There are several kinds of health care professionals who can provide prenatal care, attend births, and deliver babies.

Options for care providers:

Obstetrician:

Training: OB/Gyn doctors have graduated from medical school, and had three or more years of additional training in women's health and diseases of the female reproductive system. OB/Gyns are also trained surgeons, who can perform cesareans if needed.

Philosophy/Focus: Physicians are primarily focused on preventing complications, detecting potential problems, and providing early intervention to prevent worsening of the situation. OB/Gyn training does not typically include experience in providing hands-on support for a woman throughout an entire labor.

Patient Interaction. Average prenatal visits: less than10 minutes. During labor: may be available for phone consultations, or may come to the hospital a few times to check on labor progress. During birth: They typically arrive shortly before delivery, and stay through third stage, and early recovery.

Family Practice Doctor:

Training: Family physicians have graduated from medical school, and completed two or more years of additional training in family medicine, including maternity care. Their education focuses on the health care needs of the family from birth to old age. They can provide routine prenatal care, and attend most births, but will refer to specialists for complications, or surgical procedures. Not all family practice doctors attend births. (Childbirth Connections estimates that 25% do, and that number is decreasing due to insurance costs.)

Certified Nurse-Midwife. (Licensed in Washington State as ARNP’s)

Training: CNM’s have graduated from a school of nursing with at least a bachelor's degree (70% have a master's), become registered nurses, and completed one or more years of additional training in midwifery. Their educational focus was on normal health care during the childbearing year, parent education, prevention and screening for possible problems, and newborn care. Typically work in a collaborative relationship with a physician for consultation and referral.

Philosophy / Focus: Specialize in the care of women with uncomplicated pregnancies and births. They tend to use fewer medical interventions than a physician uses. They support the parents’ goals, and provide emotional support as well as physical care in labor.

Patient Interaction: Average CNM sees 140 clients a month and attends 10 births a month. Typically spend 60 minutes on a new client visit; 20-30 minutes on return visits. They remain with the mother through most of her labor, then attend birth and initial recovery stage.

How commonly are CNM’s used? In 2002, CNM’s attended 7.6% of all births in the US, 10% of all vaginal births.

Where do CNM's attend births? 99% of CNM-attended births were in hospitals; .26% in birth centers; .59% in the home.

Legal / financial. Nurse-midwifery is legal in all 50 states. They have prescription writing authority. 33 states mandate private insurance coverage, Medicaid covers in all 50 states.

Licensed Midwife / Direct Entry Midwife / Certified Professional Midwife:

Training: Licensed midwives in Washington have completed 3 years of midwifery training, which includes all the information required to care for women prenatally, during labor and birth and postpartum. It also covers newborn care, newborn procedures, and breastfeeding. Generally, licensed midwives attend home births and births in birth centers. Midwives should have a collaborative relationship with physicians for consultation and refer to a physician if specialty care is needed for health complications.

Philosophy / Focus: Tend to view pregnancy as a normal, healthy life event rather than a medical condition, which should be intervened with only when needed to protect mother and baby. Intervention levels tend to be even lower than CNM’s due to this non-medical-establishment approach.

Patient Interaction: Time spent with clients is equal to, or greater on average, than the time CNM’s spend with patients. Case load is typically much smaller than CNM’s. In labor: are typically with a woman throughout her active labor, delivery, and for two to three hours after them birth.

Legal / Financial status: Varies widely from state to state. In Washington, there are 120 licensed midwives. Their care is covered by Medicaid, and by several insurance companies. Generally, a licensed midwife can: do pap smears and other routine gynecological checkups, conduct prenatal exams, attend labor and birth. The only anesthesia a licensed midwife can use is a local block on the perineum. If a patient develops any condition that is defined as high-risk, or if a patient desires pain medication during labor, or requires pitocin, c-section, or other medical interventions, the midwife will transfer the patient’s care to a physician.

Lay midwives

Lay midwives practice in some communities. Training and experience can range widely. Not all lay midwives are adequately trained. If you consider using an unlicensed midwife, it’s important to be cautious and ask detailed questions about their backgrounds, training, and experience.

Philosophy of birth:

There is a range of philosophy and practice amongst individual practitioners, but they fall at varying points along a continuum of beliefs about birth. These are often referred to as the “medical model” and the “midwifery model,” although that’s a generalization, and you would want to interview your potential care provider to get a sense of their personal philosophy.

Medical model: There are potential dangers and risks inherent in pregnancy, labor, and birth. The role of the caregiver is to attempt to prevent problems, to remain aware of possible complications and variations that may arise, monitor and test for these issues, and intervene quickly to prevent further complications.

Midwifery model: Birth is a natural and normal physiological process which varies from woman to woman. The role of the midwife is to monitor the mother’s physical, psychological, and social well-being, and provide education and support. If problems do arise, they explore alternatives for coping with the issue. They may offer ideas for things the mother and her support people can do to resolve the problem, may offer medical treatments they can perform, may refer to complementary medicine providers, or may transfer the mother’s care to a physician if mom needs the specialist care of an obstetrician. For more on midwifery model.

Intervention Rates / Safety of Midwifery Care

For these statistics, overall averages includes all births, the great majority of these births are physician attended. CNM is certified nurse-midwives under the supervision of a physician; the vast majority of these births were in the hospital. CPM is certified professional midwife rates at home births.

Note that midwives only see low-risk clients, so some of the difference in rates is based on the initial health status of their clients.

Epidurals. Overall: approximately 2/3 of birthing mothers (as high as 90% at some hospitals, 40% at others). CNM: 14.6% CPM: epidural is not available at home births. Some CPM clients are transferred to hospitals, and some choose epidural there. So, for women who received care from a CPM, 4.7% had epidurals at some point in labor.

Episiotomy. Overall: a few years ago, rates ranged from 10% - 80%. The incidence has dropped hugely, so that rates are typically <25% now. CPM: 2.1%

Cesarean section. In 2002, 24% of births in Washington. 26.1% nationwide. CNM’s: 11.6% CPM clients: 3.7%.

Vaginal birth after cesarean. Nationwide: 12.7%. CNM: 68.9%

Infant mortality: In 1991: 8.6 per 1000 nationwide. CNM: 4.1 per 1000. In 1998, the National Center for Health Statistics determined that, after controlling for risk factors, the risk of infant death was 19% lower at births attended by CNM’s than by physicians. Risk of neonatal mortality within first 28 days was 33% lower for CNM-attended births. This is believed to be attributed to prenatal care which involved more patient education, and to CNM presence throughout labor. CPM: 1.7 per 1000.

Finding a Caregiver:

Check what caregivers and birthplaces are covered by your insurance. Think about what kind of care you wish to receive during labor and birth, and which caregiver and birthplace is most likely to provide that. To find a physician: Ask your current doctor for referrals; ask for referrals from your chosen hospital. Schedule an initial consultation with the physician you are considering; they might charge for this. To find a midwife: Look on www.midwife.org/find/  for CNM’s, or www.midwivesofwa.org  for more info on Washington CNM’s. For Washington state licensed midwives, see www.washingtonmidwives.org for a directory. For other ways to find CPM's, see here. You can also ask birth centers for midwife referrals. Most midwives will offer an initial interview free of charge.

Questions to ask potential caregivers

Where were you trained? How long ago?

How many births have you attended? How many labors attended from start to finish?

Will you expect to be at my birth, or is there a chance someone else will attend? Who?

What are their intervention rates? What do you consider routine interventions for labor?

Who can be with me during labor and birth? What are the roles of support people?

Can I move around during labor? Can I eat? What positions do you recommend for birth?

What things do you normally do for a woman during labor?

Besides drugs, what do you recommend for relieving pain during labor?

How do you help mothers who want to breastfeed?

For midwives: who is their backup physician? What conditions lead to a physician referral?

How do nurses fit in?

If you are birthing in a hospital, a nurse will be assigned to you throughout your labor. She will monitor your vital signs, labor progress, and baby's status at regular intervals throughout the labor, and assist the physician or midwife during the delivery. Nurses often provide emotional support and assistance with coping techniques to the laboring woman, but their primary responsibility is the health of mom and baby.

How do doulas fit in?

A doula is different from all the providers listed above in that she is not a medical professional. She can not diagnose nor treat medical conditions, she can not monitor baby or do cervical exams to monitor labor progress.

A doula's role is to provide continuous support to the family from early labor until after the birth of the baby. She offers emotional support, and assistance with comfort techniques. For lots more on doulas, see here.

Sources: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler, 2001. Alternative Birth: The Complete Guide by Carl Jones, 1991. A Good Birth, A Safe Birth by Diana Korte and Roberta Scaer, 1992. Websites for: American College of Nurse-Midwives www.acnm.org, Midwives of North America www.mana.org, American College of Obstetricians and Gynecologists, www.acog.org. CPM intervention stats from Johnson, BMJ 2005.