Choosing a Pregnancy Practitioner

Special Delivery

Jan. 21, 2002 -- Pregnancy kicks off a new chapter in your life, and one of the most important newcomers you'll meet during those nine months -- besides your baby, of course -- is your doctor or midwife. It's this expert who will demystify the incredible changes your body undergoes, answer the gazillion questions you'll have at each visit, and help create the childbirth experience you and your spouse want. That's why choosing a practitioner is probably the biggest decision you'll have to make.

Most couples choose either an obstetrician, midwife, or family physician. Individual styles and philosophies vary, but some basic generalities about each group hold true. Obstetricians offer access to all the bells and whistles that medical science has to offer. Midwives typically advocate as little intervention and as natural a childbirth experience as possible. Family physicians view pregnancy with the same holistic approach as midwives, but since they're doctors, their background more closely resembles that of obstetricians. They'll also continue to treat you and your child after birth.

Think first about the kind of birthing experience you and your spouse are hoping for, then find out which practitioners in your area can accommodate it. Is giving birth in a homelike setting rather than a hospital important to you? Do you want the option of receiving an epidural or cesarean section without being moved? The answers don't always fit into nice, neat categories: A certified nurse-midwife, for instance, might practice in a hospital where anesthesiologists are also available to administer epidurals if necessary; an obstetrician might encourage a woman to walk around and shower during labor and monitor the baby's heartbeat only intermittently. However, the provider and place of birth can narrow your options.

Above all, find someone with whom you feel comfortable, not only because you'll get the most from your prenatal visits and discussions that way, but also because you'll feel more secure during the birth. "You've got to be able to trust that individual," says Cheryl Coleman, president of the International Association of Childbirth Educators[title confirmed]. No matter how scrupulous your birth plan, she says, "when push comes to shove -- literally -- during labor, your practitioner is the one to make the final decision, either with you or for you. If you can't trust those decisions are in your best interest, you won't have a good birth experience."

One of the best ways to find a practitioner is by word-of-mouth, particularly from friends who shared your goals for childbirth. Each professional association also provides names of physicians or midwives in your area. Then visit the candidates and facilities with which they're affiliated and ask questions about their track records and philosophies. The fit between provider and patient is ultimately as unique and personal as the individuals themselves. Here's a look at three women and the different -- yet satisfying -- choices they made.

Obstetricians: Skill in High-Risk Cases, and Often More

Debbie Hall, 40, has five children, and all of them have been delivered by an obstetrician. Having been a respiratory therapist and witnessed some emergency births, she says she wouldn't dream of doing it any other way. "I just wanted to be certain that I was going to be under the best care and that the doctor I chose had the skill to handle an emergency," Hall says. Her wish list did evolve, however, to value bedside manner as much as skill, and when she moved to Irvine, Calif., before her fourth child was born, she found an obstetrician from church and PTA acquaintances who fit the bill.

"He asked questions not just about how I was feeling, but how my marriage was going, how the other children were -- it wasn't just walk in and walk out," Halls says. "He made me feel like I was the only patient he had that day." The doctor's skill and personal qualities were particularly important during her last pregnancy since test results showed a 1-in-50 chance of neural tube defects (such as spina bifida) -- a complication that had caused her to miscarry years earlier. Her doctor spent considerable time explaining what the results meant and weighing her options, and although the baby turned out healthy, her peace of mind throughout the pregnancy remained in check.

Obstetricians' four-year medical residency prepares them to treat a full range of conditions -- they have special training in prenatal care, labor, birth, high-risk pregnancy, and surgery. They are typically certified by the American Board of Obstetrics and Gynecology, and some get advanced training in a subspecialty like infertility (called reproductive endocrinologists) or high-risk pregnancies (called maternal-fetal specialists or perinatologists). Obstetricians typically resort to more technology, drugs, and surgical techniques than family physicians or midwives, but frequency rates for intervention procedures such as epidurals and cesarean sections vary by provider and institution. Obstetricians also are becoming more flexible, particularly in competitive markets, to support nontraditional requests from couples, such as the use of music, different childbirth positions, and doulas, says. John Larsen, MD professor of obstetrics and gynecology at George Washington University.

Midwives: The 'Girlfriend' Approach

A full year before she even got pregnant, Holly Sanders, 38, knew she wanted to deliver at The Maternity Center, a freestanding birthing center staffed by midwives in Bethesda, Md., after hearing about friends' experiences there. "Initially it was sort of a gut-level reaction," says Sanders. "I knew I wanted to have natural childbirth, and I've always found hospitals off-putting. I felt like birth was not a sickness but a beginning, and my own comfort level was being in a birthing center with midwives and the hominess that environment offered."

Once she began her prenatal visits, she liked the control and responsibility the midwives left to her. "I really liked the sense of women doing for themselves, of taking into our own hands this wonderful miracle that is natural to our bodies. It was the little things, like going to get your own chart and weighing yourself ... and the care was personal, like a good girlfriend sharing information with you," Sanders says.

"I felt much more relaxed asking questions because it wasn't as formal or clinical a setting as a normal doctor's office." After her daughter was born, Sanders and her husband dozed together with their daughter and woke up a few hours later to a pancake breakfast prepared by her best friend, brother, and sister-in-law. "It was a really wonderful way to have our first day with our baby."

Certified nurse-midwives are registered nurses who typically receive 18 months to two years of midwifery training and are then given credentials by the American College of Nurse-Midwives. They are licensed in the state where they practice and may provide care either in a hospital or birth center. Some nurse-midwives practice in partnerships with doctors, but they all have consulting relationships with an obstetrician in case a patient needs more specialized treatment. Lay midwives, on the other hand, may have the same training, coursework, and clinical experience as certified nurse-midwives, but they usually aren't nurses and deliver in the home or a birth center. Their experience, licensure, and legal standing varies significantly, both individually and from state to state.

Nurse-midwives generally rely on less invasive methods of pain relief and labor management than obstetricians. They use about 12% fewer interventions, such as episiotomies, epidurals, and electronic fetal monitoring, and their rate for cesarean sections was 8.8%, compared with 13.6% for obstetricians, according to a recent study. Midwives also encourage couples to make birthing plans, provide more hands-on care during labor, such as massage, and teach women "that birth can be gentle, quiet, and respectful," says Jan Kriebs, a certified nurse-midwife who practices with physicians at University of Maryland Medical System in Baltimore. "It's the woman's job to give birth and ours to support her."

Births by certified nurse-midwives also are considered safe for most women. A nurse-midwife's limitations vary depending on experience, place of practice, and arrangement with the consulting physician, but they generally won't accept women with significant health problems such as heart disease or insulin-dependent diabetes, and they don't normally handle multiple births beyond twins. They also cannot administer anesthesia or perform surgeries, but they do monitor patients carefully throughout pregnancy and childbirth, and will consult with or refer patients to a physician if they need an epidural, C-section, or other special medical care. A recent study of birth-certificate data showed that infant mortality and low birth weights were about one-third less common with nurse-midwives after adjusting for risk.

Family Physicians: Beyond the Pregnancy

They say the best way to find out about a doctor who delivers babies is to talk to the delivery-room nurses, so when Laurette Platt, 38, a labor, delivery, and emergency nurse in Fillmore, Utah, got pregnant, you could say she was the horse's mouth. In fact, that's how she chose Brent Jackson, MD, her own family physician, to deliver her fourth child, even though she had used an obstetrician for her other children before moving to the small town. She chose Jackson despite warnings from her last doctor to stick with an obstetrician because she had hemorrhaged during her last delivery. The closest obstetrician was 90 miles away.

"I'd sort of been brainwashed in nursing school and from my previous pregnancy experience that I had to use an ob-gyn. But I had worked with Jackson. I knew his skill. He's as skilled as any ob-gyn I've ever worked with. And I saw how he good he was with his patients. He was willing to try anything I wanted as long as it was safe for mother and baby. I requested not to have an episiotomy (which is a cut made below the vagina to widen the opening during delivery), and he didn't give me one."

Jackson's background in family-practice medicine, which provides training in a broad spectrum of medical care and emphasizes a patient's emotional well-being, not just physical conditions, turned out to be a plus for Platt. When her husband, Mark, was shipped out to Haiti on a military mission during the pregnancy, Platt developed an irregular heartbeat and started getting anxiety attacks. Jackson speculated the condition probably was related to the stress of worrying about her husband. "I was having a hard time, and he really worked with me," says Platt. "He was very kind and patient, and he treated me with a lot of respect."

Only about 30% of all family physicians deliver babies, and the ability to find a family practitioner to manage your pregnancy will depend on a variety of factors, including the existence of a family-practice medical training program in your area and competition from local obstetricians. In rural towns, family physicians are often the only doctors for miles and routinely perform obstetrical care.

Like midwives, family physicians try to keep the process as natural as possible. "I approach a pregnancy as a family event, a positive thing, a happy time in people's lives," says Bruce Bagley, MD, a family physician in Latham, N.Y. "We acknowledge that there's going to be some pain, we give some nonmedication ways of dealing with it, involve the husband or father and family so the woman isn't winging it, and keep medicines to a minimum." Family physicians usually won't take high-risk cases, and they consult with or refer to obstetricians and other specialists when necessary. Some perform cesarean sections, but most refer patients to specialists if necessary.

In the final analysis, whether it's an obstetrician, midwife, or family physician, all providers perform the same routine tests, screenings, and prenatal care necessary to monitor the health and safety of the mom-to-be and her baby, and they're mindful to seek the extra support their patient needs when she needs it. In 1996, about 93% of all births were performed by a doctor (including obstetricians, family physicians, and doctors of osteopathy), and about 6.5% were attended by midwives (certified nurse-midwives and lay midwives).

"It's really the personality of the person you're choosing -- somebody you get along with, somebody that listens to you, somebody who's sensitive to your issues," says Bagley. "That's the stuff that makes people like their provider, not the plaques on the wall."