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DESCRIPTION
The options in childbirth involve selecting a practitioner, type of birthing practice the practitioner works in, the type of birthing or delivery facility and birthing choices involving natural, non-medicated birthing using relaxation & visualization techniques to anesthetic choices to full surgical medical management.
Expectant parents should explore their choices and select those that match their preferences and requirements. There are limitations in many cases due to complications of a pregnancy, lack of options in smaller communities, economic constraints, prepaid health plans or insurance restrictions, and laws in some states that "attempt" to control who can attend births and perform deliveries in various settings which include home births, birthing centers, and hospital facilities.
PRACTITIONERS
DEM - Direct-Entry Midwife
CNM - Certified Nurse Midwife
Physician
Other Options - Unattended Birth
Choosing the Type of Practitioner
DOMICILIARY DIRECT-ENTRY MIDWIFE:
A Direct-Entry Midwife (DEM) is a domiciliary maternity and woman care practitioner who primarily assists expectant parents with home births. She may also be found in some free-standing birthing centers (non-associated with any particular hospital or medical group). She may also provide well-woman care, dietary & birth control counseling, and childbirth preparation instruction.
This type of practitioner may or may not be certified (CM, CPM), licensed (LM) or legally regulated in her particular community / state / country of practice. She is called a direct entry midwife because she has chosen to proceed directly into midwifery without pursuing a nursing degree. There are many excellent, qualified DEM midwife practitioners who are unable to obtain or choose not to pursue "regulatory" certifications and licensure in their practices due to legal and medical constraints in their communities of practice.
She tends to approach pregnancy and birth from a view point of being a natural, healthy function of the female body and not an illness, a pathology that needs to be cured, or something that needs to be "medically managed".
She may have entered the art of midwifery from a variety of routes, depending upon the options and training available to her. These routes may include, but are not limited to, apprenticeship, formal & informal educational routes, on-the-job experience, workshops, training seminars, and many more options.
She is fully capable of handling healthy, low risk pregnancies and births and has been trained to handle emergencies should they arise, and know when to do medical referrals and/or emergency transports to a medical facility when they are needed.
She has established practice protocols and follows evidence-based methods of health care, preventive methods and dietary guidance to promote health and well-being of the mother and baby. She uses alternative relaxation & visualization techniques, empowerment, support & other natural methods of assisting the birthing woman in place of potentially dangerous and harmful drugs and techniques used in a more medically managed institution.
MoonDragon's Main Indexlisting
For more information and links about homebirth, midwives, and natural childbirth options.
CERTIFIED NURSE-MIDWIFE:
A Certified Nurse-Midwife (CNM) is a maternity and woman care practitioner that has obtained a nursing degree before proceeding towards a midwifery educational specialty.
Although there are a small minority of CNMs that practice homebirths, most are associated with free-standing or hospital-based birth centers and hospital maternity care. She may be a primary care giver with a physician on call or she may work directly under the physician in his practice.
The CNM is restricted by regulations formed by the nursing board and is required to work under the direction of a physician or medical group. However, many CNMs are attempting to move out from underneath these regulatory confines and become more independent in their scope of practices.
Generally speaking... The CNM-entry midwives may be more medically oriented in their approach to birth and may be more inclined to a standardized "medical management" of the pregnancy than the DEM midwives. They are more likely to prescribe medications, recommend and perform more interventive procedures as dictated by their licensing board, the governing physicians, and the medical protocols that they must work under.
These dedicated women (and a few men) are highly needed in the modern, high-tech, institutionalized assembly line and interventive hospital settings. They are often the only liaison between the physician's interventions and the mother's desires to have a non-interventive birth experience for herself and her baby.
Many of the CNMs would love to have the freedom and ability to do homebirths along side of the DEMs but most of these are not wanting the legal and legislative harassments that many of the DEMs endure. While other CNMs are very content with being important caregivers in the institutionalized setting.
PHYSICIAN:
Physician practitioners may be an obstetrician/gynecologist or family physician (MD). Other types of physicians found attending births are Osteopathic (DO), Naturopathic (ND), Chiropractic (DC) and Homeopathic physicians. Although there are a few physicians who practice home births (many of these being alternative medical practitioners such as naturopaths or chiropractors), the majority are hospital-clinical based practices.
If your pregnancy appears to be a healthy, routine pregnancy then your options are open for selection of using midwife care with choices of home, birth-center or hospital settings depending upon your birth desires, or that of choosing a physician that will be able to work with your choices. However, if you are having problems and the pregnancy becomes considered "high-risk", then your options may be likely geared to the obstetrician or fetal medicine specialist.
Physicians, generally speaking, are usually geared to more interventive medical approaches to pregnancy, birth and care afterward. They are trained in pathology and surgery. This is what they know and how they practice. The rates of cesareans have risen to a national average of about 25% or higher and up to 60% in some teaching-based hospitals. Pregnancy and birth may be viewed as and considered to be a "medical problem" that needs to be "managed" by high-tech & interventive medical protocols (these protocols may not be evidence-based in practice, but might prove to be more ritual-based in their approaches and are extremely resistant to change). Pregnancy may not be viewed as something that is a natural function that women and babies were meant to experience together.
Physicians tend to spend much less time with their patients than midwives do with their clients (terms: "patient" refers to someone who is considered "sick" or "under medical care/supervision" while midwives usage of the term "client" refers to a healthy individual that hires the practitioner for the service of midwifery). Physicians are less likely to sufficiently address patient concerns or worries than midwives and are more likely to be "patronizing" toward their pregnant moms.
OTHER OPTIONS - THE PLANNED UNATTENDED OR UNASSISTED BIRTH:
Another option open to birthing couples or mothers is a home or out-of-hospital birth that is "Unattended" or "unassisted" by a health care provider or midwife of any kind. Usually these are considered to be highly controversial and dangerous, but I have also seen many planned unattended births go very well without problems. I still highly recommend prenatal care by a midwife or other health care provider with an "Unattended or Unassisted Birth" choice.
CHOOSING THE TYPE OF PRACTITIONER THAT IS FOR YOU:
There are many options open to a pregnant woman and her partner. Seek out and meet with those who provide diverse types of care. Discuss your birth plans and what you want with them. See where they stand on certain issues and find out how flexible they are regarding your plans. If you have religious preferences, then seek out those providers that follow your paths of spiritual awareness or complement your beliefs. Birth is a physical, emotional, mental, spiritual, and psychological experience that can ultimately shape and reshape a woman's being and that of her baby.
Personality considerations should be just as important as qualifications when choosing a practitioner...maybe more so, depending upon what you feel is important to you. Find one that meshes with you and your personality as well as your plans. Do not be afraid to ask questions, be informed about what you want before hand and decide what "qualifications" are important to you and your needs.
(***For me, I would rather have someone "less medically qualified and experienced", but more in tune and open to me and my plans. I need to be able to discuss my desires and fears with the person I choose and I need to feel comfortable working with them. I do not want to have to argue or fight to have things my way. I am hiring them for a service. I am able to take full responsibility for my choices and decisions regarding my health care and my body and life... instead of handing these choices over to someone else to make for me. - MoonDragon Midwife, Mother of 5, Two of which were born at home.)
Remember....You are "hiring" these people to take care of you. You have the perfect right to "fire" them as well. You have the right to choose what or what you do not want... and you can walk out and say "NO!!" to any procedure or situation that may be presented to you. Without a court order... there is nothing they can do to you without your consent and you can revoke your consent at any time, regardless of any waiver they may want or make you sign. If they proceed against your expressed will, than a lawsuit for "assault and battery" can be pursued in a court of law. Empowerment comes from within and is supported by the laws.
TYPE OF PRACTICES
SOLO PRACTICE:
There is only one midwife or physician in the practice or office. The office may be located in a commercial setting or may be located within the living-home-based residence of the midwife or physician. When the midwife or physician is away, a covering midwife or physician may be available to provides care of the clients or patients. There may be an assistant or an apprentice or other "helper" available to assist in record keeping and procedures.
PARTNERSHIP PRACTICE:
The partnership or group practice has two or more midwives and/or physicians that work in the practice and/or office. They may be of the same specialty or a combination of two or more specialties. This latter is often found in an HMO (health maintenance organization).
HOSPITAL PRACTICE:
This type of practitioner works out of a hospital setting with an office located within the institution. They are employees of that facility and must work within the confines of the protocols set up by that institution. As a rule, many of these types of practitioners do not have outside private practices or offices but practice more within the hospital clinical and research settings.
OTHER PRACTICE:
This may combine the services of a midwife and a physician, or a midwife as a primary care giver with a physician on call as needed.
BIRTHING LOCATIONS
Home Birth
Birth Center
Hospital - Medical Center
HOME BIRTH DELIVERY:
Is sometimes the first choice of many women with a normal pregnancy and expecting a normal delivery. A midwife or physician may attend the birth or it may be a planned unattended birth, as chosen by the woman and her partner.
The advantage of a home birth location is that it is usually the most comfortable for the woman giving birth. She can pick and choose who she wants to attend her birth among family, friends, attendants, children and such. Instead of having to "rush off" to a birth center or hospital, she can stay where she is and her attendants come to her. She is able to change positions, move about, eat, sleep, and use comfort-relaxation methods more effectively in the home setting.
There is much less chance of infection within her own environment and more choices open to her in facilitating her birth plans. There are no chances of lost or swapped babies, much less chance of maternal or infant injury or death, and much less chance of unwanted invasive procedures since she is empowered in her own environment. She has the decision making power and she can express it at any time and be listened to by her attendants. The mother and her baby become the focal point of the experience and she has the full attention of all attendants at all times.
If there is a need for emergency assistance, either it is handled on the spot or arrangements are made in advance for emergency transfer to a hospital if it becomes necessary. Either way, the woman and her partner have the final decision-making right.
Disadvantage of a homebirth is that this is usually planned for healthy moms giving birth to healthy babies in a stable, loving and emotionally healthy environment. Sick or high risk pregnancies are highly discouraged from actively seeking a homebirth and are usually referred to "managed care" health care providers with access to high tech equipment and medical care in a hospital setting. This is an attempt to insure that there is the best possible outcome for these high risk situations.
Transporting Disadvantages of a At-Home Planned Birth:
Transporting during a labor or birth can be disrupting and uncomfortable for the mother and baby to say the least. Although EMS personnel (either basic, advanced or paramedic levels) are highly trained in emergency situations, they are usually much less experienced in emergency childbirth procedures than the average experienced birth attendant, but they are required to follow protocols that are set up by emergency physicians with procedures that may conflict with the birth attendant's procedures. Since they are working under the emergency physician's medical license, they are required to practice emergency care under very specific protocols, which the patient/client can refuse at any time. There may also be some ego conflicts that arise between the EMTs and birth attendants.
Sometimes tough decisions must be made by the birth attendant with the parents, and occasionally these can leave bitter feelings or create blame if decisions were not made in total agreement between involved parties.
Also, the receiving hospital may be less than welcoming in attitude, sometimes even openly hostile toward the birthing parents and their birth attendant(s) that accompany them to the emergency facility. This may actually create more problems with an already serious situation and can open up legal ramifications for the parties involved, depending upon the situations, laws and resulting outcomes. This can be a very real problem in areas where midwives and other birth attendants (physicians and nurse midwives included) are considered alegal or illegal by definition of law and an active pursuit of "harassment" or "witch hunting" exists.
However, the number of pregnancies requiring hospital intervention is only a small fraction (about 5-15%)of all pregnancies (this includes all the high risk pregnancies). It is estimated that approximately 90 to 95% of healthy women having healthy babies are able to have planned out-of-hospital (OOH) births with few, if any, transportable, unmanageable, life-threatening problems for themselves and for their babies after receiving adequate prenatal care and when attended by trained, experienced birth attendants of their choice.
BIRTHING CENTER:
The birthing center or maternity center may be a free-standing facility or located in a hospital. The focus is on a "home-like" environment with family and friends sharing the birth. Often one room is used for labor, delivery and recovery.
Sometimes there is total "rooming-in" with demand breastfeeding of the infant, sometimes not, depending upon the facility. It is important to check out specific institutional protocols. There is usually limited room-space... and sometimes the rooms are fully occupied and choices must be made as to transfer to a regular hospital care facility or to return home and complete the birth there.
There may be fewer choices in birth plan arrangements and stricter protocols regarding potential problems, making transport less of a choice for the parents and more of a responsibility of the institution. In an emergency situation, there are usually standing arrangements for transfer to a hospital setting.
Emergency Transporting For Out-of-Hospital Births (Home Birth and Free-Standing Birth Center):
Keep in mind!!... that even with the best equipped and staffed hospitals, if an emergency arises it still takes approximately 30 minutes to set up and prepare an operating/delivery room for an emergency birth and gather necessary personnel to do the procedures. This is regardless of if you are in the hospital already or in transit to a hospital. So a wise rule of thumb... if you are planning on transporting an emergency situation, call first and let them know so that they can be prepping for your arrival. Many of us do not live further than 30 minutes from a medical facility.
Also keep in mind that not all medical facilities are equipped to handle all types of emergencies. Small community hospitals may not have 24 hour on-staff people available or have the equipment that may be necessary for the required procedure. In this instance, transport may be necessary to a large urban medical center either by ambulance or med-flight arrangements.
If you need to call for medical transport, here is a listing of Emergency Medical Service (EMS) Protocols for our specific region in Massachusetts. These will explain exactly what the EMS can and cannot do while in transit to a medical facility.
HOSPITAL - MEDICAL CENTER:
The hospital may or may not be a full care facility (public or private) that is equipped to handle all aspects of childbirth and any possible emergencies. Check out your hospital before you have to go there for care. Find out what they can and cannot provide. Many of the smaller community hospitals are no more equipped than many office practices or homebirth midwives (we seriously can carry a lot of supplies and equipment to a birth!).
Check to see if they have a 24 hour emergency surgical team on site for those emergencies that come in requiring immediate care. If they don't, they may not be able to put together a surgical team right away if you should need one. Also find out what situations they may "med-flight" out and where they send these cases to and the facility they are flying into.
Also ask about what their policies are before you check into the hospital. Ask about your care and options open to you. Ask about the various care providers that will be assisting you and what you should expect. Ask about what their protocols are for your various concerns, such as time restraints and monitoring devices as well as numerous other things.
It is always wise to have a birth plan set up and discussed with your health care provider or midwife prior to your birth. In emergency situations, your birth plan may not be followed or may have to be changed for the particular situation.
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