A guide to choosing a care provider and place of birth

{Before I begin I would like to disclaim that I am in NO WAY against one side or another (regarding both care providers and places of birth).  In sharing information it is always a sticky task and quite easy to misconstrue factual information as having some sort of negative agenda.  This is in no way what I aim to do, as I am simply trying to bring greater awareness to society's knowledge on the subject through both research and observation.}


Choosing your care provider and place of birth during pregnancy is an incredibly important task and can feel quite overwhelming at times.  Often moms choose their care provider because it's someone their insurance covers and recommended in the area, he/she has been their gynecologist for years, they chose them from a quick internet search, or even from misguided information.  Some choose their place of birth simply because it is nearest in proximity to their home without knowing what the facility has to offer.  Without knowing what to look for, or that something better even exists, many moms end up frustrated throughout their pregnancy, labor, and delivery.  Whatever your preferences, do your homework so that you know your options!

OB vs. Midwife?  
Ah the start of this whole process.  Do you want an Obstetrician or do you prefer a Midwife as your care provider?  First it's important to know the difference between the two.  An obstetrician is an MD (a medical doctor) with a specialty in childbirth. Therefore many people say, "ok yeah, then that's the one I definitely want... because they know more, right?".  Not necessarily.  Don't get me wrong... OB's unarguably know their stuff, but it's important to note that just like any other professional, not all OB's are the same. {I'll come back to that point in a moment.}  In general, Obstetricians are considered specialists in pregnancy and childbirth, and are experts at identifying pregnancy and birth related problems and being able to counteract these complications with medicine or surgery.  They are surgeons.  This is often where they thrive.  In other countries you see a specialist ONLY when you have a problem.  OB's in other countries are only seen IF you have a complication or are at a higher risk of developing one.  So one might think, "ok well I'd rather have the specialist so that they can better find any unforeseen problems or handle them better if they arise... right?".  Not always.  Midwives are specialists too... but they are specialists in normal birth.  In other countries everyone sees a midwife first and then are referred to an OB only in cases where problems arise.  Midwives are also fully capable of identifying complications (proactively) and referring patients to an OB when a complication extends past their scope of practice (before, during, and even after labor and delivery).  So in other countries, if you mention having an OB, you might hear, "oh... I'm so sorry" as it indicates things aren't normal in your pregnancy.  And just to add a not-so-fun fact in case you're thinking "well other countries aren't as developed as ours, so they're just behind"... our country is actually ranked 41st for maternal mortality.  That means 40 other countries (some "less developed" than ours) have better birth outcomes than we do.  In other words in case you still don't understand: 40 other countries have fewer women die in childbirth than we do!  Quoted from an article from the LA Times by Shari Roan and Lisa Girion back in 2010, "Though the U.S. spends more per birth than any other nation, maternal mortality is higher here than in 40 other industrialized countries, including Croatia, Hungary and Macedonia, and is double that of Canada and much of Western Europe."  Why????  Well, there are many areas where we can point the finger, from maternal age being higher than it used to be, poor health, overweight mothers, heredity, poor prenatal care, to underserved communities.  But one of the major preventable causes that raises eyebrows is that of intervention. Roan and Girion also write, "Some experts implicate the rise in rates of cesarean sections, which account for one-third of all births — up from one-fifth in 1997. Although many are done to save the life of a mother and her baby, perhaps half are elective, meaning the surgery is medically unnecessary. After one C-section, cesareans are typically recommended for subsequent pregnancies. Yet these are major operations and "should not be taken lightly," said Dr. Michael Lu, a UCLA associate professor of obstetrics and gynecology. Each additional cesarean increases the risk of placental complications that threaten the lives of mother and baby." -- "The induction or prompting of labor by medication, which is sometimes medically advisable but more often performed for the doctor's or patient's convenience, has climbed so steeply — it now occurs in 22% of births — that the American College of Obstetricians and Gynecologists felt compelled to advise its members last year to avoid inductions before 39 weeks' gestation.  When labor is induced a week or so before the due date, the uterus may not be ready, leading to prolonged labor. After delivery, the exhausted muscle may not contract properly to stop bleeding. Blood can no longer clot and becomes the consistency of water."  {Click here if you'd like to read the full LA Times article on the rise of maternal mortality rates}  So while we can't be certain of one direct cause, we can start with "if it ain't broke, don't fix it!".  If a pregnancy is normal, then I believe (as do good doctors and midwives) that you shouldn't mess with it or try to make it abnormal just in an attempt to find something to do!  There is no need to try and better a very natural process by speeding things up with drugs or conveniently scheduling when your little one "should' arrive. With this said, and going back to my point about not all OB's being the same... there are most certainly excellent OB's out there who fully support and honor the natural processes of pregnancy and childbirth and only step in when a true need arrises.  So if you think you definitely want an OB, then that's great... just do your homework in finding the right fit (or if you're local, ask me!) :).  Again, I'll come back to this point on how to find the right one for you in a moment.  First let's talk about the "other side".  So we already know that a midwife is a specialist in normal birth.  But it's also important to know which kind of midwife you are seeking.  In some states there are both CNM's which stands for Certified Nurse Midwives and there are CPM's which stands for Certified Professional Midwives.  Basically a CNM is a registered nurse who has gone on to become a midwife. They are legal in all 50 sates.  She has privileges in hospitals, but is always overseen by a physician.  She is able to administer drugs and some insurance companies may cover CNM care. So again, some would say "then I definitely want a CNM because they can work at the hospital where we're safest, right?!".  That is certainly fine if you feel strongly about delivering in a hospital...  but do remember that not only are they overseen by a physician but some would say (and I'm making a general statement which does not in any way reflect my personal opinion of all nurse midwives) that they are really "medwives"  as they seem to push the same interventions on moms that OB's sometimes do.  Hm... why?  Perhaps a product of their medically minded environment, or perhaps some are wannabe OB's?... who knows, but I too have witnessed this in SOME cases.  I have equally witnessed wonderful nurse midwives who are just as natural and less pushy as the home birthing kind, so again, just do your homework when finding the right CNM for you!  Now on to CPM's.  CPM's are not legal in all 50 states, though they have been in VA since 2005.  CPM's cover home births and free standing birth center births in the area and do not have privileges in the hospital.  Some believe that they have more autonomy in their practice as they are not overseen by a physician (though it's important to have good relationships with physicians in cases of transfer). They do not administer medications but instead use natural methods in their practice and are fully trained and prepared for neonatal resuscitation if the need arrises (though less than 1% of baby's born at home or birth center need resuscitation).  

Home vs. Birth Center vs. Hospital
Now, just as some moms believe that they are safest at the hospital "just in case something happens", others believe they are safest at home.  It is always important to remember when comparing the two that often the "emergencies" that arise in hospital settings are created by the interventions that have been introduced there.  I'm not saying that hospitals are unsafe, but when people say "oh had I been home, I would have died... or had I been home my baby would have died" it's important to understand that at home, many of those same complications don't arise because no one is messing with the process with medical interventions.  It's important not to really compare the two as they are two very different avenues. With that said, unfortunate, unforeseen outcomes happen every day in both home, birth center, and hospital, so none of this is to say anyone is immune by choosing one vs. another.

• Home birth (and I'll reiterate that home birth is for normal, healthy pregnancies and births): Moms are in their own environment where they are able to relax, eat, and drink without time constraints, and are able to move about freely while listening to their body as a guide.  They aren't tethered to IV cords or monitors (though it is important to understand that baby's heart rate will still be monitored periodically with a hand held doppler).  At home moms are able to avoid the sterile feel of hospitals, in a designated gown feeling like a "patient" (which often translates to feeling like one is sick or that something is wrong), and where they are able to avoid the constant poking, prodding and monitoring that has been shown to negatively impact the natural birth process by creating an adrenaline response to anxiety.  In addition, moms have a built-up immunity to the germs and bacteria in their own home (and therefore so does baby since they have mom's immunity) unlike the host of bacteria and viruses in hospitals. 
• Birth Centers:  Some believe they are "safer" than home birth because it's sort of an in-between: not so extreme as home and not so medical as hospital.  While this isn't exactly true, it's about where you FEEL most at ease. Again, be sure to do your homework.  Is the birth center run by CNM's and physicians using medicine or even attached to a hospital?  This may be just what you are looking for as it can be a really nice alternative to the medicalized setting of a hospital. They are often just like normal hospital rooms that happen to look a little cozier, have a bathtub, and keep the interventions better hidden so they aren't as "in your face".  For some this is a nice "in between". Or is it a free standing birth center that is providing a birth much like a home birth (we'll call it a home-away-from-home birth) with a full staff of CPM's and birth assistants and more "natural" equipment?  This can be a nice alternative to home birth if you live in a setting either with roommates, thin walls, or just want to get away to a nice atmosphere that is already set up for your needs (usually already equipped with massive birth tubs!).  Neither is necessarily better... just know what you're looking for when seeking your birth center!  There are a few great ones in this area if you'd like more information.  
• Hospital Birth: this is a great option for those who are certain they want to be at the hospital, definitely want an OB as their care provider, are at higher risk for complications, or are nervous about the idea of NOT being in a hospital.  Within the hospital setting, things are going to be much more medicalized, though it is completely possible to have a beautiful natural birth here if you so desire.  You will be monitored every hour (if not more frequently), you will most likely have a saline lock if not a full IV, you will have blood drawn, and will be limited (most likely) in what you are able to eat and drink.  In MOST hospitals (but not all from my experience), as long as you are unmedicated, you will be free to move around the room or walk the halls (when not on the monitors unless your hospital has wireless ones which would allow this throughout), you can usually get in the shower, or you can change positions with your doula on or around the bed.  All interventions are just a phone call away, but do realize that sometimes they are used faster because they are so readily available. 

Ok... so while this entire post could easily be about the comparison between OB's, CNM's, CPM's, where they practice, and the rise of maternal mortality (which let's be honest deserves a post all on it's own), I do still want to cover HOW to pick your care provider.  So how do you find the provider that's right for you? Happily, I can say, that these things to look for are important no matter which type of care provider you choose.  Unfortunately, sometimes the answers lie in the behavior and not in the questions... so do be observant when you're at your visits.

Scenarios and Questions

1.  "I want a natural birth and I started asking my care provider questions about it at one of my first visits (8-12 weeks).  They quickly brushed me off by answering, 'we aren't even going to discuss this at this time... we'll touch on that when you're more like 30+ weeks'."  Ok... THIS IS A HUGE RED FLAG!  If your care provider can't take the time to answer your questions FROM THE BEGINNING, then be aware that they are just going to keep putting them off until you feel that it's too late to switch, even if you don't like what you hear.  (Though do be aware that while less convenient, it is NEVER too late to switch care providers!).
2. "Every time I'm in the office I'm in and out in a matter of minutes and the Dr. never really remembers anything we discussed at our last visit."  Again, not a good sign!  Some large practices are so busy that moms start to feel like they're part of a factory.... just a number in a large line.  You should always feel that you are getting individualized care, from the start, and if you don't then move on!
3. "I asked my care provider how they feel about having a doula present.  They looked at me kinda funny and then said, 'well yeah... I'm fine with that' but they didn't exactly seem encouraging.  Thoughts?"  Yes... this usually means that they don't love doulas.  They'll "tolerate" one, but do you really want a provider who has to tolerate the presence of someone you've hired?  (I can tell you personally, it's not fun for us!) or do you want to have a care provider that not only encourages it and wants to work as a team, but can even refer you to doulas that they've really enjoyed working with?  If you think you want a doula, it's important to have a provider who is equally happy with this choice.
4. "My provider told me throughout my pregnancy that they were fine/supportive of natural birth, but now that I'm 39 weeks along, they're getting out the calendar to schedule my induction.  What do I do??"  I see this one more than most of the scenarios.  Some doctors are incredibly quick to induce if you go past your estimated due date, others even suggest it ON or BEFORE your date.  As always, ask the questions as early as possible. It's a very simple question that many moms forget to ask, or don't know how to ask, so here is an example: "how far past my due date are you willing to let me go without induction?  Are you willing to monitor me regularly around my due date with biophysical profiles/non-stress tests to make sure that my baby and I are fine?  If all is well, are you willing to let me go all the way to 42 weeks without medical intervention?" If not, how far ARE you willing to let me go?  If you find that you're running into this at the end of your pregnancy, don't ever be afraid to find someone who will allow you the time and space to go naturally within reason.  They do exist.
5.  Get a feel for your provider's philosophy.  Do they believe that this is a natural normal process and are they willing to truly let it be just that until proven otherwise?  Or are they anxious types with a fear of lawsuits looming over their actions causing them to be intervention happy or quick to cut?  It's usually not difficult to tell when speaking to them which way they lean, but I have seen those providers that answer everything just as you hoped in pre-natals but when the big day arrives they seem like a different person.  For that reason, it's also a good idea to ask their personal intervention rates.  What is their rate of induction?  What is their rate of cesarean?  If it's a midwife, what is her rate of transfer?
6. If you're someone who wants to write a birth plan, do so in enough time so that you can go over it with your care provider and gauge their responses.  If you have strong desires on your birth plan, make sure to listen to the answers they give you in regards to these issues.  If they aren't accepting of your wishes, and you know that your wishes are realistic, start shopping for another provider!
7. I could never have a man as my doctor.  Women are much warmer and more empathetic.  Yes and no.  As I've said repeatedly, not all providers are the same.  I always thought the same for myself when thinking of my future care provider and then I saw some cold, bitter, and well.. just plain rude women doctors who have the, "oh buck up, you're just being a baby" mentality.  With that said, some of the best doctors I've witnessed in this area are male.  Sometimes they're more compassionate, and sympathetic to what their patient is going through BECAUSE they haven't been through it themselves and don't even pretend to know what they are experiencing.   Just a thought before potentially eliminating a whole gender of very suitable providers!
8. Extend your homework to learn about your place of birth.  If you're delivering at a hospital, especially, look at the hospital's intervention rates. Are almost half the births there cesarean? (If so, that's high!) Are they an emergency hospital? (i.e. Do they treat every patient like their case is an emergency?)  Do remember that the entire team is part of your birth and you don't get to interview your nurses in advance.  A hospital that is used to more naturally minded parents and that sees normal births is going to be more flexible with your birth wishes than a hospital that is used to most of their births being high risk or having some sort of intervention at the very least.  In addition, find out the hospital's baby care protocols.. are they mother baby friendly?  Do they allow the baby to stay with you in your room and will they allow you that first hour (at least) to bond with your baby or do they take the baby away shortly thereafter to the nursery?  Do they leave you alone with your baby or do they feel that it's more important to weigh him/her and start vaccinating baby before you've even had a chance to breastfeed?  Do they allow you to at least DRINK fluids, (the good hospitals are coming around and allowing moms to eat actual meals just FYI) or are they stuck in the dark ages and only allowing ice chips no matter what your circumstances? Do they allow you to move around freely or do they make you have continuous fetal monitoring (rather than intermittent fetal monitoring) which keeps you tethered to the bed and its' surrounding areas?  If they do insist on continuous fetal monitoring (though most don't.. the recommendation is now 20 minutes on the monitor and 40 minutes off) will they allow you to unplug them to at least use the bathroom on your own (which in labor should be approximately every 30 minutes!). Do they allow a saline lock or do they insist on IV fluids at all times? If you are looking at a birth center or home birth, do they have the tools needed or do you need to purchase your own birth kit?  Do they allow water birth?  How far away are they from the nearest hospital and how often do they need to transfer?  Do they have good relationships with the area physicians if a transfer is needed?  All of these details are important to know when deciding on where you want to experience childbirth.

All in all just make sure that your provider is someone that you trust and feel is truly out for your best interest.  Make sure you feel comfortable enough to ask them even the toughest questions.... comfortable is key (remember you're going to have your panties off with them eventually!).  And always observe HOW they answer your questions, not just the answers themselves.   And for your place of birth, make sure that it is a place where you feel most at ease and safe.  If you do your homework, you can have a beautiful birth no matter where or with whom you choose to do it!