Choosing an OB-GYN or Midwife
While there are important differences between an obstetrician-gynecologist (OB-GYN) and a certified nurse midwife (CNM), the distinction is not as stark as it once was. The majority of CNMs deliver babies in hospital settings, and many OB-GYNs are adopting a more holistic approach to preventive care. To help you find a great obstetrical provider, we have compiled answers to common questions about OB-GYNs and CNMs. Knowing the basics about these practitioners can smooth the way to a happier, healthier pregnancy and birth.
Where Do I Start?
Choosing between an OB-GYN and a CNM is easier if you first pinpoint what is essential to you in a provider. This may be their credentials, their views about pain medication, whether they will be at your side throughout your labor and delivery, or the location of their office as it relates to your home. Take a moment to write down your priorities, keeping in mind that you may have to make some concessions along the way. At the end of this article is a printable questionnaire to use when visiting prospective providers; by the same token, answering these questions will help you formulate a more precise picture of who you are looking for.
When Should I Begin Looking?
The optimal time to locate a prenatal provider is before you conceive. There are a number of advantages to getting an early start. You can take your time finding someone you really like without the added pressure of needing immediate prenatal care. You will also avoid putting your future developing embryo at risk by adopting the health and wellness information covered in preconception visits. These include eating right, getting enough exercise, taking folic acid and prenatal vitamins, and abstaining from alcohol, tobacco, and drugs. Both OB-GYNs and CNMs see clients for preconception visits. If possible, make the appointment at a time when both you and your partner can attend.
If you are already pregnant and do not have an obstetric provider (or if you have one but feel it’s not a good match), begin your search as soon as possible. When you call, let them know you are pregnant. They may bring you in immediately or ask you some questions over the phone and schedule an appointment in a few weeks’ time.
Obstetrician-gynecologists are physicians who have completed four years of medical school and an additional four-year obstetric residency program. They take a written and oral exam to become board certified by the American College of Obstetricians and Gynecologists. Some OB-GYNs undergo additional years of training specializing in areas such as reproductive maternal-fetal medicine, endocrinology (infertility), and gynecologic-oncology (cancer of female reproductive organs).
Certified nurse midwives are registered nurses, the majority of whom have completed an additional two years master’s program in midwifery. As a part of their studies they are required to complete a program of clinical training. CNMs must pass a certification exam to be certified by the American College of Nurse Midwives (ACNM) and are licensed in the state where they practice.
What Exactly Is a Certified Nurse Midwife?
The word midwife derives from the Anglo-Saxon mit wif meaning “with woman.” CNMs regard birth as a natural, albeit challenging, experience rather than a medical condition in need of a cure. Nurse-midwifery is legal in all 50 states and the District of Columbia.
“The focus is on prevention, on emotional support, and on health and wellness,” says Lisa Summers, CNM, DrPH, senior technical advisor at the American College of Nurse Midwives in Washington, D.C. “If you want someone to support you in making your own decisions about your birth, then midwifery care might be a good match for you.”
Certified nurse midwives offer women the same nonsurgical, gynecological, and obstetrical services as an OB-GYN. These include annual gynecological exams, full-spectrum prenatal care with all tests and screenings, birthing privileges at hospitals and birth centers, and postpartum follow-ups. While not averse to the use of pain medication, most CNMs favor other relaxation and pain management techniques such as deep breathing, massage, visualization, varying a woman’s position during birth, and laboring in a warm bath.
Certified nurse midwives are always paired with a physician during a woman’s pregnancy and delivery. Depending on where she works, a midwife may or may not be able to accommodate higher risk cases. Those partnered with a perinatologist at a large urban hospital are more likely to take on women expecting multiples or those attempting a vaginal birth after Cesarean (VBAC). Midwives at smaller centers or those partnering with a family practice physician will probably refer high-risk pregnancies to an OB-GYN. During your preconception visit with a CNM, ask her which situations she and her staff (including the attending physician) are equipped to handle.
What CNMs cannot do is surgery, including Cesarean deliveries (C-sections). Should you need a C-section while laboring with a midwife, the partnering physician would perform it.
Special Health Issues
Do diabetics have to see an OB-GYN?
Not necessarily. Under specific conditions, women with metabolic disorders, cardiac irregularities, and unusual obstetrical histories can use midwives for their prenatal care and delivery.
“If you are a woman with a medical problem, particularly if you are in an urban area, you may well find an academic medical center or a practice where the midwives are collaborating with perinatologists,” says Summers. “That way, you can have the best of both worlds.”
If you feel more comfortable seeing an OB-GYN, make sure to ask about his or her experience with cases such as yours.
“Some general obstetricians are set up to follow a pregnant diabetic,” says Dr. Sharon Phelan, MD, FACOG. “In smaller communities, where there may not be an obstetrical specialist, you may end up seeing two people. You need to find out which provider in your area is best able to meet the needs of both your illness and your pregnancy.”
Is it true that I can’t get pain medication or an epidural if I deliver with a midwife?
Many women are surprised to learn that CNMs can provide them with an epidural during labor. Certified nurse midwives delivering on the labor and delivery floor of a hospital have the same authority as OB-GYNs to order epidurals for their patients. (Neither CNMs nor OB-GYNs actually administer the epidural; an obstetric anesthesiologist does it.)
If a woman decides she needs an epidural while laboring in a hospital birthing suite, she will be moved to the labor and delivery wing. Midwives performing home births or delivering at a freestanding birth center cannot supply women with an epidural. All CNMs can, however, provide patients with pain relievers such as Nubain, Stadol, and Demerol. At your preconception visit, find out which pain medications the midwife can offer and her feelings about their use. The last thing you want while in labor is to discover that your CNM cannot (or will not) supply you with the pain medication you need.
Assuming you are experiencing an uncomplicated pregnancy, your prenatal visits with an OB-GYN and a CNM will be very much the same. Both will schedule your appointments at similar intervals (roughly once a month until the 28th week, once every two to three weeks until week 36, and then once a week until you deliver). They will weigh you, listen to your baby’s heartbeat with a fetal monitor, measure your belly, and test your urine for proteins and sugar.
Certified nurse midwives, like OB-GYNs, can order blood tests and lab work, refer you to specialists, and arrange for all necessary screenings and diagnostic tests. Both OB-GYNs and CNMs should inform you of both the benefits and the risks associated with some of these screenings and procedures.
Appointments with a CNM are generally longer than those with an OB-GYN. Skyrocketing malpractice insurance is driving many OB-GYNs out of the baby delivering business. This translates into busier days and tighter schedules for those still practicing. CNMs have traditionally put great emphasis on answering women’s questions and providing them with comprehensive health and wellness information. That said, there are many OB-GYNs who are wonderfully thorough and spend quality time with their patients.
Finding a Practitioner
If you are happy with your gynecologist, but he or she is not an obstetrician, ask for two or three referrals. Friends and family members that have recently given birth are another great resource. They can give you a candid assessment of the provider’s personality and procedures before you invest time in a visit.
You can locate an OB-GYN or CNM in your area by logging onto the websites of the American College of Obstetricians and Gynecologists or the American College of Certified Nurse Midwives.
If you are concerned about a physician or want to file a complaint, contact your state medical board. The Federation of State Medical Boards lists member contact information (click on “State Medical Board Information” then “Board Directory”).
Most large insurance companies cover the costs associated with prenatal visits to an OB-GYN or CNM, and a hospital birth.
According to an informational handout available from ACNM, 33 states mandate private insurance reimbursement for nurse-midwifery services, and Medicaid reimbursement is mandatory in all states.
It is always a good idea to contact your insurance company directly and verify the details of your plan. If an insurance employee tells you that midwifery care is not covered, confirm the information by speaking with a manager.
“We have made great headway,” says Summers, “but there are still people answering phones at insurance companies who think midwifery is illegal or only for home births. So you may have to push a little.”
If you are pregnant and uninsured, you may qualify for Medicaid. If not, call the obstetrical practice or birth center you are interested in and ask if they have a sliding fee scale. If the answer is no, ask that they refer you to another practice or nonprofit women’s health organization that has one.
What Should I Look for in a Provider?
Finding a qualified provider whom you trust and feel comfortable with is of utmost importance. Whether it is an OB-GYN or a CNM, he or she should be happy to answer your questions and encourage your input.
You can increase your chances of a great partnership with the provider by letting him or her know, early on, what is important to you. For many women, pain medication is a pivotal point. If you hope to labor without pain medication, make sure your provider is supportive. Ask about familiarity with other, nonmedical forms of pain management. Alternatively, if you are planning on an epidural, avoid the practitioner who tries to talk you out of it.
Here are some other things to consider:
- Credentials/References: He or she should have reputable and current credentials. Find out how long he has been in practice. Does she come recommended by friends, family, or other professionals?
- Birth Philosophy: What are her views on pain medication during delivery? How about breastfeeding? Does she encourage you to trust your instincts and your body’s natural birthing ability? Are you comfortable with her use of medical technology and intervention?
- Procedures: A great way to get many procedural questions answered is to ask your obstetric provider to describe a typical birth. Ask her to begin with the first phone call from a laboring woman, through the birth and subsequent hospital stay.
Find out when the provider meets patients at the hospital or birth center, whether he will be present during the majority of the birth, and his use of Pitocin (a synthetic form of Oxytocin used to induce or quicken labor), forceps, or vacuum extractions. Are episiotomies (an incision to increase the vaginal opening for birth), enemas, fetal monitoring, and IVs mandatory or elective? When can you expect to see the OB-GYN or CNM after delivery?
- C-Section Rate: If you are seeing an OB-GYN, find out his or her C-section rate. According to Dr. Phelan, between 15 and 30 percent is about average (keeping in mind that doctors handling higher risk cases may have higher percentages). Ask under what conditions a doctor would opt to do a C-section.
- Cross Coverage: There is a chance that the OB-GYN or CNM you are seeing for your prenatal visits will not be the one delivering your baby. Find out as much as you can about the people providing cross coverage. In a group practice, you may be given the option to cycle through the providers during your prenatal appointments to meet everyone. If your provider is a sole practitioner, get the name and contact information for her back-up physician.
- Emergency Availability: How easy is it to reach your OB-GYN or CNM in an emergency, on weekends, and holidays? To whom can you direct questions between visits? Find out how to contact the doctor or midwife on call and ask how quickly you can expect him to get back to you. If you are anticipating a summer delivery, find out if your provider is likely to be on vacation.
- Support Staff: You do not have to love everyone in the office but you shouldn’t feel intimidated or routinely rushed, either. Ideally, the nurses, physician’s assistants, and office staff work as a team to facilitate your visits.
- Administrative Issues: Does the office have evening or weekend appointments? Do they take your insurance? Do they offer a sliding fee scale? Will they schedule prenatal appointments two or three months in advance? How long will you be sitting in the waiting room before each visit? Instead of directing these questions to your OB-GYN or CNM, ask the nurse or front office staff.
- Delivery Site: If you are not planning a home birth, find out how far the hospital or birth center is from your home. Knowing as much as possible about the hospital or birth center can greatly minimize confusion on the big day. Remember, just because your OB-GYN is comfortable with some of your requests does not guarantee that the hospital will be. Take a tour, meet with the nursing staff, and familiarize yourself with their procedures and policies. If you cannot visit, call and ask to speak to someone about the facility. (In a hospital, ask to speak with the charge nurse in labor and delivery.)
- Coming Home: It may seem like a million miles away, but the day you and your baby will be home (and on your own) is closer than you think. Find out what postpartum resources your CNM or OB-GYN can provide. These might include contact information for local breastfeeding mothers’ groups and lactation counselors, as well as resources for coping with postpartum depression. At the very least, your provider should schedule a follow-up appointment three to six weeks after you deliver and encourage you to call with questions or concerns.
It may take some time to find a great obstetric provider, but it is well worth the effort. Whether you choose an OB-GYN or CNM, remember to be proactive and to work collaboratively with him or her. Ultimately, you and your baby will be glad you did.
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