Choosing a Caregiver
for Pregnancy, Labor, and Birth:
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: There are potential
dangers and risks inherent in pregnancy, labor, and birth. The role of the
caregiver is attempt to prevent problems, to remain aware of possible
complications and variations that may arise, monitor and test for issues, and
intervene quickly to prevent further complications.
Midwifery model: 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; provide education and assistance. If problems do arise, they
explore alternatives for coping with the issue, generally attempting to
minimize technical interventions. Midwives identify and refer women who need
the specialist care of an obstetrician. For more on midwifery model.
Obstetrician:
Training: OB/GYN doctors have
graduated from medical school, and had three or more years of additional
training in obstetrics and gynecology. Much of their education was dedicated to
diagnosing and treating medical complications. OB/GYN training does not
typically include experience in supporting a woman throughout an entire labor.
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: 6 minutes. During labor: may be available for phone consultations, or
may come to the hospital a few times to check on labor progress. They then
arrive shortly before delivery, and stay through third stage, and early
recovery.
Family Practice Doctor:
Training: Family physicians
have graduated from medical school, and completed two or more years of
additional training in family medicine, including maternity care. Education
focuses on the health care needs of the family. They refer to specialists for
complications.
Certified Nurse-Midwife. (Licensed in Washington State as ARNP’s)
Training: CNM’s have graduated
from a school of nursing, 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 are required to
work in a collaborative relationship with a physician and to have physician
backup.
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 remain with the mother
through most of her labor, then attend birth and initial recovery stage.
How commonly are CNM’s
used?
In 2002, CNM’s attended 7.6% of all births in the United States, 10% of all vaginal
births. 99% of CNM-attended births were in hospitals; .26% in birth centers;
.59% in the home.
Legal / financial. Nurse-midwifery is
legal in all 50 states. They have prescription writing authority. 33 states
mandate private insurance coverage, Medicaid covers in all 50 states.
Licensed Midwife / Direct Entry Midwife / Certified
Professional Midwife:
Training: Licensed midwives in
Washington 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 should 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: Time spent with
clients is equal to, or greater on average, than the time CNM’s spend with
patients. Case load is typically smaller than CNM’s.
Legal / Financial
status:
Varies widely from state to state. In Washington,
there are 120 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,
or 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.
Intervention Rates / Safety
of Midwifery Care
These rates are for labors
attended by certified nurse-midwives, as compared to national averages for all births… a number which includes CNM
births, but is primarily physician-attended births. I was not able to find
intervention rates for licensed midwives; they are likely to be lower than
rates for certified nurse-midwives.
Epidurals. National average in 1997: 2/3 of birthing mothers at large
hospitals (as high as 90% at some), 40% at small hospitals. CNM: 14.6%
Episiotomy. Approx. 50% on average. Seattle
hospitals range widely: 10-80%. CNM: 30.1%
Cesarean section. In 2002, 24% of births in Washington.
26.1% nationwide. CNM’s: 11.6%
Vaginal birth after cesarean. Nationwide: 12.7%. CNM: 68.9%
Infant mortality: In 1991: 8.6 per 1000 nationwide. CNM: 4.1 per 1000. In 1998, the
National Center for Health Statistics determined
that, after controlling for risk factors, the risk of infant death was 19%
lower at births attended by CNM’s than by physicians. Risk of neonatal
mortality within first 28 days was 33% lower for CNM-attended births. This is
believed to be attributed to prenatal care which involved more patient
education, and to CNM presence throughout labor.
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. To find a physician: Ask current doctor for referrals;
ask for referrals from your chosen hospital. Schedule an initial consultation
with the physician you are considering; they might charge for this. To find a
midwife: Look on www.midwife.org for CNM’s, or www.midwivesofwa.org for more
info on Washington CNM’s. Ask birth centers for referrals. Most
midwives will offer an initial interview free of charge.
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?
For more information on
questions to ask, see www.safebirth.org/sb/tenquestions.htm
Compiled by Janelle Durham,
2002
Sources: Pregnancy,
Childbirth, and the Newborn by Simkin, Whalley, and Keppler, 2001. Alternative
Birth: The Complete Guide by Carl Jones, 1991. A Good Birth, A Safe
Birth by Diana Korte and Roberta Scaer, 1992. Websites for: American College of Nurse-Midwives
www.acnm.org, Midwives of North America www.mana.org, American College
of Obstetricians and Gynecologists, www.acog.org
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