Wednesday, July 23, 2014

Choosing Your Pregnancy Care Provider and Birth Location

You're Pregnant? Congratulations! You're full of excitement and love, and your family is already planning your nursery and picking names and buying toys and clothes.

You know you need to see a health care provider. You think, "I guess I'll just go to my regular gynecologist."

WAIT! There's a lot more that goes into your pregnancy and birth care provider choice than what goes into your gynecologist choice. You have a lot of options when it comes to your pregnancy care that most women don't know about before they are pregnant.

Why is this important?

1. Because women remember how they were treated during their birth for the rest of their lives. Choose someone who will make you feel respected.
2. Because it will affect the amount of information you receive, what options you have during birth, and the degree to which you are involved in decisions about your care.

So, here is a guide to finding and picking a care provider and birth location.

Your Options: Hospital, Birth Center, or Home

Most of us assume that birth will be done in a hospital, and that's that. Truly, everyone feels safer in different environments. Find the best match for you:

Hospital: A great option for high risk care for you or your baby; No need to transfer to a different location if something goes wrong in labor; Medical pain relief and other medication is immediately available; Care is standardized ("cookie cutter") rather than individualized; Interventions are used routinely whether or not there is a clear medical need; Technology is relied on to make decisions rather than a woman's body or intuition; Staff are not always available to provide continuous emotional, informational, and physical support; Requires transfer from home to hospital during labor.

Free-standing Birth Center: Greater emphasis on individualized care; Rely on your body's physiology rather than technology; Staff are available to provide psycho-social support; Requires the need to transfer from home to the birth center while in labor; Requires transfer to the hospital in an emergency; Some birth centers do not have medications available for labor; Avoid routine interventions and rely on medical need.

Home Birth: Highly tailored to your individual needs and preferences; Completely avoids use of routine interventions during labor and delivery; Continuous psycho-social support is available; Does not require transfer from home to a different birth setting during labor; Does require transfer to hospital in the case of emergency.

Your Options: Obstetrician or Midwife

The typical American woman has an obstetrician as her care provider. It is the doctor that we are used to, and it is all we have seen on TV, in movies, and our relatives do. Obstetricians are the default option for women who want to give birth in a hospital.

A midwife, to the general populace, is what our great grandparents used for birth, or what they use in primitive tribes. The thought is that they are for people who don't have doctors. Or, maybe they're just for the hippie types who don't use health care.

In reality, a midwife is a great option for your pregnancy care provider. They are highly trained and licensed, come in all shapes, sizes, ages, and from all political backgrounds. You can be with a midwife for hospital birth, a birth center, or at home. I like to share more information on midwives because many people don't realize it is an option. There are a few types of midwives:

  • Certified Nurse Midwife (CNM): Trained in both nursing and midwifery, and work in hospitals, birth centers, or sometimes attend home births.
  • Certified Professional Midwife (CPM): Certified by the North American Registry of Midwives. Requires knowledge of out-of-hospital birth settings. 
  • Licensed Midwife (LM): A direct-entry midwife who is licensed in her state to attend out-of-hospital births.
The number of deliveries attended by midwives in the United States is growing. Numerous research studies show that midwives provide equal or sometimes better care to patients with low-risk pregnancies. To learn more about midwives, check out this great video series.

An obstetrician is a physician and trained as a surgeon. They are great for pregnancies that require a bit more medical care, and they generally supervise or "back" midwives in the hospital. Because midwives do not perform emergency surgical procedures, midwives always "risk out" a patient who may need additional care. An obstetrician is a medical doctor.

Differences in models of care
The medical model of care that a physician provides focuses more on a hierarchical system of care where the woman is a patient, birth is meant to be managed by experts because it is potentially pathological. Some obstetricians are great and spend personal time with patients, but many are authoritarian, depersonalized, and do not provide emotional support. The midwives' model of care respects birth as a normal part of a woman's life and involves her more in the relationship. Decision making is ideally shared, and information is shared during more in-depth prenatal visits. Some midwives are more medical model, and some obstetricians are more midwife model. It all depends, and that's why its a good idea to interview your provider.

Other care providers
You can also have a MFM (maternal fetal medicine specialist) as your care provider for high risk pregnancies, a family physician, or ARNP, but these are generally less common than OB or midwife.

Choosing a Care Provider

One way to start choosing a care provider is to see which providers your health insurance covers. Another is to pick based on where you want to give birth - home, birth center, or hospital. A great way is to ask around among birth professionals in your area, including doulas and childbirth educators, who know the local "birth scene."

If you've started reading books, blogs, or signed up for a childbirth education course, you'll learn what your options are for birth and decide what is important to you. Is it the freedom to move around during labor? To avoid medication during labor? To have a VBAC?

Once you make an appointment with a care provider, it is important to take a tour of where they deliver. Find out what the birth experience will be like. Does the hospital have a certain reputation (e.g. high c-section rates)? Interview moms who have worked with that particular home birth midwife. Call and ask what hospital or care provider statistics are on intervention rates that you might like to avoid (e.g. induction).

Questions about the Birth Location

  • Are there restrictions on who is allowed in the room?
  • Do they allow intermittent monitoring, birth balls, laboring in the bath tub, walking around during labor, etc?
  • Can I eat and drink during labor?
  • Are they supportive of doulas attending labors? (if your provider says no, it may be that they do not have your best interests in mind. Doulas are evidence-based!)
  • What are the hospitals c-section, induction, epidural rates?
  • Are mom and baby kept together after birth? Does the hospital support immediate skin-to-skin? 
  • How does the hospital support breastfeeding? 
  • What if I choose to decline a certain intervention for myself or my baby?
  • (If at birth center or at home): Under what scenarios am I risked out of your care?
  • Do I feel comfortable here?

Questions for the Care Provider:
When you have a chance to sit down with your care provider, here are some questions to ask to gauge whether they are a right fit for your desires:

  • What is your birth philosophy? How do you feel about natural birth?
  • What do you consider "full term" or "past due"?
  • How much time will be spent with me during each appointment?
  • What routine tests are there during pregnancy?
  • What are your intervention rates? (induction, artificial rupture of membranes, episiotomy, epidural, c-section, etc)
  • How do you feel about my hiring a doula?
  • Can I push and deliver in different positions, including hands and knees, squatting, side lying, etc?
  • Is there an on call rotation?
  • What if I want to refuse a procedure for myself or my baby? Are there any procedures that are non-negotiable?
  • How do you feel about my birth plan to avoid [continuous fetal monitoring, an episiotomy, pain medication, pitocin augmentation, etc].
  • Do I feel respected by this care provider, and like my wishes will be granted?
  • Are his/her practices consistent with evidence-based medicine?
  • How much responsibility do I want to take for my pregnancy and birth?

Switching Care Providers

After you've begun to receive prenatal care from a provider, you may notice that he or she is not as supportive of your wishes as you'd like them to be. Or, you've learned that the hospital they deliver at has the highest cesarean section rate in the region! Everyone deserves respect in health care. Ideally, you should have shared decision making and be able to ask them anything. They should respect your plan for your ideal birth. If you find you might like to switch, it is a great time to get feedback and advice on providers from others in your childbirth education course, or do some research and call up a new doctors office, birth center, or home birth midwife. You need to make sure that you "click" with the person providing your care during this very emotional time. 

I've heard switching stories lots of times. It seems difficult (you're already invested in your current provider, they have your health records, you think its too late to switch, you don't want to hurt their feelings, etc). but it is generally an easy thing to do.  If you are very near the end of your pregnancy, you may have to call a few people to find someone who is willing to take on a new client so late. Again, ask your local birth community on advice on how to ask to switch (they can help you say the "right things" to get you in)!

For more great information and resources from an excellent national resource, check out Choosing a Caregiver and Choosing A Place of Birth from Childbirth Connection.


  1. This is a great post! However, I would love to see another post that addresses what to do if you don't have these choices. For instance, I live in a largely rural area, in a state that does not license midwives. OBs do not attend home births, so that's out of the question, and there are no birth centers. Essentially, I HAVE to have a hospital birth with an OB. And we have only 2 hospitals to choose from. Fortunately, our area has seen an influx of recently trained doulas.

    What advice would you give to someone like me who basically wants to have a home birth experience in a hospital? How do I talk to my doctor and ensure that my wishes will be met?

  2. That could be a whole different post @yetanotherbitterinfertile !

    "How to Have a More Home Birth Experience in a Hospital" short explanation:

    1. Hire a doula
    2. Take childbirth education and prepare for labor/know your options/ know your right to refuse
    3. Create a birth plan with your strongest wishes and discuss them with your care provider ahead of time
    4. Bring plan with you to hospital to give to nurses (with cookies ;)
    5. You and your partner advocate for your wishes and have awesome labor.

    Of course it won't be quite like a home birth, and people won't quite be on the same page as you, but it can still be great! (I've seen it! :)


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