Choosing a Provider
One of the things that has the greatest influence on how your birth experience will go is the provider (doctor or midwife) you choose to support you during your birth. This can be one of the touchiest subjects when it comes to being informed about your options during pregnancy. A lot of expectant parents don’t realize how in labor, your OB plays a really big role in what your hospital care and interventions look like while also not being there personally to discuss with you what is happening. In a hospital birth, labor management, patient care and communication is mostly done by nurses and can vary from hospital to hospital and even nurse to nurse depending on what their policies are (for hospitals) and what kind of training and experience they have had (for nurses). Choosing your provider and birth location is important in trying to figure your chances to have the kind of birth you want.
OBs vs Midwives
Most people will birth at a hospital while under the care of an OB. Some advantages to OBs are that they have extensive medical training (requiring much longer training than midwives) and lots of skill including the ability to perform surgeries. Something that doesn’t get pointed out is that OBs usually have very little experience with out-of-hospital births or intervention free labors and most of their experience comes from emergency, risky situations. For the most part, their accepted way of managing birth is to prescribe interventions and surgeries. These experiences can color their opinions about which labors require extra interventions and in what circumstances. Their education and experience can also lead to them believing their opinion is the fact and should be taken as authority even though it is not backed by any data other than their own experiences.
The other main alternative to OB care is midwifery care. There are many advantages to midwifery care. Midwives tend to use far fewer interventions in their supervision of labor and birth, leaning toward more trust of the birthing person’s body, intuition, and authority to guide labor. They try to encourage a peaceful, secure atmosphere for birth. Other advantages include longer prenatal meetings during which midwives really try to holistically care for their patients (they have a lot smaller caseload than most OBs and can dedicate more time to their patients), more postpartum visits (many midwives conduct home visits), midwives also often do not recommend inductions prior to 42 weeks gestation unless there are any indications of any high risk factors to the birthing person or baby. Many midwives are supervised by OBs who they refer to for tests and ultrasounds, especially later in pregnancy. If your aim is to avoid cesarean sections, studies show those who plan homebirths have a cesarean rate of approximately 6% where most hospitals currently have cesarean rates of 25-30% (this is obviously skewed by birthing people with more higher risk factors and complications birthing in hospitals, but I believe preparation accounts for a significant portion of the difference). Midwives often operate out of birth centers or are independent and can be contracted if you are planning a home birth, though there are some hospitals that give midwives privileges to oversee births there. Midwives also have a very hands-off approach to assessing the baby after birth and try their best to give the new family time and space to be together, not rushing to clamp and cut the cord, or do any aggressive suctioning of baby unless absolutely necessary.
There are disadvantages to choosing midwifery care also. In the US, it is more expensive. Currently, most medical insurance covers midwifery care to a lesser percentage than it covers OB care for pregnancy and labor. Also, if you want pain relief medication options in labor, midwives tend to carry much less than what is available at a hospital. If you are birthing outside of a hospital also midwives will leave the birth (if a home birth) or you will be discharged from the birth center 4-6 hours after the birth instead of staying for a day or more at a hospital postpartum. For some this is a blessing to be in your own bed and home without constant interruptions of nurses checking on one thing or another, for others, they would rather have more time with extra help before returning to normal life at home.
In any case, whichever kind of provider you choose for your care, here are some questions you may want to ask them to decide if you are going to stay with their practice or not.
Questions to ask your OB:
If you work in a group of OBs who may deliver my baby, do they have very similar approaches to birth as you do?
What percentage of their patients choose to do unmedicated labors? If the percentage is low, they may not have much experience with it.
What is their cesarean rate? (ideally less than 25%) And what are their main reasons for a cesarean?
What is the rate that they give episiotomies (ideally less than 10%)
How do you feel about a doula joining me for labor?
How do you feel about birth plans and how closely will you try to abide by my desires for how labor goes?
If my water breaks before contractions start, what is your protocol from there? How long do I wait until I come to the hospital?
How long past my due date would you insist I be induced?
At what point in the labor do you show up?
How do you feel about allowing my body to push without coaching and allowing me to choose what position I want to push in?
Do you support delayed cord clamping? Why or why not?
Questions to ask your Midwife:
How does your practice work? Do you work with partners or student midwives?
How do you feel about a doula joining me in labor?
Do you have privileges at any local hospitals?
What is your hospital transfer rate? And for what reasons?
What tools and medications do you bring to births?
When should I expect you to arrive during my labor?
How long after my birth will you stay?
How much is the total cost of care and what does it include?
Do you have experience with insurance reimbursement and how much do your patients usually get reimbursed?
In addition to these questions, pay attention to how you feel before and after an appointment with your provider. Do you look forward to the appointments? Do you feel afraid of going and what they might say to you? Do you feel like your provider listens to your concerns and works with you to figure out solutions? These feelings are important in knowing you have the right provider for your team.
Another way to get some information about local OBs, hospitals, midwives, and birth centers is to ask other parents in your area. Also, you can ask local doulas who they recommend. Just be aware that just because someone had a good or bad experience doesn’t mean you will also depending on their specific circumstance and outlook. They may have had completely different goals for their labors than you. I would specifically ask for information from them on things that concern you like bedside manner, use of interventions, etc.
Communication with your provider
Once you choose a provider, I believe it is important that you are able to communicate clearly with them and to do so prior to your day of delivery. I think creating a birth plan is more about educating yourself on the options during labor and birth and to become aware of what is important to you about labor and birth than making a plan for how things are going to go. If your provider is running the show during your birth, it is important for them to know what you want. Yes, it may not happen exactly the way you want, but you have a higher chance of success if your provider knows what is important to you and has a chance to give input on things they don’t feel comfortable doing.
I don’t think these conversations between birthing people and their providers are happening often enough, and providers’ attitudes toward birth plans can really vary. Some providers will say “good, good” when you give them the plan and will essentially ignore it while you are in labor. I personally think it is important to have a provider who understands that it is your birth and does not dismiss your desires, who will listen and try to understand where you are coming from before interjecting with possible risks and their medical opinion. They may have seen many births, but you are the expert on your body and how it responds, and that counts for a lot in birth.
The last point is that it is almost never too late to change providers. I know this is something people are reluctant to do, but it is sometimes better to change to someone who has a philosophy which aligns more with yours than to continue with a provider and be optimistic for things to change for the better once you go into labor.