Thursday, August 14, 2008

Choosing a Care Provider & Birth Place

In many parts of the United States, women can choose between a hospital birth, a birth center birth, or a homebirth; they can choose an OB doctor (obstetrician), a FP doctor (family practice), a CNM (certified nurse midwife) or CPM (certified professional midwife). Different states have a variety of legal options, and even in the states where homebirth isn't explicitly legal (or is explicitly illegal) there are "underground" networks of midwives. To find out more about the status of midwifery in your state, visit the Midwives Alliance of North America (MANA) chart.

In Maine, there is currently one birth center, The Birth House, located in Bridgton, and run by Birthwise Midwifery. To find a birth center outside of Maine, try searching the American Association of Birth Centers Find a Birthcenter page - though there may be a birth center in your area that is not accredited.

There are also quite a few CPMs who attend homebirths in Maine. For more information on finding a midwife to attend your homebirth, you can visit the Birthing Your Baby Local Resources page or the Midwives of Maine site. To find a CNM for a hospital birth, visit the Find a Midwife section of the American College of Nurse-Midwives website.

If you're interested in learning more about your options, there are lots of websites and books to help you explore.

BOOKS

The Birth Book(1994), by William Sears, M.D., and Martha Sears, R.N.
The Sears' dedicate a whole chapter, "Choices in Childbirth" to discuss the many options that are available to birthing women. There is in-depth information about choosing a birth team (who your care providers will be), questions to ask during the interview process, choosing labor-support, choosing a birth place, and choosing childbirth education classes.

I especially like their "Sample Prenatal Interview List":

"While quizzing your prospective doctor [or any care provider], be sure you know where he or she stands on these important topics:
  • labor management
  • pain management
  • natural childbirth
  • walking during labor
  • improvising various labor and birth positions
  • electronic fetal monitoring: continuous, intermittent, telemetry, none
  • labor-support persons: professional assistant, baby's father
  • episiotomy: how often performed, alternatives
  • forceps and vacuum extractors
  • birth plans
  • criteria for cesarean birth
  • vaginal birth after cesarean
  • use of water during labor [or birth]
  • epidural anesthesia
  • childbirth classes
  • pregnancy health: exercise, nutrition, weight gain, etc.
  • hospital affiliations
  • routine prenatal screening tests
  • call schedule (group or solo practice; birth philosophy of covering [providers])
  • vacation schedule (in case it's during your due date)
  • fees, insurance plans (usually handled by office staff)
  • What would birth look like in this country if most women asked some questions about their care providers philosophy before or during the first visit. What would happen, I wonder, if women no longer accepted vague reassurances when they asked about cesarean birth rates? What would happen if women flocked to care providers who allowed eating and drinking, who encouraged women to give birth in a position that was comfortable for her, even if it was not on the bed, even if it was in a tub!

    The reality, though, is that, right now, most women do not ask questions about the routine care practices of their care providers. It's not that there are wrong answers (well, vague or misleading or dishonest answers are wrong) - the philosophies of the birthing woman/family and the care provider either match, or they don't. But if a woman doesn't find out until the birth that the hospital's routine care involves an IV, and the care provider will harass her if she doesn't submit to one, or that the care provider does not believe that a natural tear is better than an episiotomy and so routinely preps and performs them, even when a woman states that she does not want one - that's too late to make a change, obviously.

    Unfortunately, I'm not exaggerating. I had a client who was really afraid of needles, and was very concerned about a routine IV. She didn't want one unless absolutely necessary. I encouraged her to ask her care provider what her options were regarding an IV, given her personal fear of needles. My client had the conversation with her care provider, who said - "If you don't have an IV, your baby might DIE!!" and who went on to explain how important she believed a routine IV is to the care of mothers and babies. My client was horrified by the scare tactics used by the care provider, and since she found out in plenty of time (second trimester) that her philosophies didn't match her care provider's, she changed practices (yay for her!).

    Another key point in the Sears' list is knowing the call schedule of your provider. So many of my clients are surprised to hear that the providers in the office alternate - if there are four providers on a call schedule, a birthing woman has a 25% chance of being cared for by her primary care provider during her birth. There are ways to make this more palatable, by meeting all the care providers in the practice, and knowing that they have similar philosophies about routine care, for example. But here's another personal example - my sister in PA went to a well-known OB/CNM practice, who asked women to meet all the possible care providers who might attend the birth - there were something like ten. So much for continuity of care! Yes, she had a ten-minute appointment with each provider, but did she really get to know any of them? No. For her second baby, she went to a birth center - for that reason and many others.

    Another section in the Sears' chapter on choices that I really appreciated personally was their discussion of in-hospital vs. out-of-hospital classes. Here's part of it:
    "Ideally, schools should prepare students for the real world in a variety of circumstances. In-hospital classes prepare you for the birth policies of that hospital. On the other hand, out-of-hospital classes have the advantage of describing a variety of birth choices so that you can prepare for the birth you want - but one that the hospital may not be willing to deliver. Ideally, birth place, birth attendant, and childbirth educator should all share the same birth philosophy, but where this is not the case, a good childbirth class should help you understand your doctor better and enable you to work with him or her and the hospital staff to achieve a birth that is safe and satisfying. Look for an instructor who emphasizes flexibility and good communication between parents and professionals" (51-52).
    Sometimes people wonder why I don't teach for a hospital, or why anyone would need or want to take a class that wasn't provided by the hospital. I like the freedom to teach what I believe is most important; I like to teach about making informed choices, and encourage my clients to think of themselves as consumers, not as "patients". I think there is value to being outside of "the system", free from any influence other than my clients' best interest. My philosophy isn't that all women should give birth one way, or another - instead, I encourage mothers/partners to think about what they want in the birth experience, and to communicate with their care providers. Birth is a once in a lifetime experience - even if a woman has several babies - each birth is that baby's only birth. I do encourage flexibility; though we talk about birth plans, we also talk about living in the moment and doing "the next best thing" if the first best thing doesn't work out, which we all know sometimes happens. Birth is a part of life! Plus, I have small classes (one to four couples), I can work my schedule to accommodate people who call me a month before they're due, or who work at night, etc., and I offer unlimited telephone and email support. It's a good deal for everyone!

    Anyway, back to resources... Next up is Mothering Magazine's Having A Baby, Naturally (2003), by Peggy O'Mara. She also offers an entire chapter on "Making Birth Choices - Choosing Your Place of Birth and Your Birth Attendant". O'Mara lists "reasons to choose" and "reasons not to choose" to birth at home, a freestanding birth center, or at a teaching/large hospital; she also mentions a few other choices like smaller hospitals, alternative birth centers within hospitals, and water birth. There is an explanation of the typical care provided by midwives, obstetricians, and family physicians.

    O'Mara offers several considerations at the beginning of the chapter to help families assess which birth setting might work best for them, including information on safety and cost. She goes on to write:
    "A more important 'cost' to assess, however, has to do with the effects that birth trauma and general hospital-style treatment have on the bonding between a mother and her child. High levels of stress incurred in hospital settings can seriously affect a parent's ability to function well in the difficult weeks after birth. Many women agonize about their negative birthing experiences, including unnecessary interventions and unkind or patronizing treatment, for months or even years after birth. Since birth sets the stage for your early parenting experiences, it makes sense to avoid anything that increases stress for you or reduces your ability to bond with your child. Making a decision on where your baby's birth will take place is second in importance only in making the decision to become parents in the first place! Take time to explore all the options you have" (35).
    The "Which One is Best for Me?" list of considerations is also helpful:
    "There is no formula that can help a mother-to-be decide what type of care provider will be best for her. That is because every provider is different, even within such different categories as 'obstetrician' and 'midwife.' Some obstetricians are very open to the idea of a birth with minimal or no interventions [like my daughter's birth, born after minimal procedures while I squatted on a birth stool, the OB hovering to play catch on the floor - it was great!]. Some midwives may practice in hospitals and be much more likely to rely on technology than others [my sister, who had her membranes sweeped, water broken, Pitocin, Nubain etc. & etc. had a "medwife" - a medically-minded midwife].

    For this reason, it is necessary to interview several candidates before making a final decision. It also helps to know that no decision is absolutely final. While it may not be ideal to change birth attendants midstream, it is better than working with someone you find you are unhappy with. To decide who to interview, consider these points:

  • Check to see if this person is able or willing to attend a birth in the location you have chosen. Most doctors will not attend home births, so this will narrow your field automatically.
  • If you want an attendant who will be with you throughout most of your labor, you should consider using a midwife. Obstetricians will generally only be with you during the final stages of labor, checking on you intermittently beforehand. You will be attended to by labor nurses for the most part.
  • Know that midwives spend significantly longer on regular checkups than most doctors do, from twenty to forty minutes per visit. Again, there are always exceptions to this.
  • Cesarean section rates, on average, are much lower for midwives than for medical doctors. In addition, rates of successful VBACs (vaginal births after a cesarean) are better for midwives. Certified nurse-midwives, for example, have a rate of 11.6 percent for C-sections and 68.9percent for successful VBACs. The national average is, respectively, 23.3 percent and 24.9 percent [much higher national average C-section rate now, hovering around a third of all births].
  • Choosing a male ob/gyn, rather than a female increases your chance of ending up with a cesarean section by 40 percent.
  • Using a family practice physician can be advantageous if this is a person who is already very familiar with you and your family. Perhaps this will be the same person who is going to care for your newborn" (42-43).
  • Finally, O'Mara suggests questions to ask during the interview process, and some pointers on how to communicate effectively with your care provider.

    Another great book resource is Henci Goer's The Thinking Woman's Guide to a Better Birth (1999). She includes three separate chapters on choices for care during pregnancy and birth, "Professional Labor Support: Mothering the Mother", "Obstetricians, Midwives, and Family Practitioners: Someone to Watch Over You" and "The Place of Birth: Location, Location, Location". There is some very solid information in these chapters, including interview questions, lots of lists of pros/cons, some advice on what to do when provider choice is limited, either by insurance or by medical conditions or mother's location, a thorough comparison of birth sites that is really terrific, and more.

    There are some great "reality checks" throughout these chapters, including the following in the labor support chapter: "If you are a first-time mom planning a hospital birth, you're probably assuming that your nurse will shepherd you and your partner through labor. Ever-present, she will comfort and ten you. I suppose it happens occasionally, but not often. Studies show that the average labor and delivery nurse spends fifteen minutes of her eight-hour shift [italics mine] offering physical comfort measures, providing emotional support, or advocating for her patients. Another study showed that time with laboring women didn't increase even with a group of nurses who acknowledged the importance of labor support and when that was the study's intent. Meanwhile, with staff cutbacks the order of the day, even the best-intentioned nurse has not time to labor-sit" (177).

    Hopefully you have not heard responses like the ones listed below from your caregiver. If you have, Henci Goer suggests, “these behaviors will tell you that you have the wrong person, someone who wants to coerce rather than convince you” (196). Here are the “red flags” listed in The Thinking Woman’s Guide to a Better Birth:
    • Scare tactics. “We can do that – if you don’t care what happens to the baby.” “Which would you rather have: a nice experience or a healthy baby?” You can have both. In fact, the things that make a nice experience also make for a healthy baby.
    • Anger. “And where did you go to medical school?” “I can’t take care of you if you don’t trust me.” Of course you should trust your caregiver, but the trust must be earned.
    • Ridiculing your concerns, desires, opinions, or competency to participate in decisions about your care. “I see you’ve been reading those women’s magazines.” “You want natural childbirth? I think that makes about as much sense as natural dentistry.”
    • Patronizing you. “Don’t worry about a thing; just leave everything to me.”
    • Vagueness. It’s a bad sign when you can’t pin a caregiver down enough to get at least ballpark estimates of personal statistics such as cesarean rates . . . It’s also bad when the caregiver says you can do anything you want during labor and won’t specify what situations might preclude that" (196-197).
    Finally, there are some great suggestions regarding choices for provider and location in The Big Book of Birth (2007) by Erica Lyon, who was the education coordinator and administrative supervisor at the Elizabeth Seton Chilbearing Center in NYC. A few of suggestions in this chapter include:
  • "Check if your practitioner's belief system matches yours. There is a range of how practitioners 'manage' or 'care for' women, from authoritarian to nurturing, of how available and accessible they are. Most of us know whether we want someone more authoritarian who can tell us what will happen [debatable, I think, if anyone can tell us for sure what's going to happen, other than a baby is going to come out, some way or another!] and what to do when we're birthing our baby, or someone who is more nurturing and gives us more personal responsibility. Asking questions to gauge if this is a good match so that you are relaxed and feel you can trust your practitioner in labor is very important . . . If you think your practitioner is eroding your confidence, causing unnecessary concer, or looking for problems where they don't exist, then changing may be a good course of action" (269).
  • "Think outside the bassinet. By this I mean look at models of care around the world that get good (better than the U.S.) outcomes and try to model your care after that [planning to discuss this in my next post]" (270).
  • Stop reading What to Expect When You're Expecting, or any book that has headlines like "Warning" or "Danger". The anxiety such a book produces is not helpful . . . to normal pregnancy and produces a lot of unnecessary guilt and concern [time enough for that after the baby is born & you're parenting - hahah!]. No one can tell you what to expect, only the various paths and options and how all of these can be relative at times" (270).
  • "Take a moment and be honest about your concerns and fears. Understanding our emotions and psychology does not necessarily give us more control over a situation but it does help us cope and identify what we truly need" (271). This is so important! I ask all my moms to ask themselves "What is most important thing your care provider could do during the birth to help you?" and they think for a minute and come up with an answer. Then I ask - "Have you talked to him/her about this?" and as of yet, every single mother has said, why no, I haven't. So there it is: care providers cannot read minds. And sometimes, we ourselves aren't sure what is most important if we haven't taken some time to think about it; only after the fact can we identify something that could have been done differently to improve our experience. So, I encourage women to do a lot of reflecting themselves, and then have some honest conversations with their partners and their care providers about the kind of care and support they want for the birth!
  • And the last one I'll mention from this terrific section, "Give some thought about what might make this more manageable for you. In which areas do you need reassurance? . . . Labor and birth are challenging no matter how we do it, but what can you put in place for yourself that will give you confidence and help you go through it . . . When we take care of the mother, we take care of the baby. (The baby is still part of us at this point!) As I write this, I can hear the 'reactive' voice to this statement: 'How selfish! Labor is not about the woman, it's about a healthy baby!' Yes, at the end of the day absolutely true; however we women know that and we will make decision that help us cope and meet that objective. (To imply otherwise is a wee bit patronizing.) . . . with information and support, we move through labor knowing that we are doing what we have to, what we believe in, what we are capable of given all the variables - and that it is okay" (272).
  • Two other very interesting books about care during pregnancy and birth in the United States are Pushed: The Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block and Born in the United States: How a Broken Maternity System Must be Fixed to Put Women and Children First, by Marsden Wagner. I'm sure there are other books that I'm not mentioning - if you're thinking of one that has helpful information on choosing a care provider or the birth place, please leave it in the comments!

    WEBSITES

    The excellent organization Childbirth Connection offers an entire section on Choosing a Caregiver, highlighting the importance of making an informed choice about, what the different care provider options are, and other insightful information. I appreciate that they also include reasons that are "insufficient" for choosing a caregiver:
    "It is not wise to select a caregiver solely because:
  • that person practices near your home or workplace — convenience is nice, but you may need to travel further to find the right person
  • you know someone who worked with that person — even if recommended by a friend or relative, you will want to be sure that a maternity caregiver's style will meet your needs and values and reflects the best available research
  • that person is a woman, or a man — if you have a preference for caregiver gender, you will want to be sure that that person's maternity philosophy and style of practice match well with your needs and values and with the best available research
  • that person has been your provider for well-woman or primary care — you will want to learn about that person's maternity philosophy and style of practice before making your decision."
  • The next pages offer information on midwives and obstetricians and family physicians, as well as "Best Evidence (a discussion of studies done about differences between midwifery and obtetric care)," "Tips & Tools" (interview questions, etc.), and "Resources" (links to helpful resources).

    Childbirth Connection offers a similar set of resources about Choosing a Place of Birth: a review of the options, best evidence, tips & tools, and resources.

    Childbirth Connection offers many more terrific resources, including an important free .pdf called The Rights of Childbearing Women, as well as a free .pdf download of the Listening to Mothers surveys (interesting to get a picture of what birth has been like in the United States for the past few years), and the amazing resource A Guide to Effective Care in Pregnancy and Childbirth - buy it on Amazon for a lot of money or read the sections that interest you here for free! A Guide to Effective Care "is an overview of results of the best available research about effects of specific maternity practices. The full text of the current edition (Oxford University Press, 2000) is available on this website [linked chapter by chapter] courtesy of the authors: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett and Justus Hofmeyr." I could keep highlighting useful information for their site like the pregnancy pictures and stages of pregnancy etc. & etc. but really, go check it out - amazing resources!

    Coalition for Improving Maternity Services (CIMS) has some useful downloads on its site, including information the Mother-Friendly Childbirth Initiative with links to "Evidence Basis for Mother-Friendly Care" and "Having a Baby? Ten Questions to Ask" and other helpful documents.

    UNICEF and WHO joined together to create the Baby Friendly Hospital Initiative, with an explanation of what a "Baby Friendly" label means, and a list of "Baby Friendly" hospitals and birth centers. In Maine, as of July 2008, we have Central Maine Medical Center in Lewiston, Maine General Medical Center in Augusta and Waterville, Miles Memorial Hospital in Damariscotta, and York Hospital, in York.

    Citizens for Midwifery offers a chart Ideals vs. Reality in U.S. Births, which compares the WHO recommendations, CIMS recommendations, and U.S. reality as of 2004.

    So that's my highlight of information that could help a mother (and her partner) choose the kind of care provider and birth setting that will work the best for them, as well as information on interviewing/choosing a specific provider and setting. The most important things to remember, in my opinion, are that you do have choices, and that the choices you make can have a very significant impact on your birth experience. If you're not happy with the care you're receiving or the setting you initially chose - please consider reviewing your options. One of the statements that is repeated over and over in all the books and sites I include in this entry is the importance of making choices about provider and setting that are right for you and your family as you get ready to meet the new little person growing inside of you.

    Happy exploring, and best wishes for making the best choice possible!

    Christina @ Birthing Your Baby
    Independent Childbirth Classes for Central Maine

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