There’s no doubt that pregnancy can be stressful and it makes sense that no one wants to switch providers mid-pregnancy or even after the 36 week mark, yet for some, this is the situation they are faced with upon finding out their provider is less than supportive.
I don't know why, but maybe it is the intimidation of the white coat because when I talk to my community, I hear so many of my friends express a dislike for aspects of their care but feel a sort of obligation to stay put. We can see a distinct line drawn in the sand when it comes to birthing with a Midwife as opposed to birthing with an OB (Obstetrician). Even when we just focus on OBs as a birth worker not associated with any specific hospital, I can see a variety of different styles and each has their own standard operating procedures. It makes sense that it’s hard to know where to go next even if you do decide you want to find a new provider. The same can be said of Midwives; after all, Labor-Land is no place for a Midwife who does not listen to you. It can all be very confusing. So, I am going to give you a little nudge today. I won't throw you to the wolves, or insist you swap providers, but I will give you some insight on the two different models of care, talk to you about some questions to ask providers, and reasons why an OB would be deemed necessary over a Midwife (There is a small percentage of pregnancies that are deemed high risk and Midwives will end up referring you to an OB).
There are some fundamental differences between the Midwifery model of care and the OB model of care. Midwives study psychological birth. For example, The Farm, a midwifery compound around since the mid 70's, has a transfer rate to the hospital of about 5% with only 3% of those being cesarean - so it is no surprise then that they are experts in the variations of normal labor and birth. Obstetricians are surgeons who major their studies in cesarean birth and minor their studies in natural, normal labor. Unlike Midwives who stay with you from active labor until birth, OBs are generally only called in for the birth of the baby or if complications arise. Now, I want to be very clear that this assumption of Obstetricians can easily be disproved as newer and younger minds enter the birth community, but to be frank, hospital numbers speak for themselves by boasting a very high 28-31% cesarean rate across the US (this is not including the small percentage of pregnant people who were already deemed high risk). Hospitals, it would seem, could learn a thing or two from Midwives. The beautiful thing is that here in our neck of the woods, we have a birth center with CNMs (Certified Nurse Midwives) and Midwives who practice at some of our local hospitals as well (I will give you their details at the end)! So now that we know where perspective lies, we can deduce that Midwives do not manage birth but watch it with a very keen eye and look for very specific signs that indicate distress. OBs on the other hand, specializing in high risk pregnancies, expect complications, and attempt to control the path of labor rather than succumbing to its oddities. Can my observations of these perspectives be off? Sure! I love hearing about OBs who seem to be more Midwife than OB. I look forward to a time where we can suss out the difference properly and help birthing people find the best one for their very unique pregnancy and birth. But the white coat can be frightening and questions get stuck in your throat. Then birth day comes and you realize your OB is simply atrocious and there is nothing that can be done now except for create the best situation from the circumstances. Hindsight is always 20/20 unfortunately and we tend to beat ourselves up for not knowing better, so hopefully this has reached you in time and if you have swept any red flags under the rug as of late, it may be time to check them out a bit more and get to the bottom of it. Here is the lowdown on the two different models of care:
Midwifery Model according to the NACPM
Pregnancy and birth are normal life processes.
The Midwives Model of Care includes:
Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
Minimizing technological interventions
Identifying and referring women who require obstetrical attention
The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.
The OB Model of care is less definable and seems to be a unicorn, but for my community and for so many others, it feels more baby centered (not that we are complaining, we just want the focus to include us too - you know the birthing person! After all, we are a team). Let me elaborate:
Procedures can't hardly be wavered from; less wiggle room for things such as due dates and length of labor.
Constant monitoring and push for medical inductions
Less faith in the body's ability to birth and more faith in their ability to help you birth.
Not comfortable with alternate pushing and birthing positions
Less involvement with care and the actual labor because nurses fill that role.
Suffice it to say that there is a bit of a divide in the practice of birth when just 10% of the population gives birth with a Midwife even though only about 5% of the population is high risk and require an OB. Still, emergencies do arise and most of my friends report feeling most at ease when in a hospital setting. Even though subconsciously they could be very tense from the constant ding and the bright lights, the sudden disturbances from shift changes and such, they still like the peace of mind the hospital provides. Don't get me wrong, I and so many others will agree that we need OBs - they are important and there is no doubt about that.
So now that you know the difference... You may have some questions, first with yourself and then some for the now growing body of providers that could potentially assist you with birthing your child. Let’s not kid ourselves though. Some of you may be squirming in your seat even thinking about bringing up questions to your current provider let alone trying to address all of these questions with a new provider. The task can seem daunting and when you are pregnant, the idea of having to make appointments to new places to talk to another person, then doing this a half dozen more times feels like a shit storm in your head and I can empathize with that. Here are a few tips to help you out just a bit:
Talk to your friends who have recently given birth - Who was their provider? What did they like or dislike about them? - What model of care did they use?
Get connected here with a local pregnancy and postpartum group on Facebook. Then ask them who they recommend and why.
Finally, ask your doula. Don't have a doula? You may be surprised to know that adding a doula to your birth team can help you have a better birth experience and they have also been shown to lower the rate of cesareans and birth trauma. So, find one that makes you feel at peace and add them to your team because when it comes to the low down on who serves the birth community, they normally have tons of connections!
Now that you have gotten some great suggestions, it will be easier to narrow down the selection to the ones who align with your needs and wants. So where do you go from here? Just because you have a list of providers does not mean you have quite settled on if you will have your baby at home, at the birth center, or at a hospital. This means that it is time to start thinking of your birth and the type of experience you would like to have. These needs vary significantly with everyone, but there is a very definitive divide between those who want to try natural but are not against pain medication - and those who refuse any type of medication and will deliver naturally. This divide can easily shuffle the latter to Midwifery care and the first to hospital care but either a midwife or OB can assist with delivery. Yet, this is not the only reason to choose one over the other. Each provider will have different birth experiences that drive their procedures so once you figure out exactly what type of birth you want, you will have a much better understanding of where you should give birth and this should narrow the provider list down a bit more. Now that you have gotten to this point, you may want to start calling the ones you have on your short list. Speak with the person who assists them, ask to speak with them directly and get a feel for how they make you feel as you ask simple questions such as their cesarean rate, use of episiotomy, and their thoughts on things such as delayed cord clamping. Some will be quickly crossed off your list while others seem like viable options and that is where the final step comes in. Now it is time to make an appointment and meet them face to face. If you feel unsure about your current OB, you don't have to end your relationship right away. Try researching others first and seeing if anyone stands out as a better alternative. This way, if you don't find anyone, you have not already dropped your previous provider. Some will say, "It is too late for me to change providers." I am gonna have to call you on this one... Honestly, you hire them and if at any time they make you feel like your needs and wants are being disregarded and you are not being listened to, you have every right to fire them and find someone who is willing to hear you and work with you as the birth person and the expert on your body. So, is it ever too late? I am going to go with no! Will you make decisions based on other aspects that may mean staying with a provider that is not everything you ever dreamed of? Maybe, but for the vast majority of people having babies, this process is the most important step to having the birth you desire and deserve. Birth trauma has become far too prevalent and choosing the right provider can create a domino effect that will forever shape your view of birth and those who attend you. I ask that you take this information, not as a foretelling of certain doom, but as a reminder that taking control of your birth can not only help increase your chance of having a memorable and satisfying birth experience no matter the outcome, but that taking charge in your birth is Nature’s first lesson in parenthood. You will have to make decisions for your family for the rest of your life, now is a great time to grab hold of the reins. Stuck on what questions you might ask or the type of birth experience you want? Let’s dive a bit deeper:
What are your rates of cesarean, assisted births, episiotomies?
Do you practice delayed cord clamping?
Will I be allowed to eat and drink as I feel necessary through labor?
Do you embrace birthing in psychological positions such as side lye, squatting, or on all fours? Do you prefer birth and pushing be done on one's back?
How long will I be able to labor before you step in and try to augment labor through induction methods?
How far past my due date will I be "allowed” to go?
What alternative forms of pain management do they recommend instead of epidural?
Do you practice intermittent or constant monitoring and can I be up and moving around?
After gathering all of the information you need to decide who you want on your birth team, the swap won't feel so daunting. The choice won't give you anxiety and those you add to your birth team with enrich it and empower you! Yet, for some, their choice in provider may be dwindled down even more by pregnancy's many woes. For instance, those who have had a previous Cesarean may have more difficulty finding a provider who is willing to try a VBAC (vaginal birth after cesarean), and there may only be a couple who are willing to. Or for those who are high risk due to medical reasons, they may find that their selection are pretty slim pickings as well. Don't allow this to stop you from figuring out which provider is best for you. Even in high risk pregnancies and birth, you can have a beautiful and meaningful experience.
Birth is not about perfection; it is about surrender. Surrender to your body, knowing that it is capable and strong. Surrender to your baby knowing that they have an astute ability to decide the best way to be born. Surrender to the team of people that you have entrusted to serve you through labor and birth. Doing this and having confidence in your body, plan, and provider gives you space to birth uninhibited, in the full knowledge that you are an important part of the equation, the very veil between life and death as you reenact the dance of birth.
Side bar: Did you know that we communicate with every cell in our body unconsciously but that we can also consciously do this as well? I would like to propose that you to sit with the knowledge that you can have a conversation with your own cells. I encourage you to test this out and begin an internal dialogue with your child while they are in your womb. Share with them all your dreams for them, share with them what birth will look like for you and the best position to be in. Share with them your trust in their instinctual knowledge and invite them to join you Earthside when they are ready. Visualizing yourself giving birth can be a great way to instruct the trillions of cells in your body to work together during labor and birth making you the conductor of the orchestra, not your provider. They are there if emergencies happen, but other than that, you and your baby are the ones working through labor and birth and because of this, your needs and wants should be heard and accommodated as much as possible, no exceptions!
Finally, I want to talk to you about what can make a pregnancy high risk. Yet again I must reiterate that high risk does not equal terrible experience. It simply means that your pregnancy will be more closely followed and it is possible induction or cesarean may be needed based on medical factors that can arise. Because of their need for more modern medical monitoring, these pregnancies are handled by Obstetricians. Accounting for roughly 5% of pregnancies, according to the Mayo Clinic High risk pregnancies are:
Advanced maternal age. Pregnancy risks are higher for mothers older than age 35. Although if you live locally Leslie Rathbun (A CNM at Charleston Birth Place) clarified that, "Although it is a growing trend to include age over 35 a high risk pregnancy there is no clear evidence that age alone increases risk for all mothers. At the birth center age is not a risk factor that excludes birth center care and birth." For more information on this check out this Evidence Based Birth article.
Lifestyle choices. Smoking cigarettes, drinking alcohol and using illegal drugs can put a pregnancy at risk.
Maternal health problems. High blood pressure, obesity, diabetes, epilepsy, thyroid disease, heart or blood disorders, poorly controlled asthma, and infections can increase pregnancy risks.
Pregnancy complications. Various complications that develop during pregnancy can pose risks. Examples include an abnormal placenta position, fetal growth less than the 10th percentile for gestational age (fetal growth restriction) and rhesus (Rh) sensitization — a potentially serious condition that can occur when your blood group is Rh negative and your baby's blood group is Rh positive.
Multiple pregnancy. Pregnancy risks are higher for women carrying twins or higher order multiples.
Pregnancy history. A history of pregnancy-related hypertension disorders, such as preeclampsia, increases your risk of having this diagnosis during your next pregnancy. If you gave birth prematurely in your last pregnancy or you've had multiple premature births, you're at increased risk of an early delivery in your next pregnancy. Talk to your health care provider about your complete obstetric history.
So to finish this up, I want to say: you can't assume you will be considered high risk based on the list above, as this will be based on your individual needs and only detailed discussions with your provider can determine this. You may be able to reduce your chances of being considered high risk by making healthier life choices and again, even if you are high risk, it does not mean any one outcome is definite. What it does mean is you will have a group of people dedicated to making sure your pregnancy and birth is healthy and safe. Aside from that, it is up to you to create your Sacred Oasis. You can do this by bringing to your birth space items which make you feel safe and allow for a sense of calm, you can do this by taking childbirth education classes, and most of all you can do this by picking the birth team that is best for you and your unique situation. There is no one size fits all approach to this and even with the best birth team, outcomes cannot be foreseen. However, if you have a team you totally trust, when baby is born, you will feel more at peace with your story than if you had ignored the red flags and been too afraid to speak up or change providers.
My last words of advice are, find that small ember inside of you and tend to it now, for once labor comes it can either smolder out or set fire. Don't let anyone extinguish your fire and don't be a passive participant in your birth, no matter how you choose to bring your baby into this world - be the conductor!
Local Birth community resources
Jessica Day - Midwife with MUSC
Dr. Angela Choi MD
Current member of Professional Doulas of Charleston