Overview

This article examines your care team during your pregnancy, birth, and postpartum. Your primary care provider is the cornerstone of your prenatal care and birth experience. In addition to your doctor or midwife, many other types of practitioners can play a role in your care. This article will help you understand each professional’s role in your care, differentiate between different professional certifications, and navigate working with these specialists.

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The Importance of Your Primary Care Provider 

Your primary care provider is the cornerstone of your prenatal care and birth experience. This is your leading expert resource that you will be working with throughout your pregnancy to make critical decisions. It is vital to be comfortable with and trust your care provider. That is more important than their qualifications, where they went to school, and how many births they have attended.

Choosing your primary care provider is more nuanced than having a midwife for a home birth or an OB/GYN for a birth at a hospital. You want to explore your options, shop around, and do your research. See this episode for more information on choosing or changing your doctor or midwife.

Doctors & Physicians

At the broadest level is a general practice doctor. Beyond that, there are hundreds of specialties and subspecialties. In the United States, the general path someone takes to become a doctor starts with an undergraduate degree, which typically takes four years. They take the MCAT (Medical College Admission Test) and enroll in a four-year medical school. Medical school graduates complete a residency at a hospital that focuses on the area they want to practice. Residency can last between 3-7 years, depending on the field. In a residency program, doctors are supervised by attending physicians and gain hands-on experience. Some doctors will complete a fellowship which adds one to three years. The entire process for becoming a doctor takes around 11-15 years of education, training, and experience.

General Physician

A general physician is a doctor who has a broad range of expertise. If you have a physician, such as a general practitioner or family doctor, that you like and would like to continue to see for your prenatal care, you want to make sure that they are knowledgeable about pregnancy and birth. It may not be their specialty, and if they do not deal with it, often they may not be the most qualified person to give you care. You want someone you are comfortable with, but you also want someone with extensive pregnancy and birth experience. Having a physician who knows you and your medical history can still come in handy if you want a second opinion on anything. You can keep a relationship with your family doctor while receiving care from a more specialized doctor during your pregnancy. 

Obstetrics and Gynecology

The most common doctor for pregnancy and birth is an OB/GYN. Obstetrics deals with pregnancy, childbirth, and the postpartum period. Obstetricians have training in surgical interventions, like cesareans. Gynecology focuses on the health of the reproductive system and breasts. A gynecologist’s practice includes pap smears, cancer screenings, treating UTIs, breast issues, etc. Obstetrics and gynecology are closely related, and most often, doctors who specialize in one also specialize in the other. An OB/GYN (obstetrician/gynecologist) is a doctor with both certifications. These are typically the primary care providers for pregnant women in the United States. 

Midwives 

In many countries outside the U.S., midwives are the primary care providers for expecting mothers. This was the case in the United States until the beginning of the 1900s, when we shifted to doctor-led care. Midwives specialize in pregnancy, childbirth, postpartum care, and overall care for women but do not practice surgery.

In the United States, the general path someone would take to become a midwife depends on the certification. 

Certified Nurse Midwife (CNM)

A Certified Nurse Midwife needs a bachelor’s degree in nursing because they are registered, nurses. Then they go through a 2-3 year graduate-level training in midwifery.

Certified Midwife (CM)

A Certified Midwife has a background in a health-related field other than nursing, then goes through a master’s level midwifery education program. They have similar training to Certified Nurse Midwives conform to the same standards, but Certified Midwives are not required to have the nursing component. 

Certified Professional Midwife (CPM)

The majority of midwives in the U.S. are Certified Professional Midwives. This certification does not have a college degree requirement. A Certified Professional Midwife gains their experience through clinical training under the supervision of a midwife. 

Licensing in the United States 

Licensing of midwives in the United States varies by state. If you want to see details on your state, the Midwives Alliance of North America breaks down each state’s laws. Certified Nurse Midwives are licensed in all 50 states in the U.S. 35 states recognize Certified Professional Midwives. Certified Midwives are licensed in only five states in the U.S. 

Licensing plays a significant role in who is legally allowed to attend births based on the setting. Traditionally midwives attend the majority of out-of-hospital births. This report on trends in out-of-hospital births breaks down what type of care provider attended births based on location. Certified Nurse Midwives and Certified Midwives attend about 1/3 of planned home births. Half of the planned home births were attended by non-CNM/CM midwives. Physicians attended less than 1%. Shout out to Dr. Stu and a handful of physicians attending home births. 

CNM/CM midwives attended just over 56% of births at a birth center. 36.7% by non-CNM/CM midwives, and only 2.7% by physicians. 

In a hospital setting, the vast majority (90.6%) of births are attended by physicians, and just 8.7% by CNM/CM midwives. This is changing as more hospitals are incorporating midwives. 

Practice Limitations of Midwives 

Midwives specialize in normal, low-risk childbirth. Typically, this means you don’t have any complications. If your pregnancy is high-risk, chances are you will be seeing an OB/GYN or specialist. If you are planning a cesarean section for whatever reason, you will be seeing an OB/GYN. Midwives are not trained or licensed for surgery, including c-sections. Midwives also have limitations on writing prescriptions for medications, and this can vary by their license and the state they practice. 

Often if you are under the care of a midwife and something comes up which makes you high risk, your midwife may get an OB/GYN involved or, if it is more appropriate, refer you to an OB/GYN for your care. Remember, most pregnancies are normal, low risk, and require very little if any, intervention. 

See this episode for more information on choosing or changing your doctor or midwife.

Childbirth Educator

A childbirth educator provides information and instruction for labor and birth. This can be through in-person or online education in a group or one-on-one setting. Someone who is a Certified Childbirth Educator has completed a training program. There is no universal set of standards or qualifications needed to become a childbirth educator. There are dozens of organizations that offer certifications, and they vary in their requirements. Typically they all require that you attend a training class, read and study materials, complete a minimum number of hours of supervised teaching, attend a minimum number of births, and pass an exam. There are also continuing education requirements. If you are comparing different options for a birth class, you may want to ask about certifications or affiliations, as well as experience.

Doula

A doula is a broad term that describes someone who provides various support for labor, birth, and postpartum. Some doulas are full-spectrum, covering scenarios like fertility and trying to conceive, miscarriage, and abortion. Some doulas specifically support transgender or gender non-conforming parents. There are even end-of-life or death doulas who support people at the end of their life. 

Birth and Postpartum Doulas 

For human history, women had support from other women in their community during and after birth. This changed, especially in countries where births moved to a hospital setting. In the 1960s, the role of a doula was created within the natural birthing movement. A birth doula is a professional trained in childbirth and provides emotional, physical, and educational support to a mother and her birth partner while expecting. A doula is trained to be your support person and advocate. A postpartum doula focuses on the days and weeks after your baby is born to support you and your family. 

Doula Certifications 

Doulas have training and experience, but there is no universal certification or licensing program for doulas. There are hundreds of different programs that train doulas, and they all vary on the amount of training and experience needed. 

DONA (Doulas of North America) International is the largest organization that offers a doula certification. DONA requires a workshop that is at least 16 hours of instruction. You need to attend a childbirth education class. You also must provide continuous in-person labor support for a total of at least 15 hours over three births. Plus, you must submit evaluations from the care providers at those births. DONA International certified doulas are required to recertify every three years. They need to maintain continuous membership in DONA International. They must complete 15 hours of continuing education or meet an alternative requirement demonstrating that they are continuing their education. 

Since there are no state or federal certification or licensing requirements, certification is optional but does show that a doula went through some formal training. 

Doula Services

There is a wide array of services offered by doulas, and the scope of the services they offer will differ depending on the doula. Doulas truly are a jack of all trades and can provide support in various ways, both emotionally and physically. 

Emotional support can include listening to you, whether to vent frustrations or voice your preferences for birth. Doulas also serve as your advocate and facilitate communication between you and your care provider or other medical staff. They can assist in providing you with information on interventions and birth procedures and discuss your options. A doula can give you reassurance and encouragement that you can get through labor and birth. They can talk you through coping techniques like breathwork, visualization, or position changes.

Although doulas cannot perform medical procedures, they can be hands-on during labor. Physical support during labor can support your weight in a squatting or standing position, using a rebozo to sift your belly or take some pressure off your back. They can provide counter pressure to alleviate some discomfort in your back or hips. A doula may have tools like a birthing ball or stool for you to use. 

The Evidence on Doulas 

A Doula is someone you would have in addition to an OB/GYN or a midwife, but they would not replace your primary care provider. There is substantial growing evidence on how doulas impact births.

The most comprehensive evidence comes from a Cochrane Review on continuous support for women during childbirth. This included 26 trials involving 15,858 women. The trials came from 17 countries, all in high and middle-income settings. They found that women with continuous support were more likely to have a spontaneous vaginal birth, meaning they did not require an induction. Women with continuous support were less likely to use pain medication, have an instrumental vaginal birth, a cesarean birth, or a baby with a low five‐minute Apgar score. Continuous support was associated with shorter labor. The mean length of labor in the continuous support group was, on average, 0.69 hours shorter. Women with continuous support were also less likely to report negative ratings of or feelings about their childbirth experience. 

For more information on doulas and how to find one that is the right fit for you, see this article.

Diagnostic Medical Sonographer

An ultrasound exam is a procedure that uses high-frequency sound waves to create a picture, called a sonogram. Doctors use ultrasounds to examine your uterus, baby, and placenta in pregnancy. According to the American College of Obstetricians and Gynecologists,  ultrasound exams should be performed only for medical reasons by qualified health care providers. A Diagnostic Medical Sonographer is a professional trained to operate an ultrasound and interpret results. They may also be called a sonographer or ultrasound technicians. Depending on the scope of the ultrasound, it could be done by your doctor or by a sonographer. If you see a midwife for your pregnancy, they will likely refer you to a sonographer for any necessary scans.

The American College of Obstetricians and Gynecologists recommends you have at least one standard ultrasound exam during your pregnancy, usually between 18–22 weeks of pregnancy. This ultrasound exam ensures that your baby is developing normally or may identify any potential problems as soon as possible. This exam can diagnose fetal malformation structural abnormalities, confirm a multiples (twins) pregnancy, verify dates and growth, confirm a miscarriage, identify excessive or reduced levels of amniotic fluid, and overall evaluate your baby’s well-being. During this ultrasound appointment, your baby will be measured from crown to rump, around their middle and head. Since this is an anatomy scan, the ultrasound technician will be looking specifically at the heart’s four chambers, the kidneys, bladder, stomach, brain, spine, sex organs, and umbilical cord.

In the U.S., most pregnant women under OB/GYN care can expect a minimum of two ultrasounds. In addition to the second-trimester scan, you will likely have a transvaginal scan in the first trimester to confirm and date your pregnancy. Your OB/GYN will likely perform this ultrasound. Your care provider may suggest additional ultrasounds if they suspect a complication or accompany invasive prenatal tests, like amniocentesis or CVS. Depending on how technical the ultrasound is, your doctor could do it, or they may refer you to a sonographer.

Genetic Counselor

A genetic counselor can help you understand the chances that your baby may be affected by a particular genetic condition, how a condition would impact your baby’s life, and go into detail on possible treatment options. This service can be with a certified genetic counselor or a doctor or nurse with training in genetic counseling. You may be referred to a genetic counselor if you know genetic conditions like cystic fibrosis or sickle cell disease or if the results of a prenatal test show your baby is at an increased risk of a genetic condition. You may also request to speak with a genetic counselor to understand test results better.

Maternal-Fetal Medicine (MFM) Specialist or Perinatologist

A Maternal-Fetal Medicine Specialist or perinatologist is an obstetrician/gynecologist who has specialized training in high-risk pregnancies and complications. To become a Maternal-Fetal Medicine Specialist is a three-year fellowship following an OB/GYN residency.

Your pregnancy could be high risk due to your health, a problem with your pregnancy, or a fetal congenital disability or complication. A Maternal-Fetal Medicine Specialist can help in your care and navigate your treatment options. You will continue to see your OB/GYN for your routine care while consulting with an MFM.

Nurses

If you have ever spent time in a hospital, you know the value of nurses and how they are the backbone of the medical system. Nurses play a significant role in patient care, especially during pregnancy, birth, and postpartum. Nurses must go through education and degree programs, pass a licensing exam, and keep up with continuing education. There are many different types of nurses that specialize in various fields. Some of the specialties you may encounter in pregnancy and birth are labor and delivery, pediatric, and neonatal nurses.

A Nurse Practitioner is an advanced practice nurse. In addition to becoming a registered nurse, a nurse practitioner needs a master of science degree. Nurse practitioners have more autonomy than nurses, prescribe treatments, order tests, and diagnose patients.

If you have your baby in a hospital, you will spend most of your labor with nurses. Depending on the amount of time you are in labor, you may see several nurses. For a low-risk pregnancy, you may not see your doctor until just before you birth your baby. The majority of your care in a hospital will be from nursing staff.

Anesthesiologist or Nurse Anesthetist

Anesthesiologists are physicians who administer general or regional anesthesia. Nurse Anesthetists are registered nurses who can also administer anesthesia. This would include performing an epidural or administering other pain medications during labor for vaginal or cesarean birth. Depending on your state, a nurse anesthetist may be required to be supervised by a physician. If you encounter an anesthesiologist or nurse anesthetist, it would be during labor and birth.

Lactation Consultant

A lactation consultant is a health professional that specializes in breastfeeding issues. Technically, anyone can call themselves a lactation consultant. Most nurses, midwives, and doctors who work with pregnant mothers have training in breastfeeding and can help you navigate breastfeeding or troubleshoot issues.

The two most common certifications are a Certified Lactation Counselor (CLC) and International Board Certified Lactation Consultant (IBCLC). IBCLCs is a more in-depth certification process with more experience required. The International Board of Lactation Consultant Examiners (IBLCE) requires 90 hours of education, 1,000 hours of lactation-specific clinical experience, an exam, annual continuing education, and recertification every day five years for this certification.

While many new mothers expect breastfeeding to come naturally, many find it challenging. I cannot emphasize enough how helpful it can be to get help as soon as you need it before a minor issue becomes significant. The thought of hiring a consultant may sound expensive, but many times you can find these resources for free. La Leche League is a great starting place for this. Also, check with the venue where you plan to give birth or ask your doctor or midwife for a recommendation. A lactation consultant can make a significant difference in your ability to overcome challenges and maintain a healthy and happy breastfeeding relationship with your baby.

Pediatrician

A pediatrician is a doctor who specializes in the health of infants and children. They will monitor your child’s growth and development, assist you in navigating immunizations, diagnose common illnesses and answer questions you have about your child’s health and development. If you have your baby in a hospital, you can expect a visit from a pediatrician before you go home. If you birth at home or a birth center, you are encouraged to take your baby to see a pediatrician within the first three days after birth.

A pediatrician is your trusted partner in your baby’s health. Together you ensure your baby is growing and developing on track. If there is a deviation from the norm, you work together to figure out what is going on and how to treat it. See this episode for more information on choosing a pediatrician and what you can expect from your visits.

Neonatologist

A neonatologist is a pediatrician with specialized training in complex and high-risk complications with your newborn. To become a neonatologist is a three-year fellowship in newborn intensive care following a pediatric residency. If your doctor identifies a problem with your baby during pregnancy, you may consult with a neonatologist. They could also be involved during your birth and in the immediate care of your baby. Common scenarios involving a neonatologist are if a baby is born prematurely or has an illness or congenital disability. Most neonatologists work in neonatal intensive care units and coordinate with the pediatrician to care for your newborn once your baby is home.

Thank you to the amazing companies that have supported this episode.

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