Overview

Your care provider is the cornerstone of your prenatal care and birth experience. You will work with this expert resource throughout pregnancy to make critical decisions. Choosing your care provider is more nuanced than having a midwife for a home birth or an OB/GYN for a birth at a hospital. Your comfort and trust in your care provider is more important than their qualifications, where they went to school, and how many babies they have delivered. Ultimately, who your care provider is will significantly impact your experience and how your baby enters the world. When choosing your care provider, you want to research, explore your options, and shop around to find the right fit. This episode covers what to look for when choosing or changing your doctor or midwife and specific questions to find a care provider that is the right fit.

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The Importance of Your Care Provider

Your care provider is the cornerstone of your prenatal care and birth experience. You will work with this expert resource throughout pregnancy to make critical decisions. Your comfort and trust in your care provider is more important than their qualifications, where they went to school, and how many babies they have delivered.

Choosing Your Care Provider

Choosing your care provider is more nuanced than having a midwife for a home birth or an OB/GYN for a birth at a hospital. There is a strong argument that midwife-led care is more of a holistic approach and is more patient-focused. Stereotypically, this may be true, but there are some fantastic OB/GYNs. The only way to know whether a particular provider is the right fit for the pregnancy and birth you want is to ask questions and shop around.

The cost of having a baby can be the price of a car and maybe even a luxury car. If you were buying a car, you would do your research and shop around. Having a baby is a much bigger decision than buying a new vehicle. Ultimately, who your care provider is will significantly impact your experience and how your baby enters the world. When choosing your care provider, you want to research, explore your options, and shop around to find the right fit.

Types of Doctors

You may have a physician, such as a general practitioner or family doctor, that you want to continue seeing for your prenatal care. The provider you see for your prenatal care must be knowledgeable about pregnancy and birth. For this reason, a general practitioner or family doctor may not be the most qualified provider. Seeing a specialist for your prenatal care does not mean you have to sever ties with your regular doctor altogether. A physician who knows you and your medical history can be helpful if you want a second opinion on anything during prenatal care.

There are a couple of specialties that focus on pregnancy and birth. Obstetrics deals with pregnancy, childbirth, and the postpartum period. An obstetrician is also trained in surgical interventions, like cesareans. Gynecology focuses on the health of the reproductive system and breasts. A gynecologist provides pap smears and cancer screenings, treats urinary tract infections, diagnoses breast issues, etc.

Obstetrics and gynecology are closely related. Most often, a doctor specializing in one also specializes in the other. A doctor with both certifications and is an OB/GYN (obstetrician/gynecologist). OB/GYNs are typically the primary care providers for pregnant women in the United States.

Midwives

Midwives specialize in pregnancy, childbirth, postpartum care, and overall care for women. In many countries outside the United States, midwives are the primary care providers for expecting mothers. This was also the case in the U.S. until about the beginning of the 1900s when we shifted towards doctor-led care and birth in a hospital setting.

Education Requirements for Doctors

Before being licensed, midwives and OB/GYNs undergo many years of education and experience. Both must apply for a license, take an exam, complete continuing education, and are highly regulated throughout their careers.

Becoming an OB/GYN takes 11-14 years of education, training, and experience. This includes 7-9 years of general medical training with an undergraduate degree and completion of medical school. This is followed by a 4-5 year hospital residency focusing on OB/GYN practice.

There are also some subspecialties that an OB/GYN can concentrate on with additional training. A subspecialty could be maternal-fetal medicine or perinatology. Maternal-fetal medicine focuses on high-risk pregnancy management, fetal complications, gestational diabetes, preeclampsia, and genetic disorders. Perinatology focuses on the medical and surgical management of high-risk pregnancies and births. A subspecialty generally requires an additional three-year fellowship.

Education Requirements for Midwives

The general path to becoming a midwife in the United States depends on the certification. A midwife can be a certified nurse midwife, a certified midwife, or a certified professional midwife.

A Certified Nurse Midwife needs a bachelor’s degree in nursing and 2-3 years of graduate-level training in midwifery. A Certified Midwife has a background in a health-related field other than nursing and completes a master’s level midwifery education program. Certified Midwives have similar training to Certified Nurse Midwives and conform to the same standards. The difference is that Certified Midwives are not required to have the nursing component.

The majority of midwives in the U.S. are Certified Professional Midwives. Certified Professional Midwives gain their certification through clinical training under the supervision of a midwife, and there is no college degree requirement.

Midwife Licensing in the United States

Licensing of midwives in the United States varies by state. Certified Nurse Midwives are licensed in all 50 states, Certified Professional Midwives are licensed to practice in 36 states, and Certified Midwives are licensed in 11 states. All midwives are legally allowed to practice in the District of Columbia.

Licensing plays a significant role in who is legally allowed to attend births. Traditionally, midwives attend the majority of out-of-hospital births. A report on trends and state variations in out-of-hospital births provides data on who attends births outside the hospital. 29.4% of planned home births are with a Certified Nurse Midwife or a Certified Midwife. Non-CNM/CM midwives attend 50.7% of home births. Physicians attend less than 1%. 19.1% of these births in this report marked the birth attendant as “other,” which could include a family member, emergency medical technician, or freebirther. A freebirther is someone who chooses to give birth without assistance from a medical professional. Midwives also attend the majority of births at birth centers. CNM/CM midwives attend 56.6% of births at a birth center. 36.7% by non-CNM/CM midwives, and only 2.7% by physicians.

In a hospital setting, the majority (90.6%) of births are attended by physicians, and just 8.7% are attended by CNM/CM midwives. We expect the number of midwives to increase as more midwives are incorporated into the hospital setting.

Practice Limitations of Midwives

Midwives specialize in normal, low-risk childbirth. Typically, this means you don’t have any complications and are pregnant with a single baby positioned head-down by the last few weeks. If you have a high-risk pregnancy or plan a cesarean birth, you will see an OB/GYN. If you are under the care of a midwife and something comes up that makes you high risk, your midwife may involve an OB/GYN or, if it is more appropriate, refer you to an OB/GYN for your care. Remember, most pregnancies are low-risk and require very little, if any, intervention. A significant difference between midwives and doctors is that midwives do not practice surgery. Some midwives also have limitations on writing prescriptions for medications, which vary by license and the state in which they practice.

Male vs. Female Practitioners

In the United States, females now account for more than half of all practicing OB/GYNs. This number will continue increasing as women comprise 82% of doctors entering OB/GYN residencies.

Historically, midwifery excluded men. In ancient Greece, a requirement to be a midwife was that you had to have given birth yourself, so this excluded men. In the UK, the Royal College of Midwives banned men until 1983. The vast majority of midwives are women, and men account for less than 1% of midwives in the United States.

One study showed slightly over 8% of female patients prefer a male OB/GYN, 50% prefer a female, and 42% have no preference. It is okay to prefer and seek out a male or female provider if that is important to you. Even a doctor who may be able to relate to being female may not have had the experience of being pregnant and giving birth if they do not have kids. While it may be tough to find a male midwife, there are many male OB/GYNs. Regardless of whether your doctor or midwife is a man or woman, they all have the same education and training, and their gender should not make a difference in your care.

Comparing Midwife-led to Doctor-led Maternity Care

Stereotypically, the midwife model of care differs from the standard medical model of doctor-led care. Midwifery focuses on pregnancy as a normal physiological process rather than a medical condition. Doctors tend to be trained from a more medicalized approach and are more likely to employ interventions. Midwives tend to focus on continuity of care and a more personalized approach, and prenatal appointments with midwives tend to be longer.

A Cochrane Review compared the effects of midwife continuity of care models with other models of care. Researchers found women receiving midwife continuity of care models were less likely to experience a cesarean section and instrumental birth and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. 

Different providers will have different approaches to their practice. While there are generalizations about midwife-led vs. doctor-led care, you can always ask a potential provider what their general philosophy is around pregnancy and childbirth.

Tips for Choosing (or Changing) Your Care Provider

Of course, it can be a challenge to know from one short meeting with an OB/GYN or Midwife that they are the perfect fit for the pregnancy and birth experience you want. The following are some tips for looking for a doctor or midwife and some considerations if you are thinking about changing your care provider.

Ask for Referrals

Getting a referral is almost always better than selecting a random name from a list online. If you have friends or family who have had babies in the past few years, ask them if they would recommend their care provider. Referrals can also come from other doctors or nurses with whom you have an existing relationship. If you have friends who work in hospitals, they can be a good referral source.

Choosing Your Birth Setting

If you know where you want to have your baby, that will narrow down your options for a provider who is associated with a particular hospital or birth center. If you plan a home birth, you will most likely be working with a midwife. Midwives also staff the majority of birth centers. If you are planning a hospital birth, you may have a choice between a midwife and an OB/GYN.

Most cities have more than one hospital. I encourage you to keep an open mind and visit several venues before deciding. If you are open to it, check out your options to have a home birth or visit a birth center. Most places will give you a tour and answer any questions. Statistics like the C-section rate are good things to look into, but the atmosphere and how they treat you are also really important.

Your Health Insurance Coverage

Your financial situation will likely affect your options for a care provider. You need to know what your health insurance will cover. You do not want to plan everything with a care provider only to discover that your insurance does not cover them. Insurance companies often bill prenatal care separately from labor and delivery, and may cover these at different rates. The best way to confirm your insurance covers the care provider you would like to work with and know exactly what you must pay out of pocket is to get on the phone with your insurance company. Block out some time, prepare to be on hold for a while, and hash it out over the phone. All said and done this will be much easier than trying to figure it out online.

Appointments and Visits

As you explore your options for a potential provider, ask how much time they allot for each appointment. This typically ranges between 15 minutes to an hour and will vary by provider. Typically, appointments with a midwife tend to be longer. Regardless of the time your provider has allotted for a visit, please do not hesitate to ask questions, even if it means going over your appointment time. If you want to play an active role in your prenatal care and make informed decisions, you need to discuss your options at length with your doctor or midwife.

Your visits with a care provider will be the same frequency whether you see a doctor or a midwife. For the first two trimesters, this is up until week 28, your visits will be monthly. Beginning in week 29, the start of the third trimester, you will go every other week until 36 weeks, when you start seeing your care provider weekly. You can expect to have somewhere around 14 appointments throughout your entire pregnancy. If possible, include your partner in these visits.

Who Will Attend Your Birth?

Many hospitals and birth centers will have someone on call to attend births. If you want a particular provider present for your labor and birth, make that clear upfront and find out if that is an option. If you plan your birth at a venue where the care provider who will be attending your birth is whoever is on call, find out if you can meet some of the other providers during your prenatal care. This allows you to meet and build a relationship instead of meeting them when you are in labor.

Changing Your Care Provider

You need to know that you are never stuck with your current doctor or midwife. You should have many options for providers. If you do not feel supported or are not thrilled with your current doctor or midwife, look for a new one that is a better fit.

Most providers prefer to start seeing patients as early in their pregnancy as possible, and changing care providers can be more challenging the further you are in your pregnancy. If you are into your second or third trimester, you still have options; you just may need to cast a wider net.

If you are considering changing care providers, shop around. You can always explore other options and stay with your current provider if you don’t find better options.

Once you find a new provider, it is pretty simple to switch. You will want to transfer your medical records to the new doctor or midwife. You can sign an authorization with your new provider that allows them to request your medical records. It could be nice to inform your former doctor or midwife that you have switched your care. If you are uncomfortable telling them over the phone, you can always send an email or call after hours and leave a message. This can be as simple as telling them you appreciate their care and have switched to a new doctor or midwife. You do not need to come up with a long, detailed story of why you are leaving.

Questions to Ask

There are some specific questions you can ask an OB/GYN or midwife when you are searching for the right care provider. If you have specific questions you want to ask, write them down or put them in a note on your phone so you can have them handy and ensure you don’t miss questions.

General Questions

• How long have you been in practice?
• How many births have you attended?
• How many patients do you have at a given time?
• Is your practice a solo or group practice? If it is a solo practice, who covers you when you are unavailable?
• Will you attend my birth? If you are unavailable, who will attend?
• Will you be present throughout my labor?
• What is your general philosophy on pregnancy care, labor, and birth?
• How much time is available during each prenatal visit?
• Are you available to answer questions in between visits?
• Will you assist me in developing a birth plan, or will you review one I have written?

Questions to ask if you want to avoid specific interventions

• What procedures are routine?
• What percentage of your patients utilize pain medication during labor?
• What percentage of your patients have an episiotomy?
• What is your c-section rate?

Questions for Midwives

• Did you graduate from a nationally accredited midwifery education program?
• Are you certified by the American College of Nurse-Midwives?
• Do you have an OB/GYN that you work with in the event I need one?

I hope you find a doctor or midwife you enjoy appointments with and who supports the birth you want. You can always explore your options and find someone who is a better fit.

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