Choosing Birth Providers
You’re pregnant! Congratulations! Now what? You need prenatal care. A few thoughts cross your mind. You think to check your insurance coverage list for doctors and midwives. You call your sister or friend for a referral, or you call your current gynecologist for an appointment. “I really like my gynecologist”, you think to yourself. “I’ll just stay with her”. Well you’re right. Those are perfect next moves. However, there’s a lot more to choosing your birth providers than picking from a list or taking a blind referral.
Birth is a transition time in a woman’s life. It’s a right of passage. It is a time when a woman becomes engrossed with herself mind, body, and spirit. You learn new aspects of yourself even if this isn’t your first time. You want a birth team who aligns with you and your spouse or partner.
Furthermore, birth spaces within the medical system can be tricky to navigate. They can also be heavily authoritative so you want to make sure you know the providers you hire are on-board with the vision you set for your birth experience. The last thing you want is to be 36 weeks pregnant and realize that you and your doctor do not agree on an intervention, leaving you with few alternatives to navigate in a short time. You don’t want to find that your doula is far more pushy in the labor room at the hospital than you imagined she would be.
Pregnancy is a delicate time for you. You want to have a support team that rallies around you in a spirit of collaboration. The earlier you make those choices, the breezier your pregnancy and labor will be. Here I will highlight factors that aren’t always considered when hiring your birth providers, but should be. These are factors to be considered when hiring a doula, doctor, or midwife for your birth.
Doulas
Doulas can be the key to get your pregnancy off to a good start. You can read about the personalized care that doulas offer their clients in my blog post, “How Will A Doula Help Me Specifically?”. Choosing a doula early in your pregnancy is a plus because they can help you navigate a lot of the choices you have to make at the beginning. Your doula is the only hired person on your birth team who doesn’t have to consider liability in front of your desires and needs. What that means is they keep your desires front and center while navigating your choices. That makes communicating with your primary provider easier later on.
For example, your doula will compare the doctors on your insurance list to those that they know in the community. If you wish to have a VBAC, your doula already knows the VBAC friendly docs in your area making your insurance list of providers smaller and more personalized to your needs. Here’s what to look for in a doula.
Birth Ideology- What types of birth does the doula prefer (hospital, home, birth center)? Purely natural (non medicated) births only? Do they state that they are unbiased and non judgmental about mom’s choices? You can usually get a good idea from their website, but this should be question number 1 at your interview. You don’t want a doula who is going to pressure you into having the birth she wants. Find a doula who matches your ideals of birth.
Insurance/Payments- Doulas are not typically covered by your insurance. That is beginning to change so definitely check with your insurance provider to be sure. If your insurance does cover doula care, it’s usually reimbursed after you have paid the full fee and submit an invoice to them. Sometimes they are covered by FSA/HSA accounts if you have that option. A lot of doulas help by setting up payment plans over the course of your pregnancy. Check out this blog post about affording a doula. Finding a doula is important, but it shouldn’t become a stressor. There are doulas for every budget.
Location- Where will appointments take place? Does the doula have an office to meet with you for prenatal and postpartum visits? Does she come to your house? Which suits you better? It can become tiring making trips for your doctor/midwife visits without adding more appointments. On the other hand you may not want visitors in your home. Make sure you’re on the same page.
Midwives
I find that most confusion in regards to choosing a midwife has more to do with understanding the role of a midwife. People are often confused about how midwives fit into the picture. Midwives are primary providers. If you elect to have a midwife as your primary provider, that is who you will see for your prenatal care primarily. If you select a midwife, it is in place of a physician. You do not need to have, nor will insurance cover both types of providers. You can watch this video where I explain the different types of midwives and the environments they work in. Here’s what to consider when hiring a midwife.
Birth Ideology- Midwives follow the midwifery model of care which is established in the fact that birth is a natural life event and therefore should be handled as such. They deliver babies at home or in birth centers as well as in hospitals. They tend not to rely heavily on medical interventions. Their care is seen as more nurturing and patient-centered than their medical obstetric counterparts. However, don’t make that assumption.
There are midwives who can be just as domineering in practice as it’s believed physicians are. There are midwives who have set ideals about birth that you may not agree with so you have to be proactive in ascertaining that information from the beginning. Also keep in mind that like your doctor, your midwife will not be by your side for your entire labor. You still need extra physical and emotional support. DOULA!Insurance/Payments- For midwifery care the payments are usually based on the environment. If your midwife works in a hospital system, they accept insurance much like your doctors offices do. If your midwife works in her own practice or in a birth center it will be different. You may have to pay the fees upfront and be reimbursed by insurance later. Your insurance provider may only have a select few midwives on their contract. This is the biggest hang-up I see for families wanting midwifery care. They don’t understand that it doesn’t work the way most medical providers do. They aren’t prepared and make a decision to forgo midwifery care altogether.
Don’t give up. If that is the experience you want, ask about payment plans, consider borrowing from your savings, or ask family and friends to help with gifts or loans rather than throwing extravagant showers. Do you have items you can sell? Again, you want to feel confident in your prenatal provider. If a midwife is for you plan financials ahead or get creative!Location- Midwives work in different environments. Some work in clinics and medical offices. Some work at birth centers. Some will come to your home for all of your prenatal care. If you are considering a home birth, you may want to consider how far you are from a hospital should an emergency arise. Your midwife should be able to tell you what the emergency plan will be and ideally will have a relationship with the obstetric team at the hospital. If your midwife works in a hospital, you want to consider the distance from home or work. I go into detail about why in this video.
Obstetricians
Most women have an established relationship with a gynecologist before becoming pregnant. Ideally you would just keep the same doctor right? Well, not necessarily. Some gynecologists only work as gynecologists. They do not take obstetric patients. That is not a conversation that readily comes up prior to you becoming pregnant. When I first started working as a nurse in an obgyn practice, the two doctors I worked with did not provide obstetric services. They referred their newly pregnant patients to their partners. Which means…change in personality and ideology. Here’s what to consider in choosing an obstetrician.
Birth Ideology- You have a gynecologist that you think the world of. Her bedside manner is comforting. He is gentle during your pelvic exams. You would never think of changing. That’s all wonderful! Prenatal care is a different beast. You’re talking about a long established care cycle that’s nearly a year long, sometimes longer. You need to know if your doctor is one who automatically induces every mom older than 35, regardless of her personal health status. You need to know how your doctor plans to navigate changes from normal delivery. Does every change lead to the operating room for a c-section, or do they allow space and time for position changes and other techniques before taking that route?
Most doctors work in call groups meaning any doctor in that group can be on-call when you go into labor. Are they on the same page as you and your doctor? Does your doctor support you having the support of a doula? Maybe they do, but does the hospital they have privileges at agree? Again, this is all information that a doula can help you navigate so you know the right questions to ask. You don’t want to be in your third trimester before you realize you and your doctor don’t agree on anything. Have these conversations early.Insurance/Payments- Most of the time doctors are contracted with insurance companies. You will need to check with your insurance company to ensure that your doctor is “In-Network” with your plan. Your doctor has a billing or insurance specialist who takes care of this on your behalf. In most practices that person will sit down with you at the beginning of your prenatal care with a contract that outlines your obligations and your insurance company’s obligations for payment.
There are families who assume that they can’t afford the midwifery care they want. They assume that because they have insurance, the ob bill will be covered in full. That unfortunately isn’t the case most times. Sometimes the out of pocket fees for a hospital birth are similar to the full cost of a midwife. So again, planning and being proactive early in your care is key.Types of Practice- People often miss how much the type of practice your doctor is in affects your healthcare. You can think of the difference in practices much like you think of big business v small business. I’m suddenly recalled to You’ve Got Mail, the film in which Tom Hanks’ new big box bookstore threatened Meg Ryan’s quaint, nurturing, loving little community book store. Now I have to watch it. I’m sure it’s been a decade or more since I last watched it.
Back to you…if you have a doctor who is part of a large hospital system, there’s bureaucracy and red tape that your doctor has to navigate in terms of decision making. Protocols and policies are in place that may have nothing to do with evidenced-based care, but is what the hospital system has deemed as best practices. This may mean that your doctor will follow blind protocols without much regard to your personal health and/or choices. It may never be an issue, but you need to know.
On the other hand doctors who work in their own established private practice may be more flexible about your choices. However, even many of them are joining call groups with other practices for work-life balance. That may still leave your care up to big-hospital politics on your labor day. Another consideration is your own schedule. Can you afford to have appointments rescheduled because your one-shop-doc covers all of his own births?
You may find it convenient to be in a practice with multiple doctors. Especially if having the same doctor isn’t a big deal to you. That also gives you a chance to learn more as each provider will have differing perspectives on pregnancy and birth. How long does it take for you to receive results from the lone doc who answers every patient call herself vs the doctor in a group-practice with nurses who can handle those calls for you. You have to know yourself, your needs, and be able to communicate those to your provider.
The vision you have for your ideal birth will set the tone for every decision you make during your pregnancy. If you equip yourself with the knowledge and build your birth team with that in mind from the beginning, you will have a smoother birthing experience. It always starts with you.
Blog Contributor, NBDA Member, Anya Willoughby
