What is Shadow Care Exactly?

[IdentityCrisisMama]

I am hearing about this idea for the first time here on MDC. Can someone describe this a little bit more? How does it vary from state to state? What are the various reasons for it? Pros & cons? Thanks.

[wombatclay]

The "exactly" portion of your question is going to be a bit tough since "shadow care" varies from situation to situation.

In general, if a woman has "shadow care" it means that she is seeing a care provider that she does not intend to birth with.

Sometimes it is a woman who plans on an un-attended birth but wants prenatal care and a "just in case" birth attendant, or a woman who plans a homebirth in a region where midwives cannot attend such a birth... she might go through the motions of OB prenatal visits and then "oops" not make it to the hospital in order to protect her midwife. And sometimes (as was the case in my third pregnancy) a woman is seeing a midwife or family practice dr but for some reason her pregnancy becomes complicated... and OB might "shadow" her pregnancy "just in case", but with the full knowledge of everyone involved.

So while the general idea is the same, the reasons for making the choice and the way in which it plays out can vary widely!

[thtr4me]

For me, I started off seeing an OB, then decided to have a homebirth with a midwife. I have not told my OB, because I know he would flip (he almost lost it when I questioned the hospital's ban on eating during labor). Since my insurance covers him, I am seeing him for routine screenings and testing. But I consider my midwife my primary care provider for this pregnancy.

[MsBlack]

Shadow care can vary quite a bit--and as others have said, it depends on the mama's situation, the mw, the state, the OB....

Some families simply want to know that if they end up needing to transfer care, they have an OB already lined up and are already registered at a hospital. And/or, they want some medical stuff during pregnancy--whether 'standard labs/tests', or special things like regular titers tests if they are Rh -, other.

Some families can't find 'willing OB backup for homebirth', so they do the whole package of OB prenatal care (with an 'oops, didn't make it in time' planned).

Some find OB backup that IS willing to support homebirth. Some of those OBs only want certain labs done (minimum, with more available as parents choose it) and only a min. number of prenatal visits to have some kind of record of care and relationship established. Some of those OBs want the woman to have the full prenatal package.

Most often, IME, shadow care is to cover 'just in case of transfer'. Less often, it is for moms with special issues they want a medical eye on, during pregnancy.

Shadow care, IME, can be a real boon to a family for various reasons (if only to keep extended fam from worrying too much about hb plans)--and a real PITA, if the doc likes to use scare tactics...

So if you're thinking of getting shadow care, consider the options carefully, and make sure you know what your mw thinks so you can be as much on the same page as possible.

[IdentityCrisisMama]

That's all very interesting. Thanks, everyone.

I think that shadow care may not have been an option for my first pregnancy because if it was I think a lot of women in the are would have used it. In that town you had the choice between 2 hospitals - one with a very nice delivery unit; the other not.

I am starting to wonder if maybe shadow care may be a good choice for me in my current city. There is a hospital birth MW here that is pretty cool. I went to her for my paps and like her a lot. She uses a very good hospital with what I hear are really nice rooms (jacuzzi tubs). I've heard of lots of great births with her. It would be cool to be able to see her and go to that hospital if I had to transfer.

It also seems like a good way to get insurance involved from the start (we have crappy insurance that I fear will do something weird if I show up on their radar as pregnant for the first time as an emergency transfer).

Does that sound like the a good reason for choosing shadow care?

What does one do if they were considering it? Do they first speak with their HB MW and then ask the hospital birth MW if she were willing to do it?

[Youngfrankenstein]

We did shadow care mostly for what thtr4me did. We decided to do a homebirth about 25 weeks into the pregnancy. My midwife didn't mind me sticking with my CNM/OB practice during that time. I just did double appointments. I had bloodwork, ultrasound, GBS, GD test, etc.

I did it so that if I needed to transfer I wouldn't be seen as a "no care" patient. Homebirth with an attendant is not legal in my state.

Let's say I had no paper train and transfered. I'd likely be giving antibiotics for GBS because my status was unknown and hospitals need to cover their hineys.

[erin_brycesmom]

I had a bit of shadow care both times that I planned a homebirth. I hired and began seeing homebirth MW team from the start of the pregnancy but developed a medical complication that warranted additional care. I ended up losing the baby half way through the pregnancy because of said complication. So the second time, I again hired my HB MW right away but also started shadow care from the start in case the medical issue were to repeat which it did. Had surgery and a pessary for weeks and once I knew the issue was completely resolved and no longer any threat, I stopped the shadow care. I think the last time I saw the OB was around 22 weeks. Continued on with just my MWs and had my homebirth.

[allisonrose]

I decided not to have shadow care for several reasons. My insurance is covering my midwife so I am very lucky and would be pushing that luck by asking my insurance to cover two seperate providers for basically the same care. Being in Cali, homebirth is not uncommon although my area is more "conservative" than some. My town only has one hospital so I imagine if the need to transfer comes up that we will likely go there (something I do need to chat over with my midwife). Also I've seen an OB/GYN for well woman care in my town (and once early in this pg because of spotting) and her practice is quite popular and often has an hour or so wait in the lobby and another 1/2 hour or so wait in an exam room. I have an active toddler so doing that each time would cause prenatal appointments to be stressful for me.

When hubby and I interviewed our midwife, we asked about shadow care and she said that it was up to us and simply asked us to let her know if we were going to.

The insurance issue sounds like a good reason for shadow care. I would first speak to your home birth midwife and mention your reason for thinking about shadow care. I would ask her her opinion about how to approach the hospital birth midwife. Many hospital based providers get weird about homebirth. You might book an appointment with the hospital based midwife and feel her out by mentioning that you "have a friend" who is planning a homebirth just to see her reaction.

[wombatclay]

One thing about shadow care is that it can have some unintended outcomes for others. I'm not suggesting that you put other people above your own birth needs, but if you like the hospital midwife you may want to be up front about shadow care.

Here's where I'm coming from...

I'm a VBAC mama. Many VBAC mothers end up with some sort of shadow care because of the difficulty in finding a VBAC supportive care provider. Around here a few OBs have gotten "burned" by women who saw them for the pregnancy and then "oops" home birthed. (apparently, in terms of insurance and billing, most of the money the care provider gets comes from the birth rather than the prenatals) As a result those practices will no longer accept VBAC clients and local VBAC birth choices are nearly non-existant (you either drive an hour+ to a regional hospital that has a midwife/OB vbac team or 3 hours to a midwife who will attend hbacs in her cabin).

Anyway... I'm not suggesting you make a choice based on that sort of consideration, but it is something to keep in mind. As a VBAC mama I entirely understand shadow care scenarios where you "can't tell" the person that you plan on birthing elsewhere, but those scenarios really aren't ideal for anyone. Especially if you like the hospital midwife and/or get the feeling that she is offering a unique service to the birth community that might be jeopardized by lost births. Maybe sound her out and either let her know your plans or choose someone who you wont feel bad "skipping out" on? And ask the homebirth midwife you're seeing what her experience has been with shadow care? Some midwives are fine with it, others really discourage it... a lot depends on the state, the individual birth community, and so on.

[Youngfrankenstein]

I don't know....if they need the money from the birth they don't attend, that's their problem. I paid about $1000 out of pocket for my pre-natal shadow care. I paid my midwife her fee. I don't feel like I was making the OB practice "lost out" on my birth money...

[wombatclay]

Again... I'm not tryng to suggest that this should be one of the main factors in a woman's choice. A woman needs to make the choices that will help her have the birth she wants, and thoughts about what may or may happen down the road don't need to play a huge role in that choice. I'm a VBAC mother in a region that is not VBAC supportive... there are obviously times where keeping a provider in the dark as to their role is the only option. But it's still good to think about the big picture, and ask around the local birth community to see if there are shadow care options that have worked well in the past.

For example, one of our homebirth midwives has an agreement with one of the local OBs... he provides shadow care for her in exchange for referals. While another OB is known for being really rude to the homebirth community AND requiring a non-refundable deposit at the second prenatal specifically because she has "lost too many births" (to homebirth). So obviously shadow care with the first OB might be less stressful than shadow care with the second... but a mom might not know that without asking, you know?

I guess I'm just trying to be thorough in terms of how different types of shadow care can play out.

[mrs_mandolini]

Another perspective.. I had hyperemesis with my first pregnancy, switched to a midwife at 26 weeks, and ended up having a precipitious, "easy birth" with her backup OB ... at 32 weeks.

If I were to have another pregnancy (which is not my intention), I would want shadow care with an OB, because I would likely need aggressive care with antinausea drugs and possible hospitalizations for rehydration. I believe that if my hydration & nutrition issues had been better handled, maybe I'd have stayed pregnant longer. A midwife, even a CNM with prescription-writing & some experience in fighting insurance companies, is probably not going to have the expertise in HG that I would need to get me past what I went through before. But for birth? I'm good at giving birth, that was fast and easy compared to the rest of it. Who needs a doctor for that?? ha.

[CBEmomma]

When doing shadow care I think you should be upfront with all involved. I did shadow care with my homebirth. My Midwife was my primary care giver, and then I had a OBGYN who I did shadow care with. I told them both that I was doing it and why. In my small town it's pretty homebirth friendly. The OBGYNs and nurses are not new to it, and my OBGYN was really supportive.

[Youngfrankenstein]

Originally Posted by CBEmomma

When doing shadow care I think you should be upfront with all involved. I did shadow care with my homebirth. My Midwife was my primary care giver, and then I had a OBGYN who I did shadow care with. I told them both that I was doing it and why. In my small town it's pretty homebirth friendly. The OBGYNs and nurses are not new to it, and my OBGYN was really supportive.

That isn't always in everyone's best interest. Ohio and my area isn't one of those (usually) who would call CPS at a transfer, but some people face that. I did speak to the head CNM at my shadow practice on the phone and while she thought homebirth was "beautiful" and did it for several years, she couldn't recommend it. I believe it was for legal reasons she said this. But I never saw her for visits. She told me one of the mw I saw had had a homebirth years ago but when I asked her about it, she said yes and changed the subject quickly.

I don't believe there would be any positive outcome from telling them. That was the same practice who then wanted to induce me with cytotec.

[allical1284]

We are seeing a group of hospital CNM's as shadow care to our HB MW. Our insurance will pretty much cover them 100%, but won't cover HB at all, so we are using them as a free source of u/s, bloodwork, etc... It is also nice in case we have to transfer for either a complication during pregnancy or labor.
Our HB MW knows about this and is fully supportive. In a perfect world, the CNM group would be supportive of our choice as well, but in reality, they would drop us in a second if they found out our intentions to birth at home. It sucks that we have to lie to them (by omission), but that is the way the system has been set-up.
We had a really great birth experience with the hospital CNM's for my first pregnancy (just hated being in the hospital), so I feel even worse because we actually have a good history and relationship built-up with them.