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A certified nurse midwife welcomes a baby in a hospital setting. Photo by Sandor Weisz

Which way do I go? Understanding maternity care options

A quick comparison of birth locations and perinatal providers

You’ve discovered you are pregnant. Now, what do you do? 

First, take a breath or two and sit with the news. Then, after you’ve recovered from the shock, the next step is to find a maternity care provider that fits your ideals for how you want to labor and where you want to deliver your baby.

First a few questions:

  • Do you want to deliver your baby in a hospital, at home, or in a freestanding birth center near the hospital?
  • Are you set on having pain relief like an epidural? Or is your goal an unmedicated birth?
  • Do you have any preexisting conditions that could impact your pregnancy, labor, or delivery (for example, epilepsy, obesity, high blood pressure, organ disease, or other ongoing health concerns)?
  • How old are you?
  • Did you use IVF to get pregnant?
  • Have you had a baby born before this pregnancy?

The answers to these questions will help narrow down which maternity care locations and providers are the safest fit for you and your baby. Below is a quick comparison of locations and  providers’ training, philosophies, and practices, including family doctors, licensed midwives, obstetricians, and certified nurse midwives. First, consider your birth place options:

Maternity care options

Swedish Health First Hill Campus. Photo courtesy Creative Commons

Hospital

The majority of babies — nearly 97% — are born in hospitals in Washington.

PROS: Hospitals offer pain control and access to neonatal intensive care units (NICUs). They provide nursing staff support, access to obstetricians, anesthesiologists and other medical specialties, complete fetal monitoring, surgical birth, and neonatologists if needed. More and more King County hospitals are offering large tubs for labor.

CONS: Hospitals can elevate stress, especially if the laboring person is uncomfortable in a hospital setting, interventions are higher in hospitals, most hospitals require (or pressure the laboring parents for) IV access in the arm or elsewhere upon entering the birth suite, restrictions on eating and drinking in some circumstances, there is a high cost to care, and most hospitals have a more sterile, institutional feel that may be unappealing.

Maternity care options

Center for Birth, in Seattle.

Freestanding birth center

Not associated with any hospital, the 21 freestanding birth centers in Washington are Independent facilities where babies may be delivered (usually by licensed or certified midwives) outside a hospital. About 1.5 % of Washington babies are born in birth centers. Of those, upwards of 15% are transferred to hospitals for safety, pain relief, or other concerns.

PROS: They often look more like a home, offer bigger rooms and comfortable large beds, have labor tubs and other labor comforts, have basic resuscitation equipment, medications to stop maternal bleeding and, in some cases, nitrous oxide (laughing gas) for pain relief.

CONS: They do not have the higher level resuscitation equipment and providers found in hospitals, and you cannot get an epidural at a birth center. They are most often located near hospitals in case of transfer and are licensed by the state health department.

Home

About 2% of laboring parents give birth at home in Washington. Of those, over 15% are transferred to hospitals for safety, pain relief, or other concerns.

PROS: Home is a familiar, comfortable setting; there is no pressure to use interventions or pain medications. Home birth results in the highest rates of breastfeeding. The laboring person may feel they have more control over the experience at home, cost of care is significantly lower, home birth may meet particular religious or cultural needs, and basic resuscitation equipment is brought to the home by the midwife care team.

CONS: According to the American College of Obstetrics and Gynecology, “there have been no adequate randomized clinical trials of planned home birth” to date, although home birth has been associated with higher infant death rates and infant neurological issues. There is no access to higher-level resuscitation equipment or personnel at home (unless 911 is called). No access to epidural pain relief. No immediate access to neonatologists. 

Once you’ve determined the setting where you hope to deliver your baby, you’re ready to consider which provider best matches desire care approach. The following providers are licensed to provide maternity care in Washington:

Licensed Midwife (LM) / Certified Professional Midwife (CPM) 

LM/CPMs view birth as a safe, natural, normal human process that is best approached with minimal intervention. They adhere to the Midwives Model of Care, which includes:

  • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
  • Minimizing technological interventions
  • Identifying and referring women who require obstetrical attention
  • The application of a woman-centered model of care has proven to reduce the incidence of birth injury, trauma, and cesarean section.

LM/CPMs complete at least three years of training in an approved midwifery education program, qualifying them to care for women throughout the childbearing year, from conception through postpartum and early parenting. They serve women at low risk for complications in birth and refer those with risk factors to obstetricians.They provide routine gynecological checkups, including pap smears. They conduct prenatal exams, attend to women during labor and birth, and provide postpartum care, breastfeeding support, and newborn care.

The Puget Sound region has many highly qualified and experienced LM/CPMs. There are nearly 175 licensed in Washington State. To become certified, midwives must attend at least 100 births, take accredited obstetric pharmacology and epidemiology courses, and pass a state exam and the national NARM exam administered by the North American Registry of Midwives. They are regulated by the Washington State Department of Health. and are required to consult with a physician whenever there are significant deviations from normal in either the mother or the newborn. 

For a comprehensive look at midwifery care in Washington, check out The Seattle Times article “The case for midwives: Washington state leads the nation in midwifery care.”

An LM may be right for you if: 

  • Your pregnancy is low risk
  • You want to have your baby at home or in a birth center
  • You do not want pain medications or other medical interventions
  • You want a provider who spends more time with you during prenatal meetings
  • You’ve had other babies with no complications
  • You trust your body and the natural process
  • You are comfortable not having certain interventions (like pain medications, surgery, or higher-level resuscitation equipment) immediately available. Note: In a medical crisis, home birth midwives will call 911 for transport to the nearest hospital.

Location of Birth: Births with LM/CPMs take place at the birth family’s 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 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 backup physician. 

Certified Nurse Midwife (CNM) 

CNMs also view birth as a safe, natural, normal human process that is best approached with minimal intervention. They, too, adhere to the Midwives Model of Care.

They are registered nurses who have master’s or doctorate degrees in the specialty of midwifery and are licensed as In Washington; they are licensed as Advanced Registered Nurse Practitioners in Washington State. They must pass an exam to be certified by the American Midwifery Certification Board and are regulated by the state health department’s Nursing Care Quality Assurance Commission. Although they are independent maternity care providers, they have the authority to prescribe medication. They often work in collaboration with physicians, usually in a hospital setting, and are overseen by the hospital chief of staff. Come CNMs attend births at home and freestanding, non-hospital birth centers.

CNMs also serve women at low risk for complications in birth and refer those with certain risk factors to physicians. CNMs provide routine gynecological checkups, including pap smears, breastfeeding support, and follow babies for the first six months of life. They conduct prenatal exams, attend to women during labor and birth, and provide postpartum care for mothers, breastfeeding support, and newborn care. While most CNMs practice in hospitals, they can attend births at home and in freestanding birth centers. Currently, about 400 CNMs practice in Washington.

Hospital-based CNMs have full access to continuous fetal monitoring equipment, pharmacological methods of inducing labor, epidurals (given by anesthesiologists), and other pain relief medications and pharmacological interventions. If a laboring person starts to show risk factors, they will consult with hospitalist obstetricians.

A CNM may be right for you if: 

  • Your pregnancy is low risk
  • You want to have your baby at home, in a birth center, or in a hospital
  • You are interested in pain medications or other medical interventions
  • You want a provider who spends more time with you during prenatal meetings
  • You’ve had other babies with no complications
  • You trust your body and the natural process
  • You are comfortable not having certain interventions (like pain medications or surgery) immediately available in a home or birth center birth setting. Hospital midwives do have full access to all interventions and obstetrical providers should a need arise.

Location of Birth: CNMs generally assist births in a hospital. Some can attend births at home or 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 on-call physicians and obstetricians. On-call complications arise during labor and birth labor in the hospital. Like licensed midwives, CNMs who deliver babies at home transfer those needing medical intervention to the nearest hospital.

Family dractice doctor (MD) 

Family doctors 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 mothers and children for the long term after birth.

Family practice doctors provide routine gynecological, birth and postpartum care like other providers. 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.

A family practice doctor may be right for you if: 

  • Your pregnancy is low or medium-risk
  • You want to have your baby in a hospital
  • You want continuity of care for you and your baby as the family practice doctor cares for patients throughout life.
  • You want most of your medical needs managed by one doctor
  • You want access to pain medications or other medical interventions in labor
  • You want a provider you already know and worked with before pregnancy

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. They are trained to deliver babies surgically.

Like other maternity care providers, OB/GYNs also give routine gynecological checkups, including pap smears. They conduct prenatal exams, attend to 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.

A OB/GYN may be right for you if: 

  • Your pregnancy is low, medium or high risk
  • You want to have your baby in a hospital
  • You feel more comfortable with a specialist trained to do surgical birth just in case
  • You want access to pain medications or other medical interventions in labor
  • Most OB/GYNs work in practice with a group of other OB/GYNs and rotate their schedule of being on-call for practice births. You are comfortable working with any of the obstetricians that practice with the one you signed up with.

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.

Maternity care options

About Doulas

Birth and postpartum doulas are not medical providers and they do not deliver babies. Birth doula offer physical, emotional and informational support before during and after labor, although they do not perform medical takes like monitoring parent and baby. Birth doulas are part of the birthing parent’s support team and there to help both parents navigate the birth experience. You hire a doula along with a midwifery or medical provide, not in lieu of one.

Pospartum doulas support families after the baby arrives, including breastfeeding, rest, food preparation, information and other supports. To review and compare birth and postpartum doulas go to DoulaMatch.

Interviewing / comparing locations and maternity providers (the “baby catchers”)

If you are newly pregnant, you’ve got plenty of time to consider and research what you really want for your birth. Start your care with your regular physician, who will confirm your pregnancy, prescribe prenatal vitamins, and otherwise advise you on early pregnancy care. With those prenatal vitamins in hand, make appointments to visit the birth location options near you. Take a tour of the birthing suites at the hospitals covered by your insurance and visit your nearest freestanding birth center.

Write down how you feel in each setting — do you feel safe and comfortable, anxious, worried? Trust your gut.

Next, do meet and greets meetings with one or two providers in each setting: Your family doctor, several OB/GYNs, some certified nurse midwives, and a few licensed midwives. Ask questions:

Again, write down how you feel about each conversation. Did the provider make you feel confident? Did you feel heard? Did you feel rushed? 

Compare and choose

Once you’ve met as many providers as feels right to you, compare the answers you’ve received to determine which provider feels like the best fit for you and your values. And remember, it’s your body, your baby, your choices throughout pregnancy. 

If the provider you have chosen feels less and less like the right fit as your pregnancy progresses, it is A to switch providers. What’s important is that you have full trust in both your body and your birth provider.

More at Seattle’s Child:

Eye exams 0 to 18: What parents need to know

Check the gum and teeth by age 1

The PUMP Act: A win for babies and businesses

Waiting for you

Black Maternal Health Week events

 

About the Author

Cheryl Murfin