(descriptions of care provider types and questions adapted from Pregnancy, Childbirth and the Newborn – by Simkin, Whalley and Keppler)

Choosing your caregiver (doctor or midwife) is usually the single most important choice you will make in planning for your birth. Yet most women spend more time picking out a car or a crib than the care provider for childbirth. Usually a woman will choose her provider out of the phone book, or ask friends who they used and use their friends’ provider, whether or not their friends’ desires for birth matched their own. At the first meeting, most women do not take the time to ask questions of a provider to see if his or her philosophies mesh with their needs. Or, women often wait very late, when birth is eminent, to discuss needs, for instance, when discussing a birth plan. Usually by this time women feel it is too late or too much of a hassle to switch providers if something comes up that signals their providers’ philosophies do not match their needs and desires.

You are an individual, and your needs are individual and important. Take the time to choose carefully. But before you can choose your caregiver, you must determine what sort of birth you want.

• Do you trust your provider to make medical decisions for you, or would you like to take equal part of your care and decision-making?
• Do you have any special circumstances (such as high blood pressure or diabetes) that might put you in a high risk category?
• Do you desire a more medically managed birth, or a less interventive, more natural birth?
• Do you have any special circumstances, such as a history of abuse or a fear of birth, that would be better managed by a gentler, more holistic approach?
• Where do you want to give birth - in a hospital, birth center or in your home? (Home birth is legal in Washington state, and many studies have shown that both hospital and out-of-hospital birth are equally as safe for low-risk women attended by a skilled provider.)
• If you desire a hospital birth or birth center, what are there standard protocols? (A phone call or visit to the hospital or birth center can be made to find out.) Which providers have privileges at the hospital or birth center you desire?
• Would you prefer a single caregiver or a group? (Sole practitioners increase the likelihood that your provider will be present at your birth, but your appointment times will have to be more flexible as they are often attending births during office hours.)
• What options are available in your area? (All of the below options are available in the Tri-Cities.)

Once you have determined the answers to the above questions, the next step is to choose the type of provider you would like. It should be noted that there are both good and bad doctors and midwives in the world, and the below descriptions are generalities of how they practices, but only through intensive dialog can you determine the philosophies and procedures they individually practice.

Certified Nurse Midwives (CNM) have a four-year bachelor’s degree from a school of nursing, as well as having completed a minimum of two years of additional training in midwifery in order to get their master’s degree in nursing, and received licensure by the state. After attending an educational program accredited by the American College of Nurse-Midwives Certification Council (ACC), they must pass the ACC examination and can be licensed in our state. Their education and the care they provide focus on normal health care during the childbearing year, psychosocial and emotional aspects of childbearing, parent education, prevention of and screening for possible problems, and newborn care, as well as the primary care of non-pregnant women. They specialize in the care of women with uncomplicated, normal pregnancies and births. Referrals are made to a physician when needed. To become certified, they must pass an exam administered by the American College of Nurse-Midwives. They deliver babies in a variety of settings - homes, hospitals and birthing centers.

Licensed Midwives (LM) have completed formal training from an accredited midwifery program, are legal in the state of Washington and are licensed by the state. The focus of their education and care is similar to that of certified nurse-midwives, although a nursing background is not required of a licensed midwife. Referrals to physicians are made when needed. To become licensed in Washington State, they must complete the educational requirements and pass an exam administered by the North American Registry of Midwives. Most licensed midwives provide care only for women planning out-of-hospital births in homes or birth centers.

Certified Professional Midwives (CPM) have received formal or informal training from a variety of sources including apprenticeship, school, and self-study. They practice outside of the hospital and their care is similar to that of licensed midwives. They must pass an exam administered by the North American Registry of Midwives (NARM). In our state, certified professional midwives’ services are reimbursable through Medicaid and private insurance carriers if they are also licensed by the state – check with your insurance company.

Advanced Nurse Practitioners provide prenatal and postpartum care, although they do not care for women during labor (they don’t catch babies). They are registered nurses with advanced training who have completed the requirements set by their state government and nursing board. They often work in a clinic or group with one or more physicians or midwives.

Obstetrician/Gynecologists (OB/GYNs) have graduated from medical school, had three or more years of additional training in obstetrics (medical care before, during and after childbirth) and gynecology (medical care of women). Much of their education focuses on detection and treatment of obstetrical and gynecological problems. To qualify for board examination, they must pass an exam administered by the American College of Obstetricians and Gynecologists (ACOG).

Perinatologists are obstetricians/gynecologists who have received further training and certification in managing high-risk pregnancy and birth. They often consult with or accept referrals from other physicians and midwives. These specialists practice only in major medical centers in urban areas. Perinatologists in the Tri-Cities do not deliver babies, but consult with other care providers in high-risk cases.

Family physicians have graduated from medical school and have completed two or more years of additional training in family medicine, including maternity care. Their education focuses on the health care needs of the entire family. They refer to specialists if their patients develop serious complications. To qualify for board certification, they must pass an exam administrated by the American Academy of Family Physicians. Not all family physicians include maternity care in their practice.

Naturopathic Physicians (NDs) are a graduates of a four-year, residential graduate program in naturopathic medicine. They are educated in all of the same sciences as an MD but also study holistic and nontoxic approaches to therapy with a strong emphasis on disease prevention and optimizing wellness. In addition to a standard medical curriculum, the naturopathic physician is required to complete four years of training in clinical nutrition, acupuncture, homeopathic medicine, botanical medicine, psychology, and counseling. In Washington State, naturopathic doctors are required to graduate from a four-year, residential naturopathic postdoctoral board examination (NPLEX) in order to have a license. Some naturopathic physicians have additional training in midwifery and may or may not hold state licensure in that area. Not all Naturopaths practice midwifery.

The Interview

Now that you have decided what type of provider is right for you, it is time to meet a few providers and ask them some questions. As early as possible in the relationship with your caregiver, or ideally before you choose your caregiver, ask questions to determine the likelihood that your needs in pregnancy and birth will be met. To make sure you feel comfortable in asking your questions, it may be beneficial to keep your street clothes on for this initial meeting. Since time is a factor, you could ask if the complete physical examination could be deferred until your second meeting.

It is important to ask specific questions instead of generalities. So instead of asking “will I have to have an episiotomy?” you could ask, “In the last ten births you have attended, about how many women who delivered vaginally received an episiotomy?” or “How do you help your patients avoid tearing and episiotomy?” If your question is answered with “I only do that when necessary,” consider that an inadequate response. Follow up with, “And how often do you find it necessary?”

As you discuss these questions, listen as much to how the caregiver answers as to what he or she actually says. Is the caregiver impatient and defensive with your or open and comfortable with questions? Do the answers satisfy you? Does this person inspire your confidence and trust? Do you feel your caregiver is making decisions with you, or without you? Often your overall feeling about the interview will provide as much information as the direct answers to your questions. An interview like this will help you discover how the caregiver feels about prospective parents who take their responsibilities seriously.

Possible Questions to Ask

• What do you see as my role and responsibilities during pregnancy and childbirth?
• Are there any restrictions on my partner being with me throughout labor and vaginal birth? During a cesarean birth? During my hospital stay?
• How do you feel about other family members (children, grandparents, and so on) or friends attending prenatal appointments or being present at the birth?
• How do you feel about a doula being present during my labor during a vaginal birth? A surgical delivery (cesarean)?
• What are your specific guidelines for nutrition during pregnancy (foods to eat/avoid, weight gain, and so on)? Do you provide nutritional counseling? Do you have specific recommendations on exercise, sex, and the use of medications and drugs (including over-the-counter; caffeine, tobacco, and alcohol; and other street drugs)?
• What are your feelings about childbirth preparation classes? Do you have any specific classes that you recommend? Any you discourage? Why?
• What are your feelings about natural, nonmedical childbirth? Approximately what percentage of your patients is interested in having an unmedicated childbirth? How many of those actually have it?
• Do you have routine standing orders for your patients in labor about IV fluids, pain medications, and so on? What are they? (Additionally you can call the hospital and ask about that doctor’s standing orders.) Can these routines be altered to conform to my needs and desires? Would you encourage and help me prepare a birth plan? Will you check my birth plan for safety and compatibility with your practice and hospital policies?
• What are the chances you will be present when I deliver? If you are not there, who covers for you? Will I have a chance to meet that person? Will that person respect the arrangements I have made with you? Will the hospital staff?
• How often and under what circumstances do you find it desirable or necessary to use labor induction or augmentation, IV fluids, artificial rupture of the membranes, continuous electronic fetal monitoring, episiotomy, forceps, and vacuum extraction?
• What is your cesarean rate? What are the most common reasons for cesareans among the women in your practice? What, if anything, can I do before and during labor to help reduce the likelihood of a cesarean?
• If I should develop complications during pregnancy or labor, would you manage my care? If not, to whom would you refer me?
• What usually happens to the baby immediately after birth? Does the baby go to the nursery or may she stay with us? May I/we hold her for initial assessments? Who will examine the baby after birth? When is this usually done?
• What is the usual hospital stay after a vaginal birth? Cesarean birth?
• Is follow-up care routinely available for me and the baby? If so, how soon after discharge may I expect the follow-up? Who initiates the follow-up? Would it include home or clinic visits with a nurse, midwife, or doctor, or just phone follow-up?