Friday, May 24, 2013

Childbirth Choices Series Part I: I've Just Found Out I'm Pregnant; Now What?

This is the first in a series of posts that I plan to enhance into an online course along the same lines. The goal is to educate women before they become pregnant, or when they are newly pregnant, about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:

Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

Choosing a Care Provider

Once you've gotten a positive home pregnancy test or a blood test confirming that you are, indeed, pregnant, one of your first steps will be to choose a care provider (CP). By care provider, I mean the person or persons who will handle your prenatal care and help you deliver your baby.

I've described below the three main types of care providers available in most states to provide maternity care. Before you can choose a CP, you'll need to decide what you're looking for when it comes to your prenatal and maternity care. I suggest you talk to friends and family members who have given birth to find out about their experiences with their CPs and the birth(s) of their child(ren). You may find that attitudes vary widely, from those who prefer a medical approach to birth to those who want a more hands-off, back-to-nature style. If you're not sure what you want, it will pay off to do some research and talk to people who have made various choices, and, most importantly, discuss why they made those choices. Your options and decision will also depend on your location. For example, you may have a Baby-Friendly hospital nearby that provides excellent maternity care. Or, your local hospital may have a dismal maternity record, but there is a birthing center not far away that is very highly rated. I'll get into where you might want to give birth right after the discussion about CPs.

Obstetrician (OB)

An OB, or obstetrician, is the type of care provider most of us think about when it comes to pregnancy. An obstetrician is a medical doctor who specializes in maternity care, including prenatal care and delivering babies, either vaginally or via cesarean section, as well as postpartum care. Most OBs also handle general gynecological issues and regular GYN checkups. OBs typically work in an individual or group practice and deliver babies at a local hospital at which they have privileges.

Why Might I Choose an OB?

As mentioned, an OB is the most commonly selected option in the United States when it comes to maternity care. Many women will simply continue to see the same doctor they have been seeing for their regular GYN care. If you are comfortable with your current OB/GYN and feel that your needs and desires for your maternity care are being addressed, then sticking with a provider you already know can be a great option. An OB can oversee your pregnancy and delivery, and it may be comforting to you to have a medical doctor and surgeon with you at delivery and throughout your pregnancy.

Why Might I Not Want an OB?

Depending on what you're looking for in your prenatal and maternity care, you may find that OBs tend to be clinical and traditional when it comes to how they view birth. This is not a blanket statement about OBs, because I know of many OBs who believe strongly in the course of normal birth and are not so quick to offer interventions. However, often OBs think in medical terms and will take a clinical approach to your care, meaning that they will be more likely to recommend interventions, medications, and tests. For some women, this is comforting and familiar and will be attractive. For others, they may want to look for either a non-traditional OB or investigate another care provider, such as a Certified Nurse-Midwife.

Certified Nurse-Midwife (CNM)

Another option for maternity care is a nurse-midwife (CNM). A CNM is a registered nurse who has gone on for special training in prenatal and maternity care, as well as general gynecological care. A CNM is not a surgeon and cannot perform a cesarean section. She (or he) can deliver a baby vaginally as well as order the use of certain medications and tests during pregnancy and delivery, if indicated. CNMs may work privately or in group practices or may be affiliated with a particular hospital or birthing center. Some CNMs work independently or in a group offering home birth services.

Why Might I Choose a CNM?

Midwives tend to take an approach to pregnancy and birth that is less medically oriented. This means they will be more likely to view pregnancy, labor, and delivery as a natural process rather than as a medical issue that needs to be addressed. Women who are interested in having a "natural" (non-medicated) birth, or who are looking for a CP who will take a more holistic approach to their care, may find a CNM an attractive choice. Please note that a competent CNM can and will monitor you and your baby throughout your pregnancy and labor and will know if it is necessary to recommend emergency intervention by an OB.

Why Might I Not Want a CNM?

First of all, CNMs generally cannot take high-risk cases, so if you have a high-risk pregnancy, a CNM may not be able to take you on as a patient. It may also be the case that you cannot find a CNM who can deliver in the venue you've chosen. For example, you may want to deliver in a hospital, but the hospital you go to may not allow CNMs to oversee deliveries. Also, if you have any concerns about the need for medical or surgical interventions during your pregnancy or delivery, you may be more comfortable with an OB.

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

A Licensed Midwife is a practitioner who specializes solely in maternity and women's health services and is licensed by a particular state's medical board. A Certified Professional Midwife (CPM) is a midwife who has been certified by the North American Registry of Midwives. Similar to a CNM, but not a registered nurse, a midwife can provide prenatal and maternity care, deliver babies, and order medications and tests, as needed. She cannot perform surgery. Not all states recognize or license midwives. In some states, out-of-hospital midwifery is illegal. You will need to find out what the options and laws are in your state if you wish to work with a midwife. Most LMs and CPMs work outside of the hospital setting, often offering home birth and home care services.

Why Might I Choose a Midwife?

A midwife will likely be similar to a CNM when it comes to practice and philosophy. Midwives typically work with low-risk women and babies in the normal course of pregnancy and childbirth. Their services are typically low-intervention and focus on pregnancy and birth as a normal process that may require assistance but not necessarily medical or surgical action.

Why Might I Not Choose a Midwife?

If you prefer to deliver in a hospital or a birth center affiliated with a hospital, you may not have the option of a midwife other than a CNM. A competent midwife will have the necessary equipment, medications, and knowledge to assist with birth, and she will also be able to determine if the mother and/or baby need to be transferred to a hospital for medical or surgical intervention if there is a problem. However, if you are more comfortable delivering in a hospital setting, or you feel strongly that an M.D. should attend your birth, for whatever reason, the option of a midwife may not be attractive to you. And, as stated above, midwifery is illegal in some states.

Do I Want a Group or Individual Practice?

You'll also need to decide if you want to see a CP who works privately or one who is part of a group practice. There are advantages and disadvantages to each.

With a CP in an individual practice, you'll be certain to see the same person at every prenatal appointment, and if you deliver your baby during your provider's working or on-call hours, you'll be certain that he or she will attend your birth. However, if your CP is not available at that time, you will be seen by whichever provider is on-call when you're ready to deliver. Some individual practitioners try to make it a point to be available to all of their patients. This is something you'll want to discuss with your provider at an early appointment.

With a group practice, there are several providers who work together. The advantage to this is that there is a good chance that one of the CPs from the practice will be available/on-call when you have your baby. If you choose a group practice, you'll probably want to schedule appointments with each provider in the group so that you can get to know each of them, so that whoever does end up delivering your baby won't be a stranger.

Choosing a Venue

As you can see, the choice of care provider and venue are closely intertwined. If you want a midwife and a hospital, you'll need to find a hospital that allows midwives to attend deliveries, and you'll need to find a midwife who has privileges at that hospital. If you want an OB and an unmedicated birth, you'll probably need to give birth in a hospital, but you'll want to choose an OB and hospital who will be supportive of your wishes. You will also need to check your state's laws concerning midwifery and home birth, and find out the availability of a birth center near you. You'll want to research your local hospitals to find one that fits best with your needs and desires. Some women will find that there doesn't appear to be a "perfect" or even a "good" option that fits with her ideals, and for those women, being armed with knowledge and research will be especially valuable.


Over 98% of American women give birth in a hospital. Many women may not even be aware that there are options other than a hospital birth. Hospital birth is seen as the norm in the United States. Most hospitals have a Labor & Delivery unit where women come to labor and give birth, then stay for an average of two to four days (depending on the method of birth and if there were any complications) while they and their babies are cared for by doctors and nurses on the hospital staff.

Why Might I Choose a Hospital to Give Birth?

As mentioned, hospital birth is considered by most to be the "normal" and expected choice for women in the United States. Nearly all women deliver their babies in a hospital setting. In a hospital, you'll be certain to have access to an operating room, if necessary, medications and anesthesia, if you want them, and nurses and doctors for both mother and baby. A hospital will be prepared with personnel and equipment for dealing with most complications of birth and the neonatal period. In a hospital, you will have the reassurance that, should something (G-d forbid) go wrong, you're in a place that can help you.

What Hospital Should I Go To?

The temptation is typically to go to the nearest hospital to your home that has a Labor & Delivery unit. No one relishes the idea of a long car ride or cab ride while in labor just to get to the hospital, and there's always that fear of giving birth on the way if the hospital is far. However, when choosing a hospital, it's important to know a few details.

- Do they have a well-equipped NICU?
Since a major reason for choosing to give birth in a hospital is the comfort of being there "just in case," it's important to know that your baby will be well cared for if there are complications. If the hospital you choose does not have a NICU and you have need of one, then your baby will have to be transported to a different location for care, and you may be separated for several days. If you have the option, giving birth in a hospital with a respected NICU may be important to you.

- What is their rate of cesarean section compared to vaginal births?
If a hospital has a high cesarean rate (and you'll have to decide for yourself what "high" is), there is a higher chance that you may be pressured into a c-section that you didn't necessarily want or need. Over 32% of babies today are delivered via c-section, and most authorities and experts agree that this number is too high. A hospital with a lower c-section rate likely first turns to methods of managing your care during labor that will reduce your risk of c-section, while a hospital with a higher c-section rate likely jumps straight to surgery as an answer to problems or blips that may not actually be emergency situations. You can investigate a hospital's cesarean rate and learn more about c-sections by visiting

- What is their policy on rooming-in? Do they have a nursery in the Postpartum ward?
Research shows that rooming-in with your new baby - keeping your baby in the room with you at all times, rather than having him/her cared for in a nursery - facilitates breastfeeding and bonding and is healthier for mom and baby, assuming neither suffered major complications during labor and delivery (which the majority do not). Find out what your hospital's policy is on rooming-in. Some hospitals do not even have a nursery for healthy babies and require that the baby remain with the mother if there are no extenuating circumstances. Others will require that the baby is kept in the nursery at night and brought to the mother only for feedings. Some hospitals will offer each family a choice between using the nursery and rooming-in.

- What kind of breastfeeding support do they offer?
If you plan to start out breastfeeding - as the majority of new moms do - you'll want to know what kind of breastfeeding support your chosen hospital offers. Do they have a high rate of suggesting formula supplementation in otherwise healthy babies? Do they offer the use of a hospital-grade breast pump if needed? Are babies supplemented with bottles or formula without the parents' consent? Are there lactation consultants on staff who are available to new mothers on the postpartum ward? Are the maternity nurses trained in basic breastfeeding support? These are important questions, which you can ask on your hospital tour, ask of friends who have given birth there, and look for more information about online. Research shows that good breastfeeding support in the hospital fosters continued breastfeeding success after mom and baby go home.

- Are they Baby-Friendly?

"Baby-Friendly" is an official designation given by the Baby-Friendly Hospital Initiative (BFHI), an initiative of UNICEF to improve breastfeeding rates and increase exclusive breastfeeding duration. Only 6.7% of births in the United States currently occur in a Baby-Friendly designated hospital. There are 159 Baby-Friendly hospitals in the United States as of January 2013. You can find out if there is a Baby-Friendly hospital near you by visiting this site. A Baby-Friendly hospital will follow all of the 10 Steps to Successful Breastfeeding that evidence has shown to increase the rates and duration of successful exclusive breastfeeding. Some hospitals are working toward the Baby-Friendly designation and may follow some or all of the 10 steps even if they have not received the official title. You can ask if your chosen hospital follows any or all of these steps, as this can greatly affect your birth and postpartum experience at the hospital.

Why Might I Not Want to Give Birth in a Hospital?

There are many reasons why you personally may not want to give birth in a hospital. Reasons some women cite for not wanting to go to a hospital include fear of hospital-borne infection, fear of doctors, fear of hospitals due to previous trauma, or lack of a good hospital close to home. Some women, rather than an issue of a specific reason not to want to be in a hospital, simply want to give birth in another setting. Many women feel that hospitals are for sick people, and pregnancy and birth are not diseases that need to be treated. In a hospital, you are more likely to be offered interventions such as epidurals, Pitocin, and constant monitoring, and your risk of c-section is likely higher.

Home Birth

A home birth is just what it sounds like: giving birth at home (usually your home). Typically, you hire a midwife or team of midwives to attend you prenatally and at delivery. The midwife will advise you how to set up your home for the birth. When you are in labor, she (or they) will come to your home and monitor you as you labor, help you with techniques for pain management and positioning of the baby, and assist with the delivery. A midwife will have equipment to allow her to listen to your heartbeat and that of the baby, to check your blood pressure, to give you an IV of saline or medication if needed, and can make the call that transfer to a hospital is necessary if an emergency situation should arise.

Why Might I Choose a Home Birth?

I'll preface this by saying that home birth is not legal in every state, and many states have regulations about where your home has to be in relation to a hospital if you choose the home birth route. If you're thinking about a home birth, make sure it is an option where you live.

Although fewer than 1% of births in the United States occur at home, the number is rising quickly. Women who choose home birth give a few reasons for their decision. One is that they enjoy being in the comfort of their own home, feeling that being in a familiar environment helps them to relax and give birth in a peaceful state of mind. At home, you may feel you are more in control of your birth, able to make decisions about where in your house (bed, bathtub, special birthing tub, backyard) you feel most comfortable, what position to give birth in, and to avoid medications and interventions. Women who choose home birth also like that they can have their family around them (or not, as desired). Some like the idea of older siblings being present for the birth, for example. Also, if you give birth at home without complications, you don't have to suddenly pick up and go anywhere: you're already home!

Why Might I Not Choose a Home Birth?

There are many reasons you may not want a home birth. Many families are uncomfortable with the idea of not being in a hospital if an emergency should arise. Some are worried about the mess or feel that their home is just too small for comfort. Some desire an epidural or other medication options, which they would not have in a home birth situation. Also, if you have a high-risk pregnancy or birth, you are not a good candidate for home birth, as your risk of requiring emergency interventions is higher, and these cannot be provided at home by a midwife. Some women simply like being in the hospital, recovering on the postpartum floor, and having a couple of days to be waited on by nurses.

Birth Center

A happy medium if you're torn between a hospital birth and a home birth may be a birth center. Birth centers are typically free-standing facilities that strive for a home-like feel, employ midwives for prenatal and delivery care, and promote a non-intervention birth environment. Some birth centers are within hospitals or on hospital grounds, while others are independent.

Why Might I Choose a Birth Center?

If you are striving for a low-intervention or unmedicated birth but you don't want to or cannot give birth in your home, a birth center may be a good option for you. At a birth center, you will typically be attended by midwives who will help you manage the pain of labor, ensure the baby is in a good position, and assist with delivery. You and your baby will be monitored as needed. Many birth centers will offer the option of giving birth in a tub, in a bed, or in whatever position is comfortable for you. You generally will not stay long after your baby is born, just long enough to ensure that you both are healthy, perhaps eight hours or so after the birth, so if you don't want to be away from home for long, this may be another reason to select a birth center.

Why Might I Not Want to Give Birth in a Birth Center?

As with home birth, if you have a high-risk pregnancy, a birth center may not be able to take you on as a patient. Birth centers typically do not have emergency services such as a ready OR or a NICU. If you would like the option of epidurals and other medications, a birth center will generally not offer these, and you may want to consider a hospital instead. Also, if you want to stay longer after giving birth, a birth center will not have the facilities for you to spend several nights there like you would at a hospital.

Making Your Choice

The best way to get most of this information is word-of-mouth from friends and neighbors who have given birth in the last few years. You may also want to join an online community to get more perspectives, or attend a support group meeting such as La Leche League or ICAN where you can learn about options you may not have considered and hear from individual women about their own experiences and why they made the choices they did.

You will also probably have financial considerations when it comes to making your decision. Find out what your health insurance will cover, as you may be limited in your options of hospital and care provider. You'll want to find out what your out-of-pocket share will be. Some insurance companies will cover the services of a midwife and a birth center birth, although most will not cover a home birth - you'll need to find out if this is the case with your insurer. It is important to know that typically the fees for a home birth and the services of a midwife are considerably lower than a hospital birth with an OB, and if your out-of-pocket commitment with your insurance company is high, paying for a home birth in cash may not be much of a difference. You should also consider the importance of a healthy pregnancy and birth for yourself and your child.

Be aware that you may switch care providers and venues far into your pregnancy. If you have made a decision and are not happy with it, even if you're 30 weeks along already, it may be worth investigating other options so that you can be satisfied with your experience.

For the record, I've had three babies, all in a hospital setting. My first was with an OB in a well-respected hospital near my home. I got my referrals from neighbors and friends who had recently given birth at that hospital and were happy with their experience. I didn't know what my other options were, and the most important thing for me at the time was to be in a hospital close to home. Because I had complications and hemorrhaging with my first, and because my first was a c-section birth, my husband and I both felt that it was important that I give birth in a hospital in the future as well. With my second and third babies, I knew about the options of home birth or birthing centers, and I knew about the option of using a midwife rather than an OB. My health insurance HMO did not give me many options of care providers or birth locations, but the hospital where I gave birth to my second and third sons was excellent and had achieved Baby-Friendly status by the time my third was born. My care providers were mostly CNMs, and I appreciated their approach to pregnancy and birth. An OB delivered my second baby, and my third was delivered by a CNM. I was very pleased with both experiences.


More articles in this series:

Part II: Meeting Your Care Provider
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

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