Choosing a Caregiver for Pregnancy, Labor, & Birth:  Part 1

There are several kinds of health care professionals who can provide prenatal care, attend births, and deliver babies.

Options for care providers

Obstetrician:

Training: OB/Gyn doctors have graduated from medical school, and had three or more years of additional training in women's health and diseases of the female reproductive system. OB/Gyns are also trained surgeons, who can perform cesareans if needed.

Philosophy/Focus: Physicians are primarily focused on preventing complications, detecting potential problems, and providing early intervention to prevent worsening of the situation. OB/Gyn training does not typically include experience in providing hands-on support for a woman throughout an entire labor.

Patient Interaction. Average prenatal visits: less than10 minutes. During labor: may be available for phone consultations, or may come to the hospital a few times to check on labor progress. During birth: They typically arrive shortly before delivery, and stay through third stage, and early recovery.

Family Practice Doctor:

Training: Family physicians have graduated from medical school, and completed two or more years of additional training in family medicine, including maternity care. Their education focuses on the health care needs of the family from birth to old age. They can provide routine prenatal care, and attend most births, but will refer to specialists for complications, or surgical procedures. Not all family practice doctors attend births. (Childbirth Connections estimates that 25% do, and that number is decreasing due to insurance costs.)

Certified Nurse-Midwife. (Licensed in Washington State as ARNP’s)

Training: CNM’s have graduated from a school of nursing with at least a bachelor's degree (70% have a master's), become registered nurses, and completed one or more years of additional training in midwifery. Their educational focus was on normal health care during the childbearing year, parent education, prevention and screening for possible problems, and newborn care. Typically work in a collaborative relationship with a physician for consultation and referral.

Philosophy / Focus: Specialize in the care of women with uncomplicated pregnancies and births. They tend to use fewer medical interventions than a physician uses. They support the parents’ goals, provide emotional support and physical care in labor.

Patient Interaction: Average CNM sees 140 clients a month and attends 10 births a month. Typically spend 60 minutes on a new client visit; 20-30 minutes on return visits. They remain with the mother through most of her labor, then attend birth and initial recovery stage.

How commonly are CNM’s used? In 2002, CNM’s attended 7.6% of all births in the US, 10% of all vaginal births.

Where do CNM's attend births? 99% of CNM-attended births were in hospitals; .26% in birth centers; .59% in the home.

Legal / financial. Nurse-midwifery is legal in all 50 states. They have prescription writing authority. 33 states mandate private insurance coverage, Medicaid covers in all states.

Licensed Midwife / Direct Entry Midwife / Certified Professional

1. Midwife:
   Training: Licensed midwives in Washington have completed 3 years of midwifery training, which includes all the information required to care for women prenatally, during labor and birth and postpartum. It also covers newborn care, newborn procedures, and breastfeeding. Generally, licensed midwives attend home births and births in birth centers. Midwives should have a collaborative relationship with physicians for consultation and refer to a physician if specialty care is needed for health complications.
   
   Philosophy / Focus: Tend to view pregnancy as a normal, healthy life event rather than a medical condition, which should be intervened with only when needed to protect mother and baby. Intervention levels tend to be even lower than CNM’s due to this non-medical-establishment approach.
   
   Patient Interaction: Time spent with clients is equal to, or greater on average, than the time CNM’s spend with patients. Case load is typically much smaller than CNM’s. In labor: are typically with a woman throughout her active labor, delivery, and for two to three hours after the birth.
   
   Legal / Financial status: Varies widely from state to state. In Washington, there are 120 licensed midwives. Their care is covered by Medicaid, and by several insurance companies. Generally, a licensed midwife can: do pap smears and other routine gynecological checkups, conduct prenatal exams, attend labor and birth. The only anesthesia a licensed midwife can use is a local block on the perineum. If a patient develops any condition that is defined as high-risk, or if a patient desires pain medication during labor, or requires pitocin, c-section, or other medical interventions, the midwife will transfer the patient’s care to a physician.
   
   
2. Lay midwives
   Lay midwives practice in some communities. Training and experience can range widely. Not all lay midwives are adequately trained. If you consider using an unlicensed midwife, it’s important to be cautious and ask detailed questions about their backgrounds, training, and experience.

How do nurses fit in?

If you are birthing in a hospital, a nurse will be assigned to you throughout your labor. She will monitor your vital signs, labor progress, and baby's status at regular intervals throughout the labor, and assist the physician or midwife during the delivery. Nurses often provide emotional support and assistance with coping techniques to the laboring woman, but their primary responsibility is the health of mom and baby.

How do doulas fit in?

A doula is different from all the providers listed above in that she is not a medical professional. She can not diagnose nor treat medical conditions, she can not monitor baby or do cervical exams to monitor labor progress.

A doula is an additional labor support person, who you may hire. Her role is to provide continuous support to the family from early labor until after the birth of the baby. She offers emotional support, assistance with comfort techniques, information about your options, and ideas for helping labor progress.

For more on doulas, see http://tinyurl.com/2tal95

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