Being an informed birthing woman and finding the right care provider, Part 2:
I cannot claim to be an expert on this subject, but because of the access I have grown up with and acquired through my work in public health, I am eager to share a few tips and tools for finding the right prenatal and birth care provider.
For brevity, let’s skip the part about finding insurance and assume that you have some way to pay for care, whether through work or the Affordable Care Act’s individual plans or Medicaid or the tribal health system, or because you live in a country other than the USA that believes health care is a right. So, payment aside, yhe first question would be:
A.) What kind of prenatal care and birth experience do you want?
One good tool for helping you examine what type of experience you want and what kind of care provider—Obstetrician/Gynecologist (OBGYN) vs. a Certified Nurse Midwife (CNM) or direct entry midwife (CDM or CPM) –can be found at this website:
Also, Our Bodies, Ourselves: Pregnancy and Birth book has clear and thorough information for understanding the differences in approach.
This website has an incredible wealth of information about types of providers and birth settings and ways of understanding your options as a mama and patient:
B.) What kind of prenatal care and birth experience do I want for myself and for others?
- I want patients in general, and in this case pregnant women and families, to get attentive, informed, compassionate, competent, culturally-humble care.
- I believe that prenatal appointments should be long enough to not only listen to fetal heart tones, etc. but also to talk about nutrition, exercise, stress, preparation for birth and other issues—and that the provider should be well-informed enough to do this effectively.
- I believe that the provider should be attentive to the psychosocial needs of their patient and invite patients to think about issues that might come up for them in the birthing or breast-feeding or pregnancy process, such as sexual trauma, body image, relationships, social support, etc. Providers should also ask about and support patients with logistics (e.g. Do they have a car seat? Leave time? Do they need referrals for social services or assistance programs?)
- The provider should be competent, able to use evidence-based approaches, and do what helps women and babies. That is, they should neither push women into the cascade of interventions that is so common in the medical approach to birth, nor sit passively by letting them labor for far too long without active help or under dangerous conditions (e.g. breech babies or moms with preeclampsia at home). That cascade of interventions I mentioned often begins with inductions (The decision to induce labor –> Pitocin –> tremendous pain –> epidural –> fetal distress and/or failure to progress –> c-section) . In fact, first time moms who receive elective inductions have a 45% chance of a c-section.
- And of course, on the most basic level, the provider should believe in each woman’s ability to give birth and should see birthing a child as a natural process to safely help along rather than as a problem that has to be solved or, worse, extricated.
If this sounds good to you, as it does to me, then how do we go about determining whether a provider or a practice is like this? In the websites above, I could not find a handy little interview guide, so that’s what I will try to share here. It fully contains my biases and areas of interest, and might leave out some of yours. Totally add to it or subtract from it as you see fit.
C.) Laura’s interview guide for determining whether the provider/practice is, on the one hand, intervention happy, or on the other hand, reckless and out there:
[First, a tip on asking questions: Don't ask in such a way that they know what answer you want. Word your questions in an open-ended way where the answer you want is not stated in the question, and pay attention to what your voice and face are communicating.]
I. General Qs:
1.) What is your C-section rate?
Sometimes it needs to happen, but it shouldn’t be happening very often. It should only be done under circumstances such as preeclampsia or hypertensive patients or those who are well overdue and low on fluid—not, for example, because the provider says your baby is big.
Shouldn’t be higher than 5%. For the most part, they do not need to be cutting open women’s perineums.
4.) How long are the prenatal appointments?
Seriously, that 15 minute business is not enough.
5.) When in labor will you be with me?
Funny story: Oscar and I recently took a tour of Providence Hospital, in case we have to get transferred there from the birth center or in case we have a preterm labor. The woman giving the tour said something about how the provider won’t be with you in labor until near the end, that you will primarily be with the nurses. I asked her, “But what about with midwives?” She replied, “Yeah, they tend to come near the end too, like the doctors.” I furled my brow confusedly and asked, “Do you mean the midwives who are based here in the hospital? Because I am with Geneva Woods…” She quickly replied, “Oh, yeah, they will be with you the whole time.” Lesson learned: not all midwifery practices follow the same model. And docs tend to stroll in quite late. Don’t be afraid to ask questions.
6.) If for medical reasoning I have to be induced, what methods will you try?
Say your water has broken and you haven’t gone into labor yet, or you have been diagnosed with preeclampsia. Then you do want some help getting labor going. But you don’t want someone starting with Pitocin and breaking your water, as is standard in many hospitals, because it causes absolutely torturous pain and increases risks.
Providers should work on cervical ripening prior to even considering Pitocin. This includes:
- Balloon catheter insertion
- Stripping of membranes
There are also some things a practice might suggest you try at home to get labor going if you want to move it along but an induction is not needed yet. These include black and blue cohosh, enemas, breast pumping, nipple stimulation, and sex—that is, as long as your water hasn’t broken)
Also, FYI: in Alaska, direct-entry midwives’ licensing regulations do not permit them to do inductions.
7.) What percentage of your patients’ babies have Apgar scores lower than 7 at five minutes?
You want good outcomes, so you want this percentage to be very low, somewhere less than 2%.
8.) What will happen with baby right after she/he is born?
Given the overwhelming evidence in support of immediate skin-to-skin bonding, you want a provider (and a facility) who understand and support it, who will determine baby’s Apgar score while baby is on your chest (barring any major complications that require NICU or other kinds of attention), who will promote breastfeeding, who will wait to cut the cord if that’s what you want, who won’t let the nurses whisk the baby off to be weighed right away, etc.
You may not even get answers to all of these things because the practice might not track or have that data available. That says something. Or you might get a provider who is defensive and upset that you are asking these questions. That also says something.
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II. Qs specific to midwives who practice out of hospital (homebirth or birth center)
[First, some background: Both Certified Nurse Midwives (CNMs) and direct entry midwives, who are called either Certified Direct-entry Midwives (CDMs) or Certified Professional Midwives (CPMs), can practice out-of-hospital birth. However, they have different skills and different licensing regulations. This is because CNMs are advanced practice nurses who also function as women's health care nurse practitioners, meaning they provide well-women's care (e.g. yearlies, family planning, menopause, STI treatment). CDMs and CPMs, on the other hand, entered midwifery directly without a nursing degree, generally can't do well-women's care, and only care for low-risk women. Also, licensing of midwives and of birth centers is different for each state.
Research has shown that midwives are, on a whole, safe and effective care providers for birth and that out of hospital birth is a good option for women who are not high risk. However, there are some whack job or incompetent or ego-driven midwives out there who do not follow their own regulations, whose risk-taking drives up licensing fees for other direct-entry midwives, who have bad outcomes for babies and moms, and who give the profession a bad reputation. I believe that all families deserve to avoid such midwives and their birth centers and that it is important to advocate for better training and higher standards.]
1.) If a complication arises in my pregnancy, what will you do?
You want to provider who is safe and humble enough to transfer you if your pregnancy becomes higher risk than is allowed by her regulations. CNMs can work with women with complications, but they may consult a doctor and/or work with the patient in the hospital. They may also collaborate with a physician if it is a high-risk issue, or transfer to a doctor if it’s a very high-risk issue. Direct entry midwives are required to transfer a patient if she has certain complications (e.g. high blood pressure, gestational diabetes). You want her to have a collaborative, friendly working relationship with CNMs to whom she can transfer patients, rather than just dumping you. If she has a contentious relationship with the other practices in town, that might not be a good sign. And if she disregards her regulations by offering to deliver breach or pre-term or VBACs or women over 42 weeks out of hospital, then she is one of those risky midwives who, for real, have bad outcomes, including higher infant mortality and even maternal mortality rates.
2.) [if a birth center:] Is your birth center licensed by the state and accredited by the Commission for the Accredidation of Birth Centers?
Google is our friend here, because all of this information is publicly available on the Internet. But it might be worth asking too, to see what they say. Accreditation is voluntary, but means that the birth center is held to a higher standard and that its staff receive support and training through the national organization.
3.) [if a birth center:] What is your transfer rate?
According to the two major birth center studies, the average transfer rate is around 15%. Too too low (or birth centers who say they never transfer patients) would mean they are not transferring people who need it and too high might mean that they may not be managing labor very well, resulting in obstructed labor, fetal distress, etc. which can often be avoided.
4.) If I have to transfer to the hospital, who will be my care provider? And will you be there with me?
It is a great relief to me and Oscar to know that if we do have to get transferred, the CNMs in the practice have hospital privileges and will take care of us there. But if we were going to a practice with only direct entry midwives and this were not possible, I would hope that the provider or practice would have good working relationships with doctors or midwives who do have hospital privileges rather than dumping me on whichever doctor happens to be on call—because some of the docs are not so nice or competent… and that is putting it mildly. I would also hope she would stay with me as a support person if I had to be in the hands of an unknown doctor.
5.) What do you do if I hemorrhage?
I am not an expert on hemorrhaging, but basically, listen for a confident, competent, medical evidence-based answer. There are medicines they should have handy and they should provide bi-manual compression. Plus, there should be an emergency transfer option if needed.
6.) [Insert your own questions and concerns about medical issues, such as shoulder distocia or cords around the neck or whatever to make sure that they practice according to the evidence and experiential wisdom.]
And it may go without saying, but make sure that the midwife’s license exists and is up-to-date. Apparently, there are a few women in Alaska who call themselves “lay midwives” who have no training or licensure at all but who catch babies. These women are breaking the law, deceiving families, and putting women and babies at risk. In Alaska, the only “lay midwives” allowed to practice are Alaska Native ones who were trained in the traditional way, such as tribal doctor, midwife, and Yup’ik elder Rita Blumenstein.
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Again, this comes from me, a social worker in the public health world, with a lot of help from my mama, a CNM and birth center owner and former Board member of the American Association of Birth Centers. So here are our biases and interests. But it also comes from the research, the evidence—including evidence that the American College of OBGYNs puts out. And it comes from what I hear from women and families about their experiences with prenatal, birth, and postpartum care. It also comes from the boards or offices charged with investigating the licenses of those in Alaska who don’t practice as they should. So I hope that this bit of insight is helpful for you or your friends, and that you can use it to create your own interview guide to bring to first appointments when looking for a provider.
On a totally different note, here is the art project invitation & CD cover that Oscar and I created for the baby shower/30th birthday party:
And here is the close-up of this week’s rainbow-colored ink painting/drawing: