The Joy of Pregnancy
Choosing a Doctor or Midwife
You will probably have your first prenatal visit somewhere between seven and nine weeks’ gestation. If you haven’t yet chosen someone else to attend the birth, this visit may be with your regular obstetrician-gynecologist, nurse-practitioner, gynecologist, or family-practice physician. If you are selecting a new doctor or nurse-midwife, you may have to wait a few weeks for the first prenatal appointment. Often, the appointment is set for nine weeks into your pregnancy.
If you don’t yet know who will care for you in your pregnancy, your first task may be to sort through job titles and their meanings. Most hospital births are attended by obstetrician-gynecologists; some gynecologists, however, do not practice as obstetricians. Formerly, most family-practice doctors attended births, but many have stopped because of the high cost of malpractice insurance. Nurse-midwives attend approximately 8 percent of hospital deliveries, and some attend birth-center and home births. Other home-birth midwives may be described with a variety of terms. Nurse-practitioners work with physicians and frequently help provide prenatal care, but they do not attend births.
Let me outline the basic differences among birth practitioners:
Obstetrician-gynecologists (OB-GYNs). These medical doctors specialize in the reproductive care of women. After medical school, OB-GYNs complete four years of specialized education and training in obstetrics and gynecology, including surgery.
Family practitioners. These medical doctors specialize in family medicine, which may include pregnancy and birth. After medical school, their training involves all aspects of general medical care for adults and children. Family practitioners care for women during normal pregnancies and deliveries, and for the babies.
Certified nurse-midwives (CNMs): These birth practitioners are registered nurses who have earned a graduate degree in nurse-midwifery. The graduate program involves specialized training in caring for women during pregnancy, labor, and the weeks after birth. CNMs work with healthy women who have normal pregnancies and labors. Should a medical problem arise, a CNM consults with a backup physician.
Direct-entry, empirical, or lay midwives. These terms all refer to midwives who have entered the profession directly, through study and apprenticeship, without becoming nurses first. A certified professional midwife has passed rigorous tests and has received a certificate from the North American Registry of Midwives (NARM). Several states license direct-entry midwives; other states do not. Direct-entry midwives provide prenatal care for healthy women and attend normal births in homes and in out-of-hospital birth centers.
Finding the right practitioner can be a daunting task. Your regular practitioner may recommend someone, and you can ask your friends for suggestions or search the phone book for possibilities. Some large clinics provide formal assistance in choosing from their practitioners, and hospital labor nurses may provide recommendations. You may need to select a provider who is covered by your insurance plan, which may also limit your choice of birth setting. Before scheduling an appointment, you’ll want to find out where the practitioner attends births and confirm that he or she works with your insurance company.
Every woman is unique in what she needs and expects from her health-care provider. As you collect referrals, consider these questions:
· Is your personal style suited to someone formal and businesslike, or would you prefer someone who runs a smaller practice and who will spend a lot of time with you?
· Would you feel more comfortable with a woman or a man, or does the person’s sex not really matter to you? (I must mention that some of the most sensitive physicians I know are men. Also, I work with one of the only male nurse-midwives in the country, and he is in high demand!)
· How important is it to you that the same person who provides your prenatal care also attends your baby’s birth? If your practitioner is in a group practice of doctors or midwives who alternate the times they are responsible for night or weekend births, any member of the group may end up as your birth attendant. If a nurse-practitioner provides your prenatal care, an obstetrician will attend the birth. If you choose a midwife but face complications in pregnancy or labor, your midwife may refer you to a backup physician.
· What kind of birth experience do you want? For example, do you want an unmedicated delivery, or do you think you’ll want an epidural? You’ll want a practitioner who has assisted other couples through the same kind of birth experience.
It is important that you feel comfortable with the philosophy of your chosen practitioner and confident in his or her skills. In talking with many women, I have found that the most important aspect of the relationship between a pregnant or laboring woman and her practitioner is trust. Whether a woman has an unmedicated birth, an epidural, or an unplanned cesarean birth makes little difference in how good she ultimately feels about the experience. The important thing is whether she felt trust in her providers and in the care she received.
To help establish this trust from the start, you might ask your prospective doctor or midwife some of these questions:
· How long is a typical office visit?
· How many births does the practitioner, or group of practitioners, manage each month?
· What are the practitioner’s feelings and practices regarding fetal monitoring, epidurals, and other medications in labor? How about episiotomy, cesarean birth, and breastfeeding?
· In what situations does the practitioner induce labor? Is labor routinely induced if it doesn’t begin spontaneously before 41 or 42 weeks?
· What percentage of the practitioner’s clients give birth by cesarean? What is the cesarean rate for the entire practice?
· At what point in labor does the practitioner arrive?
· If the practitioner is a doctor, does the practice include certified nurse-midwives?
· Will you meet everyone in a group practice before the baby is born?
· If you have a question or a problem, how do you reach the doctor or midwife?
Many doctors and midwives are too busy to provide personal interviews before a first exam, but some of your questions can be answered on the phone. Your first prenatal visit will be the time to ask the rest of your questions. I recommend writing them down before your visit. The conversation should help you decide if this is the right practitioner for you—if you feel confident in his or her qualifications and abilities, and if he or she will provide the kind and degree of support you would like. If you decide that this practitioner isn’t right for you, it will still be early enough in your pregnancy to make a change.