How did you appraoch co-care? sorry---long

[emmaegbert]

I'd really like to hear how people approached "co-care", especially people who planned from early in pregnancy to have a homebirth, and especially from people who were able to be open with their OB about their plans and found acceptance/tolerance/support from the drs. I am looking for some constructive advice and strategies here, but any kind of experience is good and informative for me.

I live in California where homebirth midwives are licensed and legal and even covered by some insurance. I am about 11 weeks pregnant right now and will be meeting few HB midwives in the coming weeks to interview them. We would like to pursue homebirth assuming I don't have any (serious) complications, and that its a single fetus (I think we'd go to the midwife-run birth center if its twins.) So, basically if I am low-risk, and I can get insurance coverage, I will be planning for a homebirth.

I am also going in for a routine nurse-practitioner appointment next week (it was the earliest I could get in! 12 weeks!) at a practice which has both OBs (who attend hospital births) and Nurse-Midwives (who attend at a hospital-based birth center, where I had my son almost 4 years ago).

I would like to have my first U/S, as well as routine labs and screening through this practice- partly b/c its completely (100%) covered by my insurance, and b/c I know its a good practice, supportive of natural birth, breastfeeding, etc. I also would like to have a chart started with them b/c its the hospital I would choose in case I need to transfer to OB care late in pregnancy. I plan to do a little research in my local community (discussion boards, word-of-mouth, and by asking the midwives we interview) to find out if there are any particular OBs there who are more supportive/tolerant of HB. And I think I would like to have at least one appt with such an OB (assuming he/she exists!). The practice is also affiliated with the only hospital in town that I know of which has some kind of vague agreement with the HB midwife community to treat their transfer patients well.

BUT, I am feeling nervous about how to bring it up with the OB-- its not like I personally know any docs there, b/c all my past care was with nurse-practitioners and nurse-midwives. I'd rather be open about my plans and why I am coming there. My first pregnancy was without complications, my birth was fine, 12 hours total labor, with no medical interventions. So its not like my medical history (which is in my chart there!) would make the docs leery. HB is legal and above-board here in CA, so I don't have to hide anything to protect myself, my family, or my midwife. Also, I am pretty sure that they can't refuse my care, because I am a student at the university which runs the hospital, and my insurance is through the university. So I don't think I have to fear any reprisals for being honest. But of course, I don't want to be working with a hostile doctor either (especially if I DO need to transfer!!).

I'd be interested to hear how and when you discussed your plans with an OB, how much did you "prepare" for the conversation (did you bring articles? stats? did you just approach it with confidence like, "its my decision and I don't need your permission"). Or did you research ahead to make sure you got to see a HB-friendly doc? Also, what exactly comprised your "co-care"-- how many visits? what tests and procedures? For how long during your pregnancy did you go to the OB? Did you share charts back and forth between OB and MW?

Thanks for reading my novel!

-Emma

[barefootpoetry]

I did not bring it up with my co-care CPs at all. They are notoriously anti-homebirth and I knew they would drop me if I suggested homebirth. But I needed them to fall back on because I was an HBAC and in the case that I needed another C-section, I wanted my insurance to cover it. I paid for the homebirth out of pocket, and it turned out just fine. They had no idea until they called me about a week after my EDD and asked me why I never came in for my last appointment. I told them I'd had the baby at home, my homebirth midwives would be doing the postpartum care, and that was that.

[mammamo]

I think that honesty is the best policy from the very beginning. This way you can weed out if there is a hostile OB and get a new one. Listen to the voice of regret talking to you

[newmommy27]

Emma,

I see you are in San Diego...there is a great doc who is completely supportive of home birth he actually caught the wee one who is resting in my arms at them moment

if you PM me I will send you his info

[nashvillemidwife]

Do the home birth midwives in your area not have relationships with physicians?

[emmaegbert]

Thanks everyone for your replies so far.

Nashvillemidwife: I have yet to meet f2f with any HB midwives (tomorrow is the first interview, I'm starting by meeting with 3, and we'll go from there, obviously I'll be asking them for their advice on the subject). But my understanding from our correspondence so far and what I have heard from other mommas is that there are very few (if any?) physicians who will "officially" supervise the homebirth midwives here. I also believe that the LM/CPMs do not have right to deliver in any hospitals.

There are nurse midwives (CNMs) who work in OBGYN practices, under direct supervision of OBGYNs, and there are two birth centers, one free standing and one in a hospital. These birth centers are great, but none of those midwives do home birth.

Anyway, I might be getting some of the differences in the licensing wrong here (apologies!), but the long and short of it is that while I am lucky to live in a state and city not *hostile* to homebirth, its certainly not the norm or particularly supported by the medical establishment either. My preference is to plan my HB from the get-go, but to have basic screening for medical risks, and emergency plans that are reasonably informed, and this includes an OB who I've met at least once, and with whom I feel I can be honest. (And it seems sort of pointless to have the birth-center midwives as my "backup"... if I required transfer to the hospital, it wouldn't be to them, it would be to L&D).

Maybe I'll be clearer after I meet with the various midwives and choose someone as my primary caregiver. But I do think its going to be up to me to establish at least a cursory relationship (or not) with an OB.

[nashvillemidwife]

Yes, I recommend talking with the midwives about what their arrangements before you begin to worry about co-care plans. Of course no one wants to "supervise" a homebirth midwife, but there are doctors out there who are homebirth friendly and will consult with a midwife and her client in the event of a complication. Of course these things vary from region to region, but I think you'd be best served to get the scoop on how the midwives work there first.

[shanahan]

i wanted to do about the same thing you are doing - but when I asked if that would be ok, I was told no - and was basically dropped - just for telling them I was considering a homebirth. Ugh.

In a way, I'm glad I know now how unflexible this practice is - and how obviously unsupportive they are about "untraditional" births - but I'm still a bit miffed... I had been hoping to at least go to them for my 20 week u/s and for a final apt. to discuss risk, health, etc.

oh well.

[Pirogi]

With my first homebirth, I did not have co-care. Although they did license lay midwives, that state was very antagonistic toward out of hospital birth, and it was very difficult to find an OB who would willingly back up a midwife. Since I switched at 20 weeks anyway, I just decided that I didn't need a relationship with an OB. I would only be going to the hospital in a true emergency, in which case I would get whoever was on call anyway.

The second time around I will be in a different state where non-CNMs are illegal. I am also now a military officer, which means that I am required to have documented care from a qualified caregiver. I also can not contract with a non-CNM unless I want to risk being charged with "conspiracy to commit a crime." So, my plan is to see the CNM who recently went into OB practice from homebirth practice, decline all testing, and have the my baby either UC or with a top-secret CPM. I would rather just chuck the CNM plans, but I don't have any other choice. The CNM will not know of my delivery plans.

[devon]

I live in WI where having a CNM is perfectly legal. This is my 3rd child. First was with an OB at a hospital, second was unplanned HB with a family practice dr as my planned dr, and this is a planned HB with a CNM.

My insurance gives women 2 options for pregnancy: see an OB group of 7 dr's, or see a family practice dr that is part of their practice. That is what I was planning with DS #2. I told the nurse OB coordinator (who arranges what dr you have when you tell the insurance you are pregnant) that we would be having a HB. She was very supportive and set me up with a family practice dr who is supportive of HB.

The family practice dr I am seeing is very supportive of HB and has been very kind to me. She would prefer I still see her on the regular OB patient schedule but I am planning on doing every other visit instead. I'll be doing my u/s, and any other tests I need through them. She has worked with a lot of other patients who have HB and have her as a backup dr in case a non-emergent (so not needing a C/S) situation happens and I can't have a HB. I feel very comfortable with her - in fact she said she was jealous that my first family practice dr (who delivered unplanned my DS #2 at home) that she got to do a home birth

My midwife doesn't have any OB's/Dr's that back her up - that isn't common around here - but has had a lot of patients with my insurance (one of 3 big ones in town) and they have had good experiences with these two family practice dr's in my practice.

Good luck!

[emmaegbert]

Wow, I guess I am lucky to be in California after all (lol I usually don't consider myself "lucky" to be here, more like homesick, I am a north-easterner transplanted for school!), at least I am not conspiring to break the law (well, as a graduate student, not a military officer, can't imagine too many people are watching my back that closely).

Its very interesting to hear about people's different arrangements and experiences, and really kind of mind-boggling how much things vary from place to place. I am very new to all this, honestly until recently I didn't know anyone who had had a homebirth and didn't really know it was a "real" option. And though it feels like the right decision for our family to pursue homebirth, I had a very positive and supportive CNM-attended birth at a hospital-based birth center, so I am maintaining some hope for a decent, though hopefully only slight!, relationship with the same medical practice where they work...

I'll talk with the midwives of course before I ever have an OB appointment (those take forever to actually get anyway), and hopefully they can give me some tips on who I should see, and what to say once I go in. I'd love to pay for the best, most supportive OBs in San Diego, but money is a very real issue for us and I will probably have to go with the practices/clinics that are covered 100%. I'll already be taking out student loans to pay the midwife. Even if the docs are unsupportive, at least I think b/c of the situation (they work for the same university through which I am insured as a student) they can't actually turn me away (but I'll check on that too!). If they are really big jerks to me I guess I can request a few appointments with the nurse-practitioners who can order all the same tests, which is mainly what I want to do with them (and have my insurance pay for).

[emmaegbert]

so, after meeting the first of several midwives (actually we were very impressed with the one we met but she requests we interview at least 3 before choosing), we learned that really our only choice given the situation in town and our insurance, is either to go ahead with normal obstetrical care and just "drop out" after we get the screenings we want and switch to HB, pay out of pocket for one of the few docs in town that will "oversee" a hb mom with irregular visits, or just have my first prenatal appt and then just "drop in" later if needed, but expect to be given a hard time by the docs. They did say that they will work with me to make sure the billing in the end doesn't overlap-- my insurance isn't going to pay for me to be getting the same prenatal care from two providers.

Since I do have an initial preganancy appt at the OBGYN practice with a nurse-practitioner next week, she also suggested I tell the her that I am considering HB w/ licensed midwife, explain the financial issues to her, and ask her if she will just order me any labs/screenings that I *think* I might want later, then I can continue to get them through the big university medical group (2 hospitals, several clinics) where I am covered 100%, since all those would be things I'd have to pay for myself until we bill for reembursement after the baby is born (thats how it works here in cali, insurance only repays after the birth). Things like 20-week ultrasound, prenatal rh-antibody screen, prenatal rhogam. And she urged me to press the n-p if she says "no", and try to find out if she really can't, or if she's just being a PITA.

So, I know a little more, but not really the answer I was hoping for I guess. If money wasn't an issue I'd just go to the progressive docs who will let me do what I want, but its already going to be a huge stretch to pay for the HB up front. The midwives I met did say that the university hospital is their first choice for a more mom-and-baby friendly place if medical oversight is needed or desired, or for a non-emergency transfer, which is good to hear.