The two blue lines on a pregnancy test are the opening gates for a lifetime of decision making. But even before feeding, sleeping, schooling, and so on, there’s a more urgent choice to make: Who is going to care for mother and baby up to and during childbirth?
Anyone who has watched a season or two of Call the Midwife knows that our current practice of delivering in a hospital under the care of a medical doctor is a fairly recent trend that started in the twentieth century, with the advent of using anesthesia for childbirth. Yet current research shows that practices in routine hospital births today may, in fact, be unnecessary.
Which Way to Go?
In the contemporary United States, mothers basically have two options: obstetrician-gynecologists or midwives. OB-GYNs are often trusted for their credentials as licensed medical doctors, with specialties (read: years of additional training) in women’s health and pregnancy. Certified Nurse Midwives—who posses a minimum of a master’s degree and pass separate board exams to be both registered nurses and certified midwives—are commonly chosen for their less aggressive approach to monitoring and intervention.
On the one hand, OB-GYNs are sometimes written off for being too clinical. They're often painted as rushed, not taking the time to personally get to know and appreciate the birth plan of each individual patient. But midwives can be perceived as “crunchy” or overly opposed to traditional Western medicine. Every woman and every pregnancy is different. So how do you know which to choose, especially if it’s your first time expecting a child?
Hospital Delivery vs. Midwife Practice
Part of an expectant mother’s decision regarding her care hinges on where she wants to give birth. OB-GYNs deliver exclusively at hospitals or at their adjacent birthing centers, while midwives can deliver babies both in hospitals and at home. A midwifery practice typically has a relationship with an OB-GYN should a situation (like an emergency C-section) arise that is out of their skill set.
Birthing with a midwife can cost anywhere from $1,500-$3,000 (most insurance doesn't cover midwives, so this would likely be paid out-of-pocket). For a woman with health insurance, a hospital delivery cost will depend on your insurance plan; without insurance though, you can expect to be billed upward of $10,000 for a vaginal delivery without complications.
While doctors' and midwives' goals are the same—healthy baby, healthy mother—their differing approach is most apparent in bedside manner and room layout. Doctors are trained to take a clinical tone toward patients. You may see a different OB-GYN at each appointment and even during childbirth—This is true of my midwives' practice as well. A hospital delivery room will have a paper-covered obstetric table, stirrups, an anesthesia machine, an IV stand, and lots of monitoring equipment.
A midwife spends more time with patients throughout the pregnancy, labor, and delivery. Matching her natural birthing methods, a midwife's delivery room is more likely to have a daybed in a setting that looks like your bedroom. A low-tech, high-touch model, midwives use technology such as fetal monitors but largely rely on their clinical experience.
You Can Have Too Much of a Good Thing
So which to choose? Earlier this year, the American College of Obstetricians and Gynecologists (ACOG) published a recommendation that may make it easier to settle on a decision. Endorsed by the American College of Nurse–Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses, the ACOG reports, “Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor.” Low-risk pregnancies can be defined in a variety of ways, but generally means a woman without conditions that would classify her as "high-risk": she is under 35, carrying a single child, not overweight, and with no known existing medical conditions. An OB-GYN should confirm a normal (i.e., low-risk) pregnancy with a health history, ultrasound, blood tests, and a physical exam. If a midwife needs to refer you elsewhere, she will, but midwives are not only for low-risk pregnancies.
For low-risk pregnancies, the "common" hospital labor practices that the ACOG calls out as being of limited benefit include: not allowing a woman food and drink in the later stages of labor; continuous infusion of intravenous fluids; continuous fetal heart rate monitoring; amniotomy (also known as “breaking the water”); limiting the birthing positions a woman can take; and a technique termed “Valsalva,” during which she is directed to push for a certain length of time with each contraction. So while these practices may be necessary in a high-risk pregnancy, if you have a low-risk pregnancy, these practices may just be increasing your hospital bill, not improving your delivery experience.
Getting Back to Nature
The new ACOG recommendation essentially suggests that hospitals should offer women more options between an OB-GYN or a midwife, and provide her with individualized support along the way. If a pregnant woman at term (37-42 weeks) goes into labor on her own and the baby is head down (the standard for normal births), she should be allowed to labor on her own, without a protocol for continuous monitoring and arbitrary restrictions. Rather, she ought to receive individualized support, including intermittent heart rate monitoring and using pain relief therapies that don't involve taking medication.
The review also goes beyond caring for the physical aspects of pregnancy: “Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula [or friend or family member], is associated with improved outcomes for women in labor.“
The recommendation states that it shouldn't be construed as endorsing one course of treatment or procedure over another, but it sure changes what most of us have expected of labor and delivery methods.
Women have been giving birth for thousands of years. Many of the advances we’ve seen in the field have improved outcomes for mother and baby, especially in high-risk situations. But clearly the most high-tech way is not the only way. If being made aware of our alternative options and individualized support means better deliveries and healthier families, I’m all in.