choosing a midwife

Planning a home birth

The whole second trimester really is kind of nice, especially if you don’t think too much about the still being nauseated part. I’m not stretched or uncomfortable yet. I can still sleep on my back (though that’s about to end, sigh). Sometimes I see my midwife every four weeks, and sometimes we schedule for every three. Pretty soon we’ll switch to every two weeks.

Which is why her assistant had to ask, after my appointment this week, how soon she wanted me to come back.

“Hmm,” my midwife said. “She can come back when she agrees to name the baby after me.” (She was joking, of course. She and Dane had just been talking names when the question came up.)

When people hear that my births are attended by a midwife, they often assume she’s a nurse-midwife.

Certified Nurse-Midwives (CNMs) are first trained as nurses, then have additional training in midwifery.

My midwife, though, is a Certified Professional Midwife (CPM), a type of direct-entry midwife. Direct-entry midwives enter the profession without prior training in nursing.

Certified Professional Midwives have training and clinical experience in midwifery, and are the only maternity-care professionals in the U.S. whose credential requires clinical experience with birth outside of a hospital.

Research shows that women giving birth at home with CPMs experience outcomes at least as safe as those that women experience in hospitals, with far fewer interventions. (And hey, one of my births was included in that research study! I got to fill out a form and everything!)

Conflict occasionally flares up over which type of midwife is the best qualified or most professional. I’m of the opinion that—especially given that research thus far shows excellent outcomes for all types of certified midwives—women can make their own decisions about what kind care providers they prefer. (Not that choice is always a realistic possibility; some states prohibit direct-entry midwives, and some states don’t allow any care provider to attend home births. Some areas have no midwives available, and many health care plans won’t cover them even if they are available, despite the low risk and low cost of midwives compared to other providers.)

Personally, I don’t much care which letters follow a midwife’s name. I care about her philosophy of practice, about her experience, and about whether we work well together—whether I trust her judgment, and whether she respects my right to informed consent and decision-making. That’s why I interviewed several different midwives before choosing one to work with.

The midwife I chose happens to be a CPM. She is an expert in physiological birth. She is trained in home birth specifically. She practices under the midwifery model of care. And that is exactly what I want.

For more about birth and midwives, check out the birth resources page.

model choices

Planning a home birth

We subscribe to a bunch of kids’ magazines around here. A couple of kids’ literary magazines, a couple of science magazines, a history magazine. This and that. A regular influx of new ideas to read and ponder = good, I think.

One of the kids’ science magazines just arrived. This month’s theme: Growing Up. Much of the focus was on animals—hatching eggs, metamorphosis, how puppies are born. But one story was about—go on, guess—human gestation. Pregnancy.

The story is set up as though the narrator is speaking to the child-reader. When you were in your mommy’s tummy, this happened! And then this! Like that.

So I read it with the kids, which led to them asking all sorts of good questions:

Why does it say the mom will see a doctor? Why doesn’t it say “doctor or midwife?”

Why does it say the baby was born in a hospital? Why doesn’t it say “might have been born in a hospital?” Or “some babies aren’t born in hospitals?”

Why is the mom lying down when her baby is born?

Dear magazine-makers: when my nine- and six-year-olds can create a more accurate and inclusive description of birth than your educational content providers did, you may have a problem.

And then the kids and I got to discuss, just a little and at an age-appropriate level, why some women choose midwives and some choose doctors.

People often think we use a midwife because she’s friendlier than a doctor, or because we like her more. Um… no. We are friendly with our midwife. We live in the same neighborhood. Our kids have been to each other’s birthday parties. Our personalities mesh well. But I first hired her because she’s an excellent midwife. And I preferred to be attended by a midwife rather than a doctor both because I wanted to give birth in a particular location (home), and because I wanted a health care practitioner that followed the midwifery model of care (as opposed to the medical model of care).

The midwifery model of care, though, doesn’t mean “care provided by a midwife,” just as the medical model doesn’t mean “care provided by a medical doctor.” Each model describes a different philosophy of care, and involves different practices and norms; each is associated with different outcomes. There are valid and logical reasons for choosing each of these models, and both have a rightful place in our health care system.

The midwifery model focuses on health, wellness, and prevention, while the medical model focuses on managing problems and complications. (The midwifery model also pays special attention to identifying and referring those women who need obstetrical intervention.) Care is individualized in the midwifery model, and made routine in the medical model. The midwifery model is associated with lower rates of intervention, and with higher maternal satisfaction. It also fits with and honors my personal belief that—under normal circumstances—my body was made to be able to give birth.

There are doctors who follow the midwifery model, and some midwives who more closely follow the medical model. (Some have argued that the models should be called the physiological model and the pathological model, to better describe them, but those names haven’t really caught on. Go figure.) Asking a few pertinent questions can usually help a woman determine what model of care a birth attendant embraces.

Not everybody believes what I believe; not everybody wants the same things I want in a birth attendant. But there are real and measurable differences between these two models of care, and we should each be able to choose a birth attendant whose philosophy best suits our circumstances and our values. Which philosophy fits us best is something we can each decide for ourselves. Of course.

For more information on these models of care:
The Midwifery Task Force’s brief definition of the midwifery model of care is available here. An expanded explanation can be read here.

Our Bodies, Ourselves offers definitions of both the midwifery model of care and the medical model of care. Childbirth Connection also compares the two models.

For more on birth and birth options, see my birth resources page.

birth research and resources

Planning a home birth

When we were talking about birth last week, Anjali pointed out that information on home birth just wasn’t readily available eight to ten years ago, the way it is now. She’s right, absolutely—and that got me thinking about what led me toward home birth in the first place.

I think it was a combination of circumstances and personality.

I’m a research-happy kind of person. Before making decisions, I have a pathological need to read up on all possible choices first, and talk at length (mostly to my long-suffering husband) about what I’ve learned, and then decide which of my options I think is best. I’m a little nutty that way.

I started out reading books like A Good Birth, A Safe Birth (no longer in print). But I was also just out of college when Abigail was born. My degree had required classes in advanced statistics and research methods and experimental design—so fun! and I’m not even joking!—and I still had access to medical journals through the university’s library system. And I think I mentioned, I love me some research.

I probably didn’t need to look that hard to find information on best practices in maternity care, and certainly no one needs to do that anymore. But once I knew what to ask about, it wasn’t difficult to find out which practitioners and which birth locations followed evidence-based best practices, and also which were able to accommodate the practices that were most important to me.

If I were researching today, I might start with some of these sources:

- Henci Goer’s articles and books. The Thinking Woman’s Guide to a Better Birth is aimed at pregnant women, and Obstetric Myths versus Research Realities is aimed at medical professionals.

- Jennifer Block’s articles and book, Pushed.

- Marsden Wagner’s book, Born in the U.S.A.

- Adrienne Lieberman’s Easing Labor Pain, an overview of all sorts of pain management options.

- Sheila Kitzinger’s Complete Book of Pregnancy and Childbirth, for information on healthy pregnancy and childbirth in any setting.

If I wanted to learn more about out-of-hospital birth choices, I might read these:

- Citizens for Midwifery’s resources page. There are links to news, studies, opinion, and explanation.

- Ina May Gaskin’s Spiritual Midwifery, a classic collection of home birth stories.

- Ina May’s Guide to Childbirth, which is all about natural childbirth.

- Mothering Magazine, in print or online, which regularly includes out-of-hospital birth stories and articles on natural childbirth.

If I wanted to know more about the midwifery model of care (as opposed to the medical model of care), I would look into these:

- North American Registry of Midwives. NARM licenses Certified Professional Midwives. CPMs are direct-entry midwives (midwives who are not also nurses).

- In the U.S., the American College of Nurse-Midwives. CNMs are first trained as nurses, and then receive additional training as midwives. They might attend births in hospitals, freestanding birth centers, or homes.

- Midwives Alliance of North America. MANA is an advocacy organization for all types of midwives.

- Citizens for Midwifery is a consumer group that advocates for midwifery and midwives in the U.S.

- The Big Push for Midwives campaigns for the regulation and licensure of Certified Professional Midwives in all 50 U.S. states.

- Heart and Hands: a midwife’s guide to pregnancy & birth, an accessible midwifery textbook that you can probably find at your library.

I would also interview the health care providers I was considering hiring. (I did this when I was pregnant with Abigail. Midwives expected it, and scheduled in-person consultations. Doctors and hospitals, I mostly interviewed over the phone, and sometimes I spoke to an office’s “medical assistant” rather than to the obstetrician.)

I had a long list of questions—among other things, I wanted to know how often they dealt with various complications, how regularly they performed various interventions, and, for out-of-hospital practitioners, how often they transferred care and under what circumstances. Their answers, as well as how comfortable they were being questioned, gave me enough specific information to choose the best health care provider for me. Presumably another woman, interviewing the same practitioners, could come to another conclusion based on what was important to her. And that, I think, is as it should be.

I know that not all options are available to every woman. In the real world, we’re constrained by money (which locations and health care providers will your health care plan pay for, if you have one? can you afford to pay out of pocket for other options?), by location and transportation (can you get to the birth location of your choice? can a health care provider get to you?), and by state and local politics (are midwives legal in your area? if so, are there any? and if they practice out-of-hospital, do they have good working relationships with local obstetricians, allowing for supportive transfer to a hospital in case of complication?). But for women who do have options, I hope resources like these are helpful.

What have I missed? What resources helped you decide where and how to give birth? Are there books and websites available now that you wish you’d had access to years ago?

For more about birth and midwives, check out the birth resources page.