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Who’s Best for You? Choosing a Midwife, Family Doctor or OB/GYN in the Puget Sound



EDITOR'S NOTE: This article first ran in Seattle's Child in 2008 and has been updated as of January 5, 2011.

You've gotten the clear POSITIVE on the pregnancy test, but the next big query on the path to parenthood can seem far less pink and white to expectant moms. Midwife, doctor, obstetrical specialist – who should care for my baby and me? There are a number of things to consider when choosing who will catch your precious bundle. The following questions should help inform your decision:


Am I at higher risk than the majority of childbearing women of having a complication during pregnancy or birth?

If you have or have had a serious illness, diabetes, several previous cesareans, high blood pressure or are carrying multiple babies (twins or more), you are most likely a high-risk mama. That generally means an obstetrician/gynecologist (OB/GYN) is the best provider for you. Many family practice doctors will take moderate to higher-risk women working in consultation with an OB/GYN. If you are at low risk (determined during your first or subsequent prenatal visit), your options are wide open, from choosing a home birth midwife to an OB/GYN. The vast majority of women are at low risk for complications and should thus feel confident in the care of midwives or doctors.

How much time do I want with my provider?

Generally speaking, midwives spend more time with their clients during prenatal visits and during labor and delivery. Licensed midwives and certified professional midwives (LM/CPM) and home birth or birth center certified nurse midwives (CNM) will generally visit a client at home one or more times, particularly when a home birth is expected. This gives them an opportunity to learn more about the family environment as well as the progressing pregnancy. Hospital-based certified nurse midwives visit clients in a clinic but often will spend 20 minutes or more with a client during a meeting. Medical doctors generally carry heavier caseloads and thus spend less time with women during prenatal visits.

During labor, midwives generally spend the most time attending women – that is, being present at their labor. Most doctors do not stay for the majority of labor but rather check in from time to time and come when baby is close to being born. If you are at low risk for complications and feel you need time with your provider, and you expect your provider to be there throughout your labor, a midwife may be a better option. On the other hand, some women feel that their family physician, who has cared for them for a long time, may also know them uniquely and may be the best option.

How do you feel about pain medication?

If you are certain you want it or are sure you want it in the building and available during your labor, you will need to be in the care of a certified nurse midwife or doctor, and you will need to have your baby in a hospital. If you want an unmedicated birth, choosing a LM/CPM in a home or birth center setting gives you the best chance to meet this end. A certified nurse midwife (a provider who also supports the low- or no-intervention direction of the midwifery model) is the next best choice when working toward an unmedicated birth. Be warned, however: The act of merely entering the hospital increases the likelihood that you'll use pain medication.

Where would I be most comfortable and what environment is right for my baby at birth?

Hospitals are not generally known for their homey nature and stress-free atmosphere, although many have come a long way, baby, in designing more comfortable birthing suites. Still, it is the rare hospital, indeed, that allows candles or birth in water. Medical equipment that some people find intimidating is a common sight in most hospitals, and sound tends to carry in wide hallways and side-by-side birthing suites.

If you feel safest and most confident in a medical facility where you can be certain advanced emergency equipment is nearby, where you know you will be monitored frequently with state-of-the-art medical technology, and where attendants will adhere to a fairly strict timeline for birth progression, a hospital may be the best place for you. In this setting a CNM, family doctor or OB/GYN are the providers available.

On the other hand, if you feel more relaxed the moment you leave a medical facility, if you feel sure that birth is a non-medical process most of the time, if you are interested in water birth and if you feel most comfortable surrounded by candles, quiet and your own sheets and comfort items in a familiar setting, home birth with a licensed midwife or CNM is a safe and sound decision. Midwives carry the same emergency equipment used by 911 emergency medical technicians and, in fact, are often called on to train EMTs in birth management.

A birth center offers the same home-like atmosphere as your place. For those who bristle at the thought of a hospital or are not comfortable with the idea of birthing at home – or who just don't want to miss the excitement of getting in a car to "go" to have a baby – the birth center is home away from home.

Your Maternity Care Options

It's helpful to know how maternity care providers differ from field to field as you are making this important choice. Here's a quick comparison of training, philosophies and practices of midwives and doctors.

Licensed Midwife/Certified Professional Midwife (LM/CPM)
LM/CPMs view birth a safe, natural, normal human process that is best approached with minimal intervention. They serve women at low risk for complications in birth and refer those with risk factors to physicians. They complete a minimum of three years of training in an approved midwifery education program, qualifying them to care for women throughout the child-bearing year, from conception through postpartum and early parenting. LM/CPMs provide routine gynecological checkups including pap smears. They conduct prenatal exams, attend women during labor and birth and provide postpartum care, breastfeeding support and newborn care.

Location of Birth: Births with LM/CPMs take place at home or at a birth center. Insurance: Most LM/CPM care in Washington is covered by Medicaid. Several insurance companies also cover this care.
Referrals, Transfers, Emergencies: A midwife will refer a woman to a physician or obstetrician prenatally if the client has any condition that is defined as high-risk – including high blood pressure, diabetes, placental anomalies or multiples (twins or more). Midwife clients who desire pain medication during labor or those who need other medical intervention during labor are transferred to the nearest hospital and/or a back-up physician.

Certified Nurse Midwife (CNM)
CNMs also view birth as a safe, natural, normal human process that is best approached with minimal intervention. Unlike licensed midwives, they are required to work in collaboration with a physician and are overseen by the medical chief of staff of the hospital. They also serve women at low risk for complications in birth and refer those with risk factors to physicians. CNMs graduate from a two-to-four year nursing program to become registered nurses. They then complete a minimum of one year of training in midwifery care to serve women throughout the childbearing year. CNMs also provide routine gynecological checkups including pap smears. They conduct prenatal exams, attend women during labor and birth and provide postpartum care for mothers, breastfeeding support and newborn care.

Location of Birth: CNMs generally assist births in a hospital under the direction of a medical doctor. Some attend births at home or at a birth center.
Insurance: CNM care in Washington is covered by most insurance, including Medicaid.
Referrals, Emergencies: A CNM will refer high-risk pregnancies to a physician or obstetrician. The CNM works in collaboration with the physicians and obstetricians on-call when complications arise during labor and birth labor in the hospital. Like licensed Midwives, CNMs transfer those needing medical intervention to the nearest hospital or their back-up physician in the birth center or home setting.

Family Doctor (MD)

Family practitioners complete two or more years of additional training in family medicine and maternity care after graduating from medical school. Their focus is often on preventive care. They often continue to provide primary medical care to mother and child for the long term after birth. Family doctors, like other providers, provide routine gynecological, birth, and postpartum care. They generally refer breastfeeding support to lactation consultants, and many provide newborn care in lieu of a pediatrician. They generally refer patients at high risk for birth complications to obstetricians.

Location of Birth: Family practitioners generally deliver babies in hospitals.
Insurance: Physician care in Washington is covered by insurance.
Referrals/Emergencies: Family Practice Physicians refer high-risk patients to specialists, including OB/GYNs.

Obstetrician/Gynecologist (OB/GYN)
OB/GYNs graduate from medical school and then undergo several more years (a minimum of three) of specific training in obstetrics and gynecology. Because OB/GYNs focus on diagnosing and treating medical complications, they generally do not stay at the bedside throughout labor but rather consult with nurses throughout labor and are there to deliver the baby and placenta and stay for a short while after the birth.

Like other maternity care providers, OB/GYNs also give routine gynecological checkups including pap smears. They conduct prenatal exams, attend women during labor and birth and provide postpartum care for mothers. They generally do not provide breastfeeding support and newborn care, and refer new moms to lactation consultants and pediatricians.

Location of Birth: OB/GYNs attend birth in hospitals.
Insurance: OB/GYN care in Washington is covered by most insurance, including Medicaid.
Referrals, Emergencies: OB/GYNs refer patients to OB/GYN colleagues or other medical specialists.

Cheryl Murfin, former executive director of the Seattle Midwifery School, is a doula who also has extensive experience working with OB/GYNs and family practitioners.

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