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 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 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. 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 (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 http://www.acog.org/member-lookup/ and for family physicians at http://familydoctor.org

To find a midwife: For a nurse-midwife, search at http://www.acnm.org/find.cfm. To find a licensed midwife, or certified professional midwife, search at http://www.mana.org/memberlist.html 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?

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

More Pregnancy Info