience, but are hoping for a more natural experience, a CNM may be for you.  CNMs are more likely to take a “wait and see” approach if all is going normally during labor, and they are less likely to push unnecessary interventions (but this depends on personality, too, so make sure you know your CNM!).  They typically spend a bit longer, 20 – 25 minutes during each visit.  Since you are under the care of an OB, too, you will usually have all the same tests and many are required.  Be aware, too, that it depends on how heavily the OB is involved in care.  In most cases, you will have to meet him/her once or twice during your pregnancy (often for ultrasounds) just so you’ve met should something go wrong in the delivery room.

Certified Professional Midwives

CPMs practice almost entirely out-of-hospital births.  In some states they can attend birthing center births; in others they attend only homebirths (depending on the state’s laws).  CPMs do not have formal medical training.  They sometimes attend midwifery school directly; other times they learn through apprenticeships.  All go through apprenticeships whether or not they go to midwifery school.  They are then licensed by a national organization, which is recognized in some states and not others.  They have typically attended many (30 or more) births by the time they are certified and have functioned as a midwife under the observation of a licensed midwife in several of them.

A CPM typically is not medical minded.  She tends to believe that pregnancy is a natural, normal part of a woman’s life and that in most cases, does not require much intervention.  She will not perform ultrasounds or blood tests (other than possible finger sticks to check anemia).  She will often perform urine tests, palpitations (feeling the fetus’ position from the outside), check the baby’s heartbeat, the mother for swelling, etc.  Her equipment is low-tech and she checks for any signs that something MAY be wrong and refers any women with warning signs to an OB for follow-up testing.  CPMs do not deliver high risk mothers in most areas (though in states where they are legally recognized, may assist in doing so if working with an OB).  CPMs do not do things to “move things along” including inductions, breaking a mother’s water, using pitocin, etc. under ordinary circumstances (there are rare circumstances that a CPM may use some natural methods to move labor along).  A CPM typically spends 45 – 60 minutes per appointment with her clients throughout pregnancy.

If you are looking for a completely natural experience, where you trust your body and do not want any unnecessary testing, a CPM may be for you.

Practice VS. Single

Whichever option you are looking at, you will run into this question: should you choose a single doctor/midwife or a practice with several?  When you have only a single person to rely on, you run the risk that they may be sick, on vacation, or at another birth when you go into labor, and you may have a complete stranger delivering your baby.  This may or may not bother you, and it’s unlikely to happen (but always possible).

With a practice, you are guaranteed to get SOMEONE in the practice, but you often have no idea who you will get.  Typically they have an “on-call” rotation, so that Dr. X is on call Monday and Thursday, Dr. Y is on call Tuesday and Friday, Dr. Z is on call Wednesday and Saturday, and they all rotate Sundays.  This means that whatever day you go into labor, that’s who you’ll get.  It also means if you go into labor at 6 PM on Wednesday but don’t deliver until 6 AM on Thursday that you’ll have to switch doctors in the middle!  You will at least have met the person who delivers your baby (you will have appointments with a different doctor at each appointment, often times, so that you WILL meet them all), but you may or may not prefer him/her.

With CPMs, they sometimes work in teams.  If they don’t, they usually have a “back up midwife” whom you’ll meet once or twice during your pregnancy.  Sometimes they have a “back up’s back up” for nights when things get REALLY busy and in that case you may not have met the person who delivers your baby.  But, it’s up to you to decide what you are comfortable with.

Selecting Care

You do NOT have to keep the first doctor with whom you schedule an appointment.  You are allowed (encouraged!!) to go to your first appointment with a list of questions so that you can determine if that doctor is really a good fit for you or not.  I will include a list below.

If the doctor doesn’t answer your questions to your satisfaction, or seems brusque, rude, busy, or avoids any particular questions, etc. — go somewhere else!  Do not feel that you need to stay with this person if you do not feel comfortable.  It does not matter how many fancy degrees the person has or how much experience.  If they are not willing to be in a partnership with you and make you feel listened to and appreciated during your pregnancy, you don’t need them for a doctor.  It can even be DANGEROUS in some cases to have a doctor (or midwife) who does not listen to you.  Mother’s instincts are strong and if you feel that something is wrong but they brush you off with “Oh, that’s just normal pregnancy stuff,” it could have serious consequences for you and baby.

If you are already pregnant and are with a doctor whom you don’t feel comfortable, it is never too late to switch.  There are women who switch right up to their 36th week, and a few switch during their labor!  (I, for one, was ready to kick my doctor out of the room and let the on call doc deliver me during Bekah’s birth.)  Don’t let any person tell you that you have to do anything you are truly uncomfortable with, and never be afraid to switch.  You have rights!!  (Which we will cover in the future.)

Questions to Ask

1. What is your philosophy towards birth?

2. What percentage of women in your practice have c-sections?  Of first-time moms?

3. What percentage get an epidural or other pain medication?

4. Do you have a policy about IVs in labor?

5. Do you allow or encourage a birth plan?  When do we discuss it and how closely will we stick to it, assuming all is normal?

6. How many support people do you allow in the delivery room?  Who can I have?  Are there limitations?  (NOTE: Some practices have banned doulas!  This is an unacceptable breech of women’s rights and any doctor who places such limitations on you should be avoided.)

7. If something goes wrong, will you discuss my options with me?

8. What experience/credentials do you have?

9. Will I get to hold my baby immediately, assuming all is well?  Will we be able to room-in?

10. What tests or procedures do you perform routinely?  Can I opt out of any of them?  Will you explain the benefits and risks to me of each test/procedure? (This could be a HUGE red flag if the doctor says “The tests are required and they are definitely beneficial to you” and will not explain much further.)

11. Will I be working with anyone else in the office (if a practice)? When do I get to meet them?

12. What happens if you are unable to attend my birth?

13. What is your policy about eating/drinking during labor?

14. How do you feel about fetal monitoring during labor?  What do you typically do?

Please feel free to included other questions that are important to you.  These are the ones that jumped out to me as being important.  Use each not only to get information but to gauge the doctor’s attitude towards birth and towards patients.  Don’t go back if you are not happy or comfortable!  That is VERY important to know!

Good luck selecting the best option in maternity care!  And remember this is YOUR choice and your partner’s, not your parents’, not your neighbors’, not anyone else’s.  We’ll talk about THAT later too!

Where do you or would you get maternity care?  What options exist in your area?