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Overview

Your care provider is the cornerstone of your prenatal care and birth experience. This is your expert resource that you will be working with throughout your pregnancy to make some very important decisions and you need to be comfortable with and trust your care provider. That is more important than their qualifications, where they went to school, and how many babies they have delivered. You need to see them as an integral member of your team, and most importantly you need to trust them and be comfortable with them. This article breaks down some considerations for choosing the right care provider. We will cover the difference between a midwife and an OB/GYN. We will discuss changing your care provider if you are not happy with your current one. Plus, this article includes a list of questions you can ask to find the right doctor or midwife for the prenatal and birth experience you want.

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The Importance of Your Care Provider

Your care provider is the cornerstone of your prenatal care and birth experience. This is your expert resource that you will be working with throughout your pregnancy to make some very important decisions and you need to be comfortable with and trust your care provider. That is more important than their qualifications, where they went to school, and how many babies they have delivered. You need to see them as an integral member of your team, and most importantly you need to trust them and be comfortable with them.

Choosing Your Care Provider

Choosing your care provider isn’t black and white. It is more nuanced than having a midwife for a home birth or an OB/GYN for a birth at a hospital. There is a pretty 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 amazing OB/GYNs out there. The only way to tell whether a particular person is a right fit for the pregnancy and birth you want is to ask questions and shop around.

The cost to have a baby is really high. Hopefully, you have health insurance that will cover a lot of the cost but having a baby is not cheap. It can be the price of a car, and maybe even a luxury car. If you were going to buy a car would you walk on the lot and buy one. You would do your research beforehand, right? Having a baby is a much bigger decision than buying a car. You want to explore your options, shop around, and do your research. Ultimately who your care provider is will have a big impact on your experience and how your baby enters the world.

Types of Doctors

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 will want to make sure that they are knowledgeable about 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 a lot of 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. Seeing someone else for your prenatal care does not mean you have to completely sever ties with them forever.

Obstetrics deals with pregnancy, childbirth, and the postpartum period. Obstetricians are also trained in surgical interventions, like cesareans.

Gynecology is focused on the health of the reproductive system and breasts. The practice of a gynecologist 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. A doctor who has both certifications and is an OB/GYN (obstetrician/gynecologist). These are typically the primary care providers for pregnant women in the United States.

Midwives

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

Education Requirements for Doctors vs. Midwives

Both Midwives and OB/GYNs have to apply for a license, take an exam, and are required to complete continuing education throughout their careers. Both types of providers are highly regulated and go through a lot of education and experience before being licensed. They are different and each has its specialty.

In the United States, the general path someone takes to become an OB/GYN is to earn an undergraduate degree, then go on to graduate from medical school, this is a total of 7-9 years of general medical training. After graduation from medical school, they would need to complete a residency at a hospital that focuses on OB/GYN practice, and this residency lasts 4-5 years. The entire process takes about 11-14 years of education, training, and experience. There are also some subspecialties that an OB/GYN can specialize in with additional training, this is generally a three-year fellowship. An example of this would be maternal-fetal medicine or perinatology, which focuses on medical and surgical management of high-risk pregnancies. If something were to come up during your pregnancy that puts you or your baby at particularly high risk, you may be referred to this type of specialist.

In the United States, the general path someone would take to become a midwife depends on the certification. 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. Another credential is a Certified Midwife who has a background in a health-related field other than nursing, then goes through a masters level midwifery education program. They have similar training to CNMs, conform to the same standards, but CMs are not required to have the nursing component. The majority of midwives in the U.S. are Certified Professional Midwives do not have college degree requirements, and instead, gain their training 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 would like 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 US. CPMs are licensed to practice in 35 states. Certified Midwives are licensed in only 5 states in the US.

Licensing plays a big role in who is legally allowed to attend births based on the setting. Traditionally midwives are attending 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. Less than 1% were attended by physicians. Shout out to Dr. Stu and a handful of physicians attending home births.

Just over 56% of births at a birth center were attended by CNM/CM midwives. 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. I think this is something we are seeing changing as more midwives are being incorporated into the hospital setting.

Practice Limitations of Midwives

Midwives really specialize in normal, low-risk childbirth. Typically, this means you don’t have any complications. If you are in a high-risk pregnancy 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, this, of course, includes c-sections. Midwives also have limitations on writing prescriptions for medications and this can vary by their license and the state they practice in.

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.

Male vs. Female Practitioners

One study showed slightly over 8% of female patients prefer a male OB/GYN, 50% preferred female, and 42% have no preference.

In the United states the number of female OB/GYNs has been increasing and they now are more than half of all practicing OB/GYNs. This number will only go up as women make up 82% of doctors entering OB/GYN residencies.

The majority of midwives are women and there are not a lot of men in the profession. This goes back ages when 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 up until 1983. It was tough to find a verifiable statistic on how many midwives are male or identify as a gender other than female. The best stats I could find was that it is less than 0.5% in the UK and only 2% in the U.S.

Comparing midwife-led to Doctor-led Maternity Care

There are some studies comparing midwife-led to doctor-led maternity care. These reviews all focus on low-risk women. There are some cases where you should be seeing an OB/GYN or a specialist. The majority of women are low risk, and would do well with midwife-led care. In one review researchers found that women saw a midwife for care before, during, and after their birth, were overall less likely to experience interventions like an epidural, episiotomy, or assisted delivery, more likely to experience a spontaneous vaginal birth, meaning no induction was used. Seeing the same practitioner for prenatal care, birth, and postpartum care is called continuity of care.

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 you when looking for and selecting a care provider and considerations if you are thinking of changing your care provider.

Ask for Referrals

If you have friends or family who have had babies in the past few years ask them if they would recommend their care provider. If they have been through a pregnancy and birth with a care provider they will have a good sense of their practice. Referrals can also come from other doctors, if you have friends who work in hospitals they could be a good referral source. My favorite midwives and OB/GYNs have come from a referrals.

Choosing Your Birth Setting

Think about where you want to have the birth of your baby. A 2017 report showed that 1 of every 62 births in the US was an out-of-hospital birth (1.61%). This number has been steadily increasing in recent years. Home births increased by 77% from 2004–2017, while birth center births more than doubled.

I urge you to keep an open mind and go visit several places before making a decision. If you are open to it, check out your options to have a home birth or visit a birth center. It is easy to have preconceived notions that can be totally wrong about what a particular hospital or birth center will be like. Statistics like C-section rate are good things to look into but the atmosphere and how you are treated is also really important. If you are in a big city chances are you have several different options available to you. Most places will give you a tour and answer any questions you may have. See what is out there before making a choice. Remember, a key part of this process is making informed decisions.

If you are planning a home birth you will most likely be working with a midwife. The majority of birth centers are also staffed by midwives. If you are planning a hospital birth you may have a choice between a midwife and an OB/GYN. I expect we will see more midwives in hospital settings in the future.

Once 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 are planning a home birth you will need to find a midwife who specializes in home birth.

Your Health Insurance Coverage

The next step is to find out what your health insurance will and will not cover. You do not want to plan everything with a care provider, only to find out that they are not covered by your insurance. Your financial situation will play some part in where you decide to go for your prenatal care but make sure you understand it. I really wish this were not the case, but the truth is it will likely play a part in your care provider decision. Make sure that you a very clear understanding of what will be covered, and what expenses you will have to pay out of pocket. Often your prenatal care is billed separately from your labor and delivery, and these may be covered at different rates. The best way to confirm the care provider you would like to work with is covered and know exactly what you will need to pay out of pocket is to get on the phone with your insurance company. Block out some time, be prepared 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

Your visits with a care provider will be pretty much the same frequency whether you are being seen by 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, which is the start of the third trimester, you will go every other week until 36 weeks, and at that point you are seeing your care provider on a weekly basis. Include your partner in these visits. You can expect to have somewhere around 14 appointments throughout your entire pregnancy. On 14 days you will see a doctor or a midwife, that’s it.

A big part of each of these visits is that it is an opportunity for you to ask questions. Ask any question you need to know to make sure you are comfortable with them. Do not be shy! This goes for your partner too. Your partner should also be able to ask any question they wish. It is really important that you have a relationship with your care provider where communication is open. The right care provider will encourage you to ask questions. Bottom line, do not be intimidated to ask questions and speak up.

A great question to ask a potential provider is how much time is allotted for each appointment. This typically ranges between 15 minutes to an hour and will vary between different doctors and midwives. If you want to ask a lot of questions or have a lengthy conversation about anything the time your care provider has allowed for your appointment will play a role in this.

Who Will Attend Your Birth?

Make sure you know who will actually be attending the birth of your baby. Many hospitals and birth centers will have someone on call to attend births. If you want a particular person there, like your midwife and not just the midwife who happens to be on call when you go into labor, make sure you make that clear up front and find out if that is an option. Don’t assume that your OB/GYN or Midwife will be attending your birth and make sure you talk about it with them. If you are having 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 care providers beforehand so the first time you are face to face isn’t when you are in labor.

Changing Your Care Provider

It is important for you to know that once you choose a doctor or midwife you are never stuck. If you are currently seeing a midwife or OB/GYN that you do not like, leave. I wouldn’t recommend you remain in any relationship that you are unhappy in. This is certainly true for your relationship with the person who you need to work with to make some major decisions about your prenatal care and how your baby makes his or her way into the world. If you are unhappy with your current doctor or midwife, find a new one, there are tons out there to choose from. You are never stuck.

Changing care providers can be more challenging later 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. Most care providers prefer to start seeing patients as early in their pregnancy as possible but just because you are in the third trimester does not mean that you cannot switch your care to another provider.

If you are considering changing care providers, shop around. You can always see what else is out there and stay with your current provider if you don’t find someone who is a better fit. Logistically, it is pretty simple to switch providers once you find a new one. You will want to transfer all of your medical records to the new doctor or midwife. This is usually done by signing an authorization with your new provider that allows them to request your medical records.

It could be nice to give your old doctor or midwife a heads up that you have switched to another one. This will prevent them from continuing you to call you for appointments. If you are uncomfortable telling them over the phone you can always shoot them an email or call after hours and leave a message. It can be as simple as telling them that you appreciate their care and you 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 finding 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.

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 for you when you are not available?
  • 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 to develop a birth plan or will you review one I have written?

Questions to ask if you want to avoid certain interventions

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

Questions for Midwives

  • If you are interviewing a midwife you may also want to ask:
  • 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 one is needed?

I hope that you find a doctor or midwife that you enjoy appointments with. I hope you have a provider who is supportive of you and the birth you want. If you don’t, you can always explore your options and find someone who is a better fit for the prenatal and birth experience you want.

 

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

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