Our Bodies, Ourselves (78 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
An optimal provider and birth setting will offer you:
⢠Care that is consistent with the best available research on safety and effectiveness
⢠An environment and treatments that support or enhance, rather than interfere with, the natural process of pregnancy and birth
⢠Individualized care that takes into account your health needs and those of your baby, as well as your personal preferences and values
⢠Abundant support, comfort, and information
⢠Access, either directly or through an efficient referral mechanism, to treatments for complications, should the need arise
Identifying your priorities, learning about the differences among various approaches to childbirth, and finding out which options are available to you can help you make decisions that fit your circumstances and preferences.
Most providers are part of group practices, which means that you will be attended at birth by whichever provider is on call at that time. In addition, the provider on call will respond if you have any concerns during pregnancy that come up outside regular office hours. This can be frustrating if you have a good relationship with a particular provider but are offered care by another whom you do not know as well. On the positive side, working in such teams can give midwives and doctors more predictable, limited work hours; this entails less fatigue and can reduce medical errors. Some groups have you see one doctor or midwife for the whole pregnancy, while others rotate you through the group so you get to meet everyone. If you will be working with a group practice and have a choice, look for one in which all members have comparable philosophies of care that are well matched to your needs and preferences. Some practices host public events to introduce all the providers.
MIDWIVES
Midwives have been attending and supporting women during pregnancy and childbirth, and teaching other women to do so, for centuries. All midwives are trained to provide women with prenatal care, care during labor and birth, and follow-up care after the baby is born. In the United States today, midwives attend approximately one in ten vaginal births, primarily in hospitals.
MODELS OF MATERNITY CARE
Before choosing a care provider and place of birth (the two usually go hand in hand), it is helpful to understand the two main paradigms in maternity care education and practice, described as the midwifery model and the medical model.
*
The classic midwifery model is based on the assumption that most pregnancies, labors, and births are normal biological processes that result in healthy outcomes for both mothers and babies. It focuses on maximizing the health and wellness of a woman and her baby, identifying and managing medical problems early on, and attending to the emotional, social, and spiritual aspects of pregnancy and birth. Midwifery care seeks to protect, support, and avoid interfering with the unique rhythm, character, and timing of each woman's labor. Midwives are trained to be vigilant in identifying women with serious complications. Medical expertise and interventions are sought when necessary but are not used routinely.
A strict medical model of care focuses on preventing, diagnosing, and treating the complications that can occur during pregnancy, labor, and birth. Prevention strategies tend to emphasize the use of testing, coupled with the use of medical or surgical interventions to avert a poor outcome. Medical expertise and interventions are vital for women and babies with complications. However, routine interventions on women at low risk of problems can actually lead to problems. Training in the medical model does not typically focus on developing skills to support the natural progression of an uncomplicated birth.
Although it is crucial to understand the differing philosophies and training among practitioners, it is also important to note that the letters after someone's name do not tell you much about her or him as an individual. Some doctors have attitudes, styles, and approaches that fit the midwifery model, and some midwives incorporate the medical model that is more common for doctors.
The midwifery model and medical model also give rise to two different ways of organizing maternity care systems. In most industrialized countries, midwives coordinate the care for the majority of childbearing women and collaborate with obstetricians or other specialists when a woman has medical complications or risk factors. Healthy women often give birth in midwife-led hospital units or birth centers or at home. In contrast, in the medical model prevalent in the United States, doctors manage the care of most women, almost all of whom give birth in hospitals. When midwives do provide the care, they are usually supervised by doctors and working under medical rather than midwifery protocols.
Most communities in the United States fail to promote a midwifery model of care despite powerful evidence in numerous studies that underscore the benefits of midwifery care and the heightened satisfaction of women who use midwives. A 2008 Cochrane systematic review comparing midwife-led to physician-led models of care concluded, “Midwife-led care confers benefits and shows no adverse outcomes. It should be the norm for women classified at low and high risk of complications.”
2
© Traci Palagi
Certified nurse-midwives (CNMs) are educated in nursing and midwifery. Certified midwives (CMs) are educated only in midwifery. Both CNMs and CMs are specialists in the care of healthy women in pregnancy and childbirth. They also provide well-woman care, which includes gynecological checkups, pelvic and breast exams, Pap tests, and family planning services. CNMs and CMs are certified by the American Midwifery Certification Board.
CNMs and CMs are able to attend births in hospitals, birth centers, or homes, and they typically
have established relationships with doctors with whom they can consult as needed and who will assume care during pregnancy or labor if certain complications develop. Their services are usually covered by health care insurance policies. Depending on their style of practice, a CNM or CM might be with you for your whole labor or might function more as physicians do, coming in periodically to check on you and then being present when you give birth.
Because I had conceived through in vitro fertilization and had previously had a miscarriage, I was worried about my pregnancy. The reproductive endocrinologist I worked with frowned on any birth setting but a hospital. In addition, I had a serious gastroesophageal complication and wanted my providers to be on equal footing with each other. All this led me to choose an obstetrician. But when she announced she was leaving the practice (in my sixth month), I took the opportunity to reexamine my situation
.
Not only had my OB and my gastroenterologist never communicated with each other, they gave me contradictory advice. I met with the other members of the obstetric practice and was uncomfortable with how they discussed epidurals and C-sections. I realized that no matter how I had conceived, I now had a normal pregnancy. Well into my third trimester, I switched to a midwifery practice and was able to have a natural childbirth like I wanted
.
Certified professional midwives (CPMs) specialize in healthy pregnancy and natural childbirth. They attend births at home and, in some states, birth centers. They learn their profession by attending freestanding midwifery schools or through apprenticeship to other midwives, combined with reading and study. CPMs have nationally recognized credentials through the North American Registry of Midwives. The licensing of CPMs varies from state to state, and in some states this type of midwifery is illegal or unregulated.
Recommended reading:
To learn more about your state's rules concerning CPMs, check out Citizens for Midwifery (cfmidwifery.org/states). To find out about efforts to change legislation in states that do not yet regulate CPMs, visit The Big Push for Midwives (thebigpushformidwives.org).
CPMs may or may not have formal relationships with individual physicians and/or hospitals. It is important to carefully explore the issues of medical backup and emergency care with your provider, because you may need to arrange for physician or hospital backup yourself. (For information on who is a good candidate for home birth, see “Birth Places,” page 367.)
Insurance coverage of CPMs differs from state to state and insurer to insurer. It is more common where home birth midwives are licensed.
Some midwives are not certified and consider themselves “traditional,” “independent,” or “direct entry” midwives. Although many such midwives are experienced and practice safely, the lack of a national credential and, in most cases, a license to practice makes it difficult to evaluate their skill and safety record. If you are considering a midwife who is not certified, ask careful questions about the midwife's training and experience and her arrangements for referral and transport if complications develop.
In the United States, physicians attend 90 percent of all births. Here's a look at the different type of physicians who commonly provide care to pregnant women.
A family physician is a medical doctor who is trained to provide basic, comprehensive care to people of all ages. Some family physicians provide maternity care and have hospital delivery room privileges. A few are trained to perform cesarean sections. These doctors often know the whole family, which can enhance planning for a woman's care as well as the care of the baby after birth. Studies have shown that family physicians' use of common interventions such as episiotomy, cesarean, and labor induction tends to fall between that of midwives and that of obstetrician-gynecologists.
3
Increasingly over the last several decades, obstetrician-gynecologists (ob-gyns) have replaced family practice doctors in providing maternity care. Ob-gyns have completed a four-year medical and surgical residency program in obstetrics and gynecology after completing medical school. Because ob-gyns are trained to diagnose and manage complications of pregnancy and birth, they are appropriate providers for women or babies who have serious medical conditions. (For examples of these conditions, see
“Hospital,”
) Women with such health problems may benefit from shared care with a midwife. Ob-gyns also provide care for childbearing women without specific medical concerns who either prefer to work with an obstetrician-gynecologist or must do so because of limited options.
Ob-gyns commonly provide prenatal checkups and oversee labor but rarely stay with you throughout labor and may be present only at the time of birth. (During labor, your hands-on care is generally provided by labor and delivery nurses.) Because obstetrics is a surgical specialty, OB care typically involves much higher rates of intervention than midwifery or family practiceâbased care.
Maternal-fetal medicine physicians (MFMs) are subspecialists in the obstetrics field who have additional training in complicated obstetrics. They often assume care of women with serious conditions such as diabetes or heart disease. These doctors usually practice in large academic medical centers or urban areas and see women only on referral from a physician or midwife. Many perform prenatal and genetic testing procedures and have expertise in the field of genetics. Frequently, they devise a plan of care in collaboration with a pregnant woman's midwife or physician in her home community. If you are referred to a maternal-fetal medicine specialist, find out whether she or he actually attends births; many no longer do.
The vast majority of us enter pregnancy as healthy women, with no major medical problems. If this is true for you, you can choose from the full range of providers and birth settings available in your area. If you have a serious medical condition or are at risk of developing such a condition, an obstetrician or maternal-fetal medicine specialist should be on your team and you should plan to give birth in a hospital, but you still may have midwives involved in your care. Choosing a clinician and birth setting that fit with your beliefs and preferences will be more effective than writing a birth plan and hoping to influence routine practices in medical settings.
To get names of practitioners, ask your family and friends for recommendations and, if
you have insurance, find out which providers and services your health care insurance covers. Doulas and childbirth educators can provide excellent guidance about caregivers in the community. Interview the people who you think are most likely to be a good fit for you. (Some insurers will cover an interview visit, and some practices will not charge for the interview; this varies.) For a list of
questions to ask.
Setting up a counseling visit before you become pregnant is one way to get to know a doctor or midwife you might consider for your pregnancy care. You can also choose your birth setting first and select a provider from those who attend births in that location. If you are not happy with the care you receive, you have the right to change providers at any time, but be aware that some care providers have a cutoff point for accepting new clients.