Choosing a Care Provider and Birth Location

Your Care Provider

Pregnancy and birth care providers have varying styles, levels of expertise, and birth philosophies. It is important to choose a care provider with whom you feel confident and compatible. When it comes to pregnancy and birth, there are two types of care to choose from: the midwifery/physiologic model of care and the medical/interventionist model of care. It is very important to note that 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. For this reason, some people believe it is more accurate to refer to the different models of care as a physiologic model (that is, care in accord with the normal functioning of the client’s body) versus an interventionist or pathology-driven model.

The Midwifery/Physiologic Model of Care:
This model of care is founded on a deep respect for the normalcy of birth and for the uniqueness of each childbearing person and their family. This approach to care promotes health and helps prevent complications. Care providers who practice this model of care have excellent outcomes while providing safe individualized care. Unique aspects of this type of care include:

  • Monitoring the physical and psychological well being of the client throughout the childbearing cycle.
  • Attending to the emotional, social, and spiritual aspects of childbearing.
  • Providing the client with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support.
  • Minimizing technological interventions, and only using them when necessary and indicated.
  • Identifying and referring clients who require obstetrical attention.

The application of this client-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean birth (May 1996, Midwifery Task Force).

The Medical/Interventionist Model of Care:
This type of care is founded on the belief that medicine and interventions improve upon the physiological processes of pregnancy and birth. This model is focused on the physical and biological aspects of specific diseases and conditions, and therefore treats pregnancy and birth as pathological conditions. 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 people and babies with complications. However, routine interventions on people 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 uncomplicated pregnancies and births.

In the U.S. there are two kinds of midwives. The difference is in how they were trained and where they ultimately end up offering care.

Certified Nurse Midwives (CNMs) are nurses before completing midwifery training. Certified nurse midwifery training programs are masters or doctorate level programs, usually at accredited universities. Most CNMs work in hospitals as part of large OBGYN practices, although there are some working in birth centers or independently as homebirth midwives. CNMs do well-person care, reproductive health care, and full-spectrum pregnancy, birth, and postpartum care. CNMs are licensed to practice in all 50 states. They are often licensed in individual states as Nurse Practitioners (NPs).

Direct-entry midwives are educated or trained as midwives without having to become nurses first. They may be Certified Professional Midwives (CPMs) or Certified Midwives (CMs). Most direct-entry midwives work in birth centers or do homebirth. The legal status and requirements for direct-entry (non-nurse) midwives vary from state. They are usually licensed in individual states as Licensed Midwives (LMs) or Registered Midwives (RMs). The Midwives Alliance of North America (MANA) tracks the laws and regulations in each state for direct-entry midwives.

There are several types of doctors that are medically trained to provide prenatal care and attend births. Family practitioners and obstetrician-gynecologists (OBGYNs) are some of the most popular medically trained doctors that people choose for pregnancy and birth care.

Family practitioners are primary care doctors. They care for a broad spectrum of medical conditions, from earaches in children to heart failure in older adults. Family practitioners usually have three years of training beyond medical school. They generally have a broad range of knowledge on a variety of different disciplines of medicine. Although the training and certification process for most family practitioners is very similar, some choose to emphasize obstetrics and undergo additional training. In rural areas, there may be no OBGYN nearby, or there may be only a few to choose from. It’s common for family practitioners in rural areas to perform most deliveries. However, some family practitioners do practice and deliver babies in major urban or university centers as well. They can take care of you, your baby, and your partner as well.

OBGYNs take care of most pregnant people in the U.S. OBGYNs are doctors who have completed four years of training in the field of obstetrics and gynecology beyond medical school. These doctors are trained to provide a wide range of healthcare services. They can range from normal to complicated obstetrics. Their main focus is on pregnancy and women’s health concerns.

Maternal-Fetal Medicine is a subspecialty of obstetrics and gynecology. Maternal-fetal medicine doctors are sometimes called perinatologists. In addition to completing traditional medical school, they have completed a four-year standard training program in obstetrics and gynecology. They also have completed an extra two to three years of specialized training in dealing with problem or high-risk pregnancies. In the U.S., they are board-certified in both specialties. Maternal-fetal medicine specialists offer specialized care for pregnant people and their fetuses, and are trained to help when pregnancies are not routine. Special cases can include:

  • twin or multiple births
  • preeclampsia
  • hypertension
  • chronic health problems
  • a fetus with abnormal growth or birth defects

Your Birth Location

Your environment sets the tone for your birth experience. Each location has challenges and benefits worth exploring.

Today, most people in the U. S. give birth in hospitals. However, this is not the only option available. People also give birth in freestanding birth centers, hospital-based birth centers, or in their own homes. Be aware that some hospitals use the term “birth center” to refer to their regular labor and delivery unit. The American Association of Birth Centers defines a birth center as a home-like setting where care providers, usually midwives, provide family-centered care to healthy pregnant people. Most birth centers are located separately from hospitals, while a few are physically inside hospital buildings. In-hospital birth centers must meet certain standards for independence and must be separate from the labor and delivery unit in order to be considered true birth centers. A landmark study published in the Journal of Midwifery and Women’s Health, shows that birth centers provide first-rate care to healthy low-risk people in the U.S. Similarly, the largest study of planned homebirth in the U.S. to date shows that homebirth with trained midwives is safe for low-risk expectant parents.

Where you choose to give birth will depend on your birth philosophy. If you’d like an unmedicated, unhurried birth, consider having your baby at home or at a birth center. If you’re working with a doctor, you will probably give birth in a hospital.

A comfortable environment is going to help you stay relaxed and this is crucial in allowing the physiologic process of labor to occur. An intricate blend of hormones is released during labor—some are helpful, but others can be counterproductive. Fear and stress may “stall” labor and create a need for medical interventions. If you do choose a birth environment other than your home, consider laboring at home as long as possible, and explore ways in which you can make the transition to the birth center or hospital as seamless as possible.

One important resource that you can use to evaluate a birth location (and by extension the care providers who practice there) is the Mother-Friendly Childbirth Initiative. This is a document that will help you evaluate your current care provider and birth location to see if they are offering evidence-based care that is proven to be beneficial for mothers and babies.

Making an Informed Decision About Your Care Provider and Birth Location
Now that you know a bit more about the types of care providers and birth locations available, it’s important to consider if you feel comfortable with the person and place you have chosen. How will you know if you’re getting good, evidence-based care? Here is a list of some signs that you can trust the care you are receiving.

If you go through that list, and come away feeling doubtful, or even downright disappointed, don’t despair! Don’t be afraid to talk with your birth partner about possibly switching care providers and/or birth locations. Even if you are already close to or past your due date, it’s not too late to switch! Your care provider and birth location are integral components of your birth experience. You owe it to yourself and your baby to decide if they make you feel safe, respected, and comfortable. A care provider that won’t talk with you about your questions and concerns is a red flag!

Most care providers offer a free consultation interview so that you can get to know each other, answer/ask questions, and get a feel for each other’s personality and style. Similarly, birth centers and hospital labor and delivery units offer tours so that you can see the facility and get a feel for what birthing there may be like.

Register for my online childbirth class to access guides for interviewing potential midwives and doctors and to learn about more red flags that indicate you’re not receiving evidence-based care.