Midwife or Doctor? Two Leading Practitioners Help You Choose
Photo: Jill Velazquez, This is Family Photography.
We’re honored to launch the BirthGuide Blog with advice from two preeminent, thoughtful and very generous Chicago-area practitioners.
Gayle Riedmann, CNM
Maura Quinlan, MD
Maura Quinlan, MD, is immediate past Chair and current Legislative Chair of the Illinois chapter of the American College of Obstetricians and Gynecologists (ACOG), the leading professional organization for obstetricians.
Gayle Riedmann, CNM, is the President of the Illinois Affiliate of the American College of Nurse-Midwives (ACNM), the leading professional organization for certified nurse midwives.
Maura and Gayle share their insights on finding a midwife or doctor who will be a good fit for you.
How do I decide between having a doctor or a midwife?
Maura: For most women, there’s more than one kind of provider who’s qualified to deliver your baby. As long as you’re low-risk, as most women are, this notion that you must see an OB is not right. So it’s important to ask yourself, “What do I envision this to be like, what do I want?” And then ask yourself, “Who will help me to make that happen?”
Is it important to you to have an unmedicated birth? Midwives are typically accustomed to managing a single labor at a time, they may have longer appointment times, they’re expert at managing an unmedicated labor. If you’re low-risk and if a natural childbirth is important to you, then a midwife could be a good choice.
If you are considering a midwife, you do need to know that right now, the only midwives who can practice legally in Illinois are certified nurse-midwives (CNMs). All the midwives who work in hospitals and birth centers are CNMs, and they are fully licensed and credentialed. But some of the midwives who attend home births are not CNMs, and they are not practicing legally. As the head of Illinois ACOG, I am involved with a group that is working on a bill to legalize those midwives if they go through a credentialing process. And we are not opposing that legislation. But until we get some kind of new law in place, among home birth providers only CNMs are practicing legally.
So again, some women really hope to avoid pain medication, and for them a midwife makes good sense. On the other hand, if you want an epidural when you hit the door, then what a midwife brings is less important and other considerations might be more important. For instance, if you know you want an epidural, you should find a hospital that offers dedicated OB anesthesia. And in those circumstances, you may also want to weigh the importance of continuity of care more heavily. Some people don’t realize that midwives can’t do a C-section. Even if you’re low-risk, you have maybe a one in five chance of having a C-section—or one in three at some hospitals.
If you’re with an OB and you run into complications, the same person who saw you for your prenatal care can take care of you through labor and delivery, even if you end up needing a C-section. So that’s one advantage of working with an OB.
There are also groups of midwives and OBs who practice together. The default in those practices is for low-risk women to see the midwives, and they also get to see the OBs for one visit during pregnancy as well . If you choose a practice like that, you’ll have met the OB, you know that they’re supportive of the midwifery model because they practice with midwives. You know that the midwife has the mind-set and skills to avoid unnecessary C-sections, and if you end up needing a C-section for good reasons, you’ll have met the OBs, you’ll know what to expect, and the transfer of care will be seamless. It can be the best of both worlds.
Of course, if you are higher-risk or develop complications, that’s when the specialist training of the OB can be really important. Midwives are expert in caring for low-risk, healthy women; OBs are expert in dealing with more complicated pregnancies and labors.
Gayle: Midwifery care is optimal for a broad range of women, but particularly for those who desire a natural childbirth. The word “midwife” means “with woman”—and that is our specialty. We believe in the natural process of labor and birth. We have the skills to support labor without medication; we are patient with the process and skilled in risk assessment. This is referred to as “the midwifery model of care.”
As a woman considers her provider, she should also be considering place of birth. A feeling of safety and support is crucial to an effective labor. Thus, who attends her birth and where the birth takes place are both very important. There are three options for place of birth: hospital (and hospital birthing center), freestanding birth center, and home. Certified nurse-midwives (CNMs) attend birth at all three. Physicians generally practice in hospitals and may not attend women in birth centers or at home. In all three settings, midwives offer a spectrum of pain management options, including massage and counterpressure, position change (such as walking or bouncing on a birth ball), hydrotherapy, and sterile water papules for back labor. There are also other options such as nitrous oxide (laughing gas) and narcotics. Epidurals are not available at a home birth or in a freestanding birth center, but you can have an epidural with a midwife if you’re in a hospital setting, and sometimes a patient will choose an epidural after considering her pain management options.
In general, midwives have more time to spend with their patients during prenatal visits, in labor, and postpartum. For that reason, midwifery care can be very helpful to women who are anxious during pregnancy and about pregnancy, labor, and birth. We have more time to “be present,” be supportive, and listen to the patient’s hopes and fears. Midwives tend to take a very holistic approach and be very aware of how emotions affect pregnancy and labor.
The patience, training, and perspective of the midwife translate to lower C-section rates compared to physician-attended births, even when matched with populations that are at similar risk. If it is important to you to have safe care and yet minimize your risk of having a C-section, that’s another reason you might consider midwifery care.
I have generalized the practice approach of different providers, but keep in mind there are obstetricians who practice quite a bit like midwives, and midwives who practice a medical model. It is important to meet the provider ahead of time (if you can) and ask them about their philosophy of birth.
How can I tell if a particular doctor or midwife will be a good fit for me?
Maura: It can be helpful to know how their practice is structured and how they handle backing each other up. In some practices, you have “your” doctor, and you only get someone else for your delivery if that person is on vacation or otherwise unavailable. In other practices—and this is increasingly common—the practice operates as a group and all the patients are patients of the group as a whole.
It’s also important to know how big the practice is. There are pluses and minuses to big versus small practices. A bigger practice is more likely to have weekend and evening hours that are convenient, more likely to get you in at a moment’s notice. I practice with 10 other OBs, for instance, so we can always fit you in. Our patients never need to go to the ER. The downside of a larger practice, of course, is that there are a lot of faces you might see, and you might not meet everyone. And you’re less likely to get any one particular doctor who you might have bonded with.
You should ask how the practice handles their shifts. As a larger practice, we do 10- or 12-hour shifts and we don’t have other claims on our time during that shift. Since I’m on for 12 hours, I’m generally there with you for the duration. In a smaller group, they have a smaller number of patients, but they’re juggling office hours and other procedures with a smaller group of docs. They can’t just be in labor and delivery for long periods of time, so they may not show up to your delivery until the last minute. Not that every small group does that, but I know that happens because I sometimes find myself covering deliveries for someone in a small practice who is in surgery downstairs finishing a hysterectomy, or down the street seeing a full load of patients. His patient is crowning, so I turn up instead, “nice to meet you.” So you need to know the group structure.
Some women like the idea of going to a solo practitioner. The advantage there is that you know your doctor really well and you’re pretty sure they’ll be there for you to deliver. But they are also typically very stretched, they may be with you after really long shifts, they may be really tired, they may be juggling a lot of patients. So understand how long the shifts are for each doctor. I give such better care after 12 hours than I do after 24 hours. I only have 12-hour shifts now, and I think that’s a plus for our patients.
You also might want to ask if the whole group practices at one site. In my last practice, we were at different sites, so it was hard for people to meet everyone in the practice.
Here we’re all together, so our patients can meet everyone. We all discuss complicated patients. And if a patient wants something that isn’t what we normally do, we discuss that too. I had a patient today who wants it to be really quiet at the time of her delivery. She had a long labor last time and found it really jarring when everyone celebrated loudly with excitement. So we talk about preferences like that with the whole group and get everyone prepared for what she’s asking for.
So questions to ask to understand all of this: Do you have your own patients, or will I be a patient of the group as a whole? Who will attend me if you aren’t available? Will I get to meet everyone in the group who might be attending my birth? How long are your shifts? How do you share information with the rest of the group about my preferences and priorities for my labor and delivery?
And again, it goes back to the question of what kind of birth [do] you imagine for yourself. If you want a natural childbirth or if you are very focused on avoiding a C-section, there are other questions you should ask. Does the practitioner you’re considering allow doulas? A doula can be a great help in having a natural childbirth. There are also practitioners who allow VBACs, who will deliver multiples vaginally, who know how to turn a baby in the breech position. These are all important markers if your priority is to reduce your likelihood of having a C-section.
Gayle: What you want to find is a match between what you want—your hopes and dreams for YOUR birth—and [have it be in alignment with] what the midwife believes in AND what she can provide. A midwife may believe in something (such as natural childbirth), but the practice or the hospital is not able to fully support that option. That distinction is important.
A “good fit” is characterized by mutual respect and trust. The midwife will listen to the hopes, wishes, and fears of the patient. The patient will listen to the response and recommendations of the midwife.Respect is important when there is a difference in opinion. The element of trust is imperative to establishing a birth plan that is safe.
Ask yourself: Do you feel listened to when you talk to this midwife? Do you feel like they respect your preferences for childbirth? Do you sense that they are compassionate? As you would not want to be questioning your care while in labor, you need to trust that if interventions are proposed, it is because they are truly necessary. For that, you need someone who respects your general approach to birth and will involve you in decisions about your care.
If you’re planning for a natural childbirth, ask approximately what percentage of their patients have an epidural. If this number is high, then perhaps you would rather choose someone with the skills and support to help you have a natural childbirth.
You can also ask questions like: Do you like working with doulas? How much time will you be spending with me during prenatal visits and during labor? Are an IV and continuous electronic fetal monitoring required? Can I be monitored intermittently? Do the nursing staff support natural childbirth? Will I be able to labor and deliver in different positions? You can also ask what type of childbirth education they recommend. Ask what interferes with the goal for natural birth. Ask who is responsible for decisions.
You could also ask for the midwife’s practice statistics: the C-section rate, successful VBAC rate, induction of labor rate, etc. Most practices will collect statistics to monitor trends in their practice.
Take childbirth classes and learn about birth and the options available to you. Hire a doula to support you during labor. Listen to the wisdom of women and decide what is right for you. And if you are not happy with your provider, seek out someone who has a similar birth philosophy. As a woman moves through pregnancy and learns more, she will understand what she hopes for in her own birth experience. Find that!
It may take three or four months to establish trust and figure out if your relationship with your midwife is a good fit. It is not uncommon for patients to transfer providers in the sixth, seventh, and even eighth month of pregnancy because they discover that they have doubts about whether they can be supported in the type of birth they want, or are not comfortable with the practice they started out with.
I think it’s important to listen to your concerns, and act on them if needed. Don’t worry about hurting the provider’s feelings. Remember that they aren’t comfortable caring for patients who don’t want the kind of care they offer any more than you’re comfortable being cared for by someone who has different values or approaches. And anyway, this is YOUR baby and YOUR birth.
Find the best fit!
July 2018