Choosing a Provider: A Comparison of Care

Pregnant? What Should You Consider When Choosing a Health Care Provider for Childbirth?  Your Current Gynecologist? A Midwife?  What are the Differences Between Ob-Gyns and Midwives?  Here’s What You Need to Know

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The history that lies behind our birth choices in the United States:                                      

Until the late 1800’s most childbirth happened with a midwife at home.  This was especially true in the South where Black women served as granny midwives for other black women and poor Whites.  While they had no formal training, the midwifery tradition was passed down from woman to woman through experiential learning which often resulted in deeply respected and knowledgeable midwives, who safely delivered many babies.  At the end of the 19th century as childbirth moved from home into the hospitals, male doctors began taking the profession over, and midwives were blamed for poor birth outcomes.  But in fact, it was the introduction of two factors that strongly effected positive health outcomes for mothers:  Hand washing between patients; The introduction of antibiotics to fight infection.  These two factors once implemented caused significantly better outcomes in maternal care. (source)

As the midwifery profession began to vanish and birth became more medicalized, doctors became the authoritative voice in childbirth.  Women, who were often anesthetized so that they were unaware of the birth that was happening, turned their births over to the hands of the doctor.  In doing so women’s knowledge about childbirth, whether it was intuitive or passed down in one’s culture and family, went unrecognized as doctors told women how to birth.  Fathers were sent to the hospital waiting rooms and were only summoned after the birth to view their baby.  In 1943, my own mother-in-law went into labor expecting to have one baby.  When she woke up from the anesthesia, she discovered that twin babies, a boy and a girl, had been delivered.  Other family members and friends knew before she did.  What a surprise! 

In the 1970’s, women began to seek out midwives and more family centered birth.  Fathers were permitted in the labor rooms, and babies began to spend more and more time with the mother after birth.  Today, “rooming in” is a standard practice, where babies seldom leave their mother’s room unless they need specialized care.  Most hospitals in Chicago are now striving for, or have received, “Baby Friendly Status” where breastfeeding is promoted by all staff members who have been specifically trained, and the baby from birth onward, is kept with the mother.  Formula is no longer offered or sent home with the parents, and mother and baby enjoy a grace period of 1-2 hours after childbirth to have skin to skin contact, and initiate breastfeeding - a very different picture than just a few years ago.  In 2014, The American College of Nurse Midwives reported that midwives perform just 12.1 per cent of vaginal births in the United States and only 8.3% of all births. (source)  Contrast these statistics in the United States to those in Europe where 75 % of births are handled by midwives. (source). This high number of midwife births in Europe reflects the history of midwives who have provided health care for women in pregnancy and childbirth for thousands of years in these places.

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Do you need to choose a different physician or midwife to see in pregnancy and childbirth? 

You may already have a gynecologist (who also delivers babies) whom you like, so the easiest thing is to stay with them.  But before you decide that, consider whether the same person who you use for women’s health care, is also the person you want for childbirth.  Having a yearly exam or getting birth control is very different than the hours you will spend in childbirth, one of the most important events in your life, where you are also your most vulnerable self.  Consider the differences in care and support described here, and then interview your own and/or other Ob-Gyns and midwives to decide whom you want for childbirth. 

When deciding on the provider who will handle your care during pregnancy, labor and birth, there are some important differences between providers that you will want to consider.

Let’s start with the differences in training between an Ob-Gyn Physician and a Certified Nurse Midwife (the only type of midwife who can practice legally in Illinois) 

A Certified Nurse Midwife must be a licensed Registered Nurse (RN), who has completed a 2-3 year Masters’ Degree Program in Midwifery.  This includes classroom time and clinical internships in office, labor and delivery, and postpartum areas. Midwives then pass a rigorous certification exam.  They are trained to care for low-risk pregnancies; They can prescribe medications, order labs and ultrasounds; They use birth technology such as fetal monitoring, and can repair any tears that have occurred during delivery.  Ob-Gyns are physicians who after four years of medical school, complete an additional residency in obstetrics and gynecology.  They are trained to care for high-risk pregnancies and births, and perform related surgical procedures such as cesareans, and vacuum or forceps deliveries, when needed. 

Sometimes people confuse Doulas and Midwives, when in fact, they are very different.  Doulas are trained to support women in childbirth but to do nothing medical, whereas Midwives are highly trained in the medical care of normal deliveries.  Doulas provide emotional, physical, and informational support, but more about them in a future blog.

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Now let’s look at the differences in actual practices between Midwives and Ob-Gyns          

The midwifery model of care emphasizes that pregnancy and birth are normal physiological processes. Most Nurse Midwife groups work in collaboration with an Ob-Gyn practice, and can refer as needed to an Obstetrician if complications arise in pregnancy or childbirth.  Midwives believe that a woman’s body knows what to do in labor and birth, and reserve interventions for times when a mother or baby need medical assistance.  They want women to make informed decisions about their own and their baby’s health by being a part of the discussion on the benefits and risks of any suggested procedure.  Midwives want you to be involved in your care by asking questions that are important to you.  Women often report that their midwives seem to take more time listening to their concerns.  Many women, laboring with midwives, choose to labor without IV fluids or to have only a heplock, instead hydrating well with fluids by mouth.  As long as labor is normal, Midwives frequently use Intermittent Fetal Monitoring with a hand-held Doppler (ultrasound) which allows women more freedom to move about without the constraints of monitoring belts. This ability to move about and assume different positions helps the baby to position itself well for birth and to move down.  Many mothers also find labor pain much easier to deal with when they can walk and change positions. 

Obstetricians generally prefer IV fluids hooked up and Continuous Electronic Fetal monitoring, where two belts are placed around the mother’s abdomen to measure continually the baby’s heart rate and the mother’s contractions. These belts are connected to a machine which monitors the results on a graph.  This can restrict the mother’s movements to the area between the bed and the machine.  Studies, since Continuous Electronic Fetal Monitoring was introduced in the 70’s, have shown that Intermittent Fetal Monitoring is just as effective as Continuous Electronic Fetal Monitoring in predicting outcomes.  There is also evidence that the rise in Electronic Fetal Monitoring may be connected with the increase in cesarean rates. (source(The Thinking Woman’s Guide to a Better Birth, Henci Goer. P 97-98.)

Once a laboring mother is admitted to the hospital by the Midwife, she sees her frequently throughout her labor.  The Midwife is present to do exams, suggest position changes and to encourage and confer with the mother and her partner.  Midwives also tend to be more receptive to a doula’s presence whom they see as someone they can work with throughout the labor.  Obstetricians, typically, see the mother less frequently throughout the labor, unless significant changes require intervention.  Mothers may be visited more frequently by the residents on the floor.  While some physicians are amenable to a doula, many see no need for a patient to have one. 

Studies suggest that midwives have a lower use of inductions, augmentations, epidurals and episiotomies.  Perineal lacerations are lower, and breastfeeding rates are higher.  The lower use of these interventions were associated with fewer cesareans.  Babies of Midwife patients more often stay with the mother for the entire hospital stay, and have fewer complications. Obstetricians are more apt to recommend or use epidurals, and to perform episiotomies and instrumental deliveries. The maternal and fetal health outcomes of the Midwives and Ob-Gyns were both found to be equal.  It leaves no doubt that midwifery care is safe and effective with a reduced use of interventions. (source),  (Rosenblatt et all, Interspeciality differences in obstetric care of low-risk women, American Journal of Public Health 1997),  (Johantgen et Al, Comparison of Labor and Delivery Care provided by Certified Nurse-Midwives and Physicians:  A Systemic Review, 1990-2008, American Journal of Public Health),  (Journal of Midwifery and Woman’s Health, 2018, 63.1, pg 90-107)

Because Midwife attended births are mostly in hospitals, the statistics suggest  how important it is to find out the rate of cesareans at the hospital you will be delivering at, as well as the cesarean rate for your Midwife or Ob-Gyn group in particular. The rate of a particular group can differ dramatically from the hospital rate.  The World Health Organization recommends a cesarean rate between 5-15% suggesting that rates outside of this may do more harm than good.  In Illinois, cesarean rates increased from 19.3 % in 1997 to 30.4% in 2007 with contributing factors thought to be:  a low priority in believing in and supporting women’s ability to birth; and a casual attitude toward cesareans that suggests a limited awareness of the harm they might cause. (source)

In summary, Midwives tend to see childbirth as a natural event which needs to be supported with as little interference as possible in a nurturing environment:  Ob-Gyns are more apt to see birth as a medical event where a physician is often needed to treat the difficulties that arise.  There are, however, physicians who will work with a mother to allow birth to proceed naturally, just as there are Midwives who treat birth from a more medical viewpoint.

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Questions to Ask Oneself When Selecting a Provider for Pregnancy and Childbirth

Working with Midwives would likely mean less interventions, fewer complications, and a better chance for a vaginal birth. If, however, you would feel safer with a physician experienced in all types of births where there might be medical complications, you might prefer an obstetrician.

Following are some questions you might want to consider in choosing between a Midwife and Ob-Gyn for childbirth:  1) Do you want to be able to discuss 1-2 questions at each appointment? - more than two should be saved for the next appointment.  2) Is your priority to have a vaginal birth?  3) Do you want your health provider to be part of your labor, visiting your room often?  4) Would you like intermittent fetal monitoring and to labor without an IV in an environment that encourages movement? 5) Would you like the least intervention possible, recognizing that flexibility will be needed depending on the labor and birth you get?  6)  Do you want an epidural as soon as possible, or are you more interested in avoiding one altogether, or waiting as long as possible?  7) Are you high risk such as carrying multiples or Diabetic?  8) Do you want to take a Childbirth Class to learn the movements/positions that facilitate birth, the natural methods of pain control, and evidence based information for making decisions in childbirth? 9) What does your gut, your intuition, tell you?  The latter I think is so important because intuition plays a major role in childbirth often helping the mother know how to move and make sounds to help a baby descend, and plays a major role in the decisions made throughout labor. (some of above questions come from:  (source).

What kinds of answers suggest that you might want to choose a different provider?        

There are some responses from health care providers that suggest they do not want to address your individual concerns.  Listed below are comments reported to me by mothers during their appointments with providers.  These do not reflect all obstetricians, but when used, imply a perspective that the physician is deciding about this birth without consultation with the mother.  Here they are:

“We don’t need to talk about that now.  We’ll wait till you are much further along”.  (By then, it may be too late to change providers if you are uncomfortable with the answers)

“I don’t have time to talk about that now.” (Perhaps a more honest answer, but when will she have time?  And will it be in time to change providers if you are uncomfortable with her answers?)

“I strongly recommend an epidural to make labor go well - you can get one as soon as you are admitted to the hospital”.  (Has the mother been asked what she wants?  Have any benefits and risks of an epidural been discussed?)

“Why do you want to put yourself through all that pain? (This comment feels like a criticism rather than asking what was influencing the mother’s choices)

“There’s no need for a doula; Your nurse will be taking care of you and telling you what to do” (Clearly this physician does not want a doula present, and expects the patient not to be involved in choices.)

“If you feel this way about labor and birth, I’d suggest you move to a midwife practice.” (This comment at least respects the mom’s requests, although it has a negative ring to it)

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In closing, I hope that each pregnant woman will carefully consider her choices for care, if she is fortunate enough to have them.  The doctor we choose for gynecological care is not necessarily the doctor or midwife who we would feel most comfortable with during childbirth.  In the process of choosing, keep in mind the following:  Does your health care provider see birth as you do?  Does he/she put you at the center of your birth, respecting and listening to you, making you part of all pregnancy and childbirth decisions? (A Good Birth:  Finding the Positive and Profound in Your Childbirth Experience by Anna Drapkin Lyerly, MD)   I want to conclude with a quote from this same book:

Only when the conscious experience of mothers’, potential mothers, and mothering persons are taken fully into account can we possibly develop understanding that might someday merit the description of ‘human’.  Virginia Held in the Introduction.