Choosing Your Birth Practitioner

pregnancy checkup

After choosing the place for your baby’s birth, your next important decision will be choosing the person who will care for you during the next nine months and attend the birth.

There are four main types of providers you can choose from: midwives, obstetricians, family physicians, and osteopaths.

    Midwives: Throughout the history of the world, a midwife, whether formally or experientially educated, has been the most common type of birth attendant. In days past, a midwife was generally a member of the community who was considered to be a wise woman. Today, midwives attend about 80 percent of births worldwide. According to the National Center for Health Statistics (www.cdc.gov/nchs/fastats/births.htm), they attend about 8 percent of all births in the United States, and that number grows each year.
    Several types of midwives are available. Some start out as nurses, and some receive their training through apprenticeships or various midwifery certification programs. Some consider their role as that of a spiritual aide, and some are well prepared to handle emergencies.
    It’s important to understand the various terms used to describe midwives, so that you can be sure you are going to receive the kind of care that is right for you.
                Certified nurse-midwife (CNM) and certified midwife (CM): A CNM is a registered nurse who has had two years of advanced practice in caring for pregnant and birthing women in a certified CNM program. Certification is given by the American College of Nurse-Midwives Certification Council. This same group also awards the credential of certified midwife (CM). CMs receive their training as direct-entry midwives. In other words, they do not start out as nurses, but enter midwifery through apprenticeship training or midwifery school. About 85 percent of CNMs and CMs practice in a hospital setting, but some also attend births in birth centers or in homes.
                Certified professional midwife (CPM): A CPM has received her credentials from the North American Registry of Midwives (NARM), an international certification agency. These midwives have received their training in different ways: some through apprenticeship, some through established midwifery training programs and schools. They are required to have some out-of-hospital training to qualify for the CPM credential. Most do practice outside of hospitals, but a few CPMs work in hospital settings.
                Direct-entry midwives (DEM): These midwives have gained experience through apprenticeship, self-study, or through a midwifery program distinct from the discipline of nursing. Some of them may go on to get certification through one of the above-mentioned programs. Lack of certification, however, does not necessarily mean lack of expertise. DEMs normally attend out-of-hospital births.
                Lay midwife or traditional midwife (also called independent or granny-midwives): This type of midwife has gained her experience through on-the-job training, possibly as an apprentice, rather than through any type of specific training programs. She attends out-of-hospital births. You will need to check her qualifications by carefully interviewing her, or by listening to the experiences of other women who have used her services.

    Several states in the United States license or register midwives. In these states, midwives take a test and receive a state midwifery license. Each state recognizes different qualifications.
    Amazingly, 11 states (www.mana.org/statechart.html) in the US prohibit the practice of midwifery, other than by Certified Nurse-Midwives, despite the fact that no studies provide any good reason to doubt the safety of midwifery. In fact, several studies prove the opposite: better outcomes with midwives (a good place to review some of the studies on the outcome of births with a midwife is the American College of Community Midwives’ website: www.mana.org/statechart.html). If you live in one of the states that prohibit midwifery, you’ll have to look harder to find a good, certified midwife since they may not publicly advertise. There are also a couple of states that only allow non-nurse midwives if they have been awarded the CM certification.

    Obstetricians: Obstetricians are medical doctors who have had four years of residency training in the field of obstetrics and gynecology following medical school. Where and when they received their training may strongly influence how progressive they are, or how open they are to input from patients. Younger doctors may be more open-minded, especially if they have obtained supplementary training in a complementary or integrative medicine modality, such as acupuncture or homeopathy.  Few doctors, however, receive education about homebirth and midwifery, and some don’t receive much education about breastfeeding.
    Certain parts of the country tend to be more progressive, such as Washington state, where homebirths approach 10 percent; New Mexico, where midwives attend 25 percent of births; and Chicago, where four clinics provide physician-attended home births. Most births in the US, however, are attended by OB/GYNs (www.cdc.gov/nchs/fastats/births.htm).

    Family Physicians: These are medical doctors who have three years of family practice residency, including a minimum of three months in the specialty of obstetrics and gynecology. While most of these doctors attend births in hospital settings, the American Academy of Family Physicians has issued a statement encouraging birthing as a family event that can be safely experienced in a variety of settings, including the home. Your particular physician may or may not be open to non-hospital options.

    Osteopathic Physicians (DOs): Osteopathic physicians attend four years of training at an osteopathic medical school. These are fully accredited by the United States Department of Education. Following school, they are required to do internships and a residency program. Their training qualifies them to prescribe medicine and perform surgery. Many osteopaths specialize in specific areas of medicine, including obstetrics. In addition, an osteopath is required to pass specific state licensing examinations. In 2006, osteopathic physicians attended about 4 percent of all births in the United States (www.cdc.gov/nchs/fastats/births.htm). Osteopaths, as a general rule, tend to view birth as a normal physiological process and may, therefore, be less likely to perform highly medicalized birth practices.

Which Practitioner is Best For Me?
    There is no formula that can help a mother-to-be decide what type of provider will be best for her. Even within each category there are big differences. Some midwives rely on technology more than others. Some obstetricians are very open to the idea of birth with few interventions. For this reason, it is necessary to interview several candidates before making a final decision. Here are some questions you might ask during your interview process:

    *How much time will you spend with me during regular checkups (generally midwives tend to spend much longer than doctors do)?
    *Will you help me with nutritional guidelines or refer me to someone who can? What is your view on weight gain during pregnancy?
    *What sorts of prenatal testing do you normally recommend?
    *Will you assist me in the birthplace I have chosen (home, hospital, clinic)?
    *If you are not available at the time of my labor and birth, who usually covers for you? Will I be able to meet that person ahead of time?
    *For homebirths and birth centers: what backup hospital do you use? Under what conditions do you transport a patient to the hospital?
    *How will my partner be involved in prenatal visits, during labor, and at the birth?
    *Approximately how many of your patients have un-medicated births? What is your rate of cesareans and under what circumstances do you recommend them? Do you routinely do episiotomies?
    *How often do you use labor-inducing drugs? Under what circumstances?
    *What labor positions do you recommend to your clients? Do you encourage movement during labor? How much fetal monitoring do you routinely use during labor?
    *What would be your routine for the baby and me directly after birth? Will I hold the baby immediately at birth?

    You may have other questions of your own to ask, as well. And don’t forget to take careful note of whether you like this person. Does she smile? Hold eye contact? Is she too chatty, or not chatty enough? What is your gut response to this person?