Choosing Your Birth Attendant and Location
Midwives, OBs, Doulas, Birth Centers, Homebirth, & Hospitals
May 2, 2009
Depending on where you are live in the country, rules for providers and facilities vary greatly. Nationwide, choices for providers include Obstetricians (OB), Certified Nurse Midwives (CNM), and Direct Entry Midwives (DEM): midwives who enter the profession of midwifery directly, without first becoming nurses. The term includes Licensed Midwives (LM), Certified Professional Midwives (CPM), and traditional or lay midwives.
CNMs are advanced practice nurse practitioners and are licensed in all states, but their scope of practice varies according to the state licensure laws. For example in Iowa, CNMs can practice autonomously and prescribe medications within their practice scope. However in Texas, CNMs are required to have an OB "backup," that is, someone to sign off on their prescriptions and to be on call. Hospital policy also mandates where CNMs can practice, so even if you live in a state where CNMs have a lot of freedom, you may still not be able to have a CNM for your hospital birth if the hospital of your choice does not employ them or give them "privileges." CNMs practice mostly in hospital or birth center settings.
CPMs are specialists in normal pregnancy and childbirth in out-of-hospital settings. Certified Professional Midwives are now licensed in 26 states as of last month. The CPM credential is a nationally-recognized certification for direct-entry midwives and involves serious classroom time and clinical training through apprenticeship (the original midwifery education). Many consumers and midwives are pushing for states to recognize the CPM credential so there can be a standard for care and proper respect for these educated providers, not to mention legal status. In states where no licensure is available, Direct-Entry Midwives are driven underground to practice, so you won't likely find them in the yellow pages! However, even in states where midwives are not licensed, CPMs and other direct-entry midwives are likely to be practicing. Word of mouth will often easily land you in the caring hands of a midwife if you are seeking one.
Direct-Entry Midwives who are recognized through state licensure are known as Licensed Midwives (LM). Most LMs are also CPMs.
Certified Midwives (CMs) are similar to Certified Nurse Midwives in their university-trained midwifery background, but are not trained as nurses. They are licensed in NY, NJ, and RI only.
Doulas can provide pre-natal, labor, and/or postnatal care. Many people choose to have a doula during their labor to be an objective voice and pair of hands--in addition to the partner who may become squeamish with the needs of the laboring mama. Doulas provide a wide range of services from labor coaching and breastfeeding support, to photo albums, to catering, to laundry, to placenta encapsulation. There's a saying among moms who have had doulas: Doulas are worth the Moola!
When choosing your attendant(s), be it your doula, midwife or doc, don't be shy about interviewing several people. Everyone offers something a little different and you will find that you click with some more than others. Remember it's your birth, and it's the only one you're going to get with this baby, so don't feel bad about having it your way!
Check the hospital and your midwife or OB's C-Section rate. The C-Section rate recommended by the World Health Organization is no more than 10-15%, but many hospitals are practicing at 30-40%! If they can't tell you what their rate is, it's a bad sign. Again take the time to shop around for hospitals and birth centers. Look for the designation "baby friendly" which is given by the WHO and means that the hospital offers breastfeeding support and allows the baby to "room in" with the mom.
There are around 80 birth centers in the US, and they offer a wonderful alternative to the hospital for low-risk women (around 90% of women). Birth Centers are great for women who want to have a natural birth and are seeking a happy medium between the hospital and a homebirth. Check here to find a birth center near you.
The verdict is in on several studies on homebirth, and the good news is: they are just as safe as hospital birth, with many fewer interventions. So if you're feeling leery about exposing your newborn to the latest outbreak or nosocomial infection, you can feel confident about choosing a homebirth over the hospital as long as you do your homework on finding a provider you trust. Truly, we should get with the rest of the world who never stopped having homebirths and who continue to have significantly better maternal and infant mortality rates than the US every year.
Two films which came out fairly recently and offer great information are The Business of Being Born & Orgasmic Birth.
Happy Birthing!
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