Chances are, if you’re reading this blog, you’re probably already thinking about hiring a midwife. You know all about the Midwives Model of Care and you’re ready to find the perfect midwife for your family. There’s a midwife for every woman. What’s right for one woman may not be right for another. So, how do you choose the right midwife for you?
What’s most important to you? What personality traits are most important to you? What type of practice style suits you?
Start with the big decision first. Where do you want to give birth?
This topic may require a whole other blog post, but let’s assume you’ve made up your mind about whether you want a hospital birth, birth center birth, or home birth; your decision about the birth setting will largely determine care provider options. For instance, if you want a hospital birth and you want a midwife to attend, you will hire a Certified Nurse Midwife (CNM). If you want an out-of-hospital birth, you can choose a CNM or a Certified Professional Midwife (CPM). Some women choose other options, such as unlicensed midwives and unassisted birth, but the focus in this blog post is on licensed care providers in a variety of birth settings.
Make a list of questions.
Before you meet the midwife, come up with a list of interview questions. If you don’t have a list, the midwife will likely still be able to give you a good overview of her philosophy and the care she provides, but if you have a list of questions, you’ll be more likely to come away from the experience feeling as if you have all of the information you need to make a decision. After meeting with hundreds of families over the years, these are some questions that I’ve heard:
1. How many births have you attended? How did you become a midwife?
There is no right answer here. New midwives bring new energy and up-to-date knowledge to their care. What they don’t have in experience, they make up for in resourcefulness. They tend to be very well-connected to a wide community of student midwives and experienced midwives, and they know where to turn when they encounter a non-emergency situation that requires further research.
Experienced midwives tend to have the gift of having seen a lot of births, of having helped a lot of different types of families, and having seen wide variations in what’s normal. Their knowledge and experience is vast. Where others might be nervous, the experienced midwife has “been there, done that.” Experienced midwives work hard to stay current in their field, attending continuing education classes and conferences, and participating in midwifery associations, although some are very busy in their practices and may find it difficult to find the time to participate in activities other than helping mothers and babies in their care. An experienced midwife is a gift to her community.
2. What happens if there’s an emergency? What is your role if I transfer? Do you stay with me until my baby is born? What about postpartum visits for moms who transfer?
Every midwife has a plan for hospital transfer. If you’re planning a home birth, the midwife will come up with a plan customized to your particular needs and based on your location. As a client, it’s good for you to understand what happens when there is a transfer. If you go by ambulance, does the midwife ride with you? Who goes with the baby? What hospital do you go to? What have her experiences been like there? How long does the midwife stay?
3. How many postpartum visits do you provide? Are those provided in-home or in-office?
There’s significant variation from practice to practice with regards to postpartum care. Most practices provide a postpartum visit within 24-48 hours after the birth and again at 6 weeks postpartum. There’s usually at least one other visit between those two visits. Some practices see you for a few more postpartum visits than that, and some keep in touch by phone between visits.
4. What is your fee and what’s included? Do you bill insurance? How does that process work?
Finances can get complicated. Often, if you’re a healthy person, this is the first time you will have had a major medical expense covered by insurance. The billing process is often not straightforward. Ask the midwife to explain how she handles it. Who does her billing? Will you be dealing directly with the biller or with the midwife? Is there an insurance billing fee? Is she in-network or out-of-network? Does she offer insurance benefit verification? How much is required as a prepayment towards what she bills insurance? What payment options are available? How does the reimbursement process work?
5. What labs do you require? Will you draw labs for me or will I need to go to the patient service center for that? Do you require ultrasounds? How many? Do you offer them in-house or will I need to go to an imaging center? What if I decline certain labs or ultrasounds?
How your midwife answers these questions is important. If she launches into “I require____” that tells you something about how much she values your opinion and right to make informed choices about your care. Some women want the midwife, as “the expert,” to make such decisions and have clear rules, and she may be the right midwife for you. If, on the other hand, the midwife says something like “there are certain tests I recommend, some tests are required by law in this state, and others may be worth considering depending on your history. I generally recommend ____, but I also recommend you do your research and that we discuss your options before you make a decision…” this shows a respect for you as the ultimate decision maker for your care and the expert on your own body, your right to make informed choices, as well as a commitment to a shared decision making process. For many women, this is an important characteristic in the care they seek.
6. What is your policy about postdates?
There are various factors that may affect a midwife’s postdates policies, such as hospital rules, laws in your state, physician supervision, or experience with postdates. “Postdates” means different things to different providers. To some providers, postdates means after 41 weeks. To others, it means pregnancy after 42 weeks. Does she have a firm cut-off date for you to go into labor? What happens if you go past that date? Explore the possibility of a postdate pregnancy and how the two of you would navigate such a situation. For instance, the midwife may work with an acupuncturist or chiropractor who specializes in postdate care. She may be able to offer herbal or homeopathic options for labor stimulation. The midwife may prefer that you have an ultrasound at 41 weeks to check on the baby’s well-being, or she may simply want you to count the baby’s movements.
7. What is your policy on prolonged rupture/release of membranes (PROM/ROM)? How does that change if I test positive for GBS (Group Beta Strep)?
Ruptured membranes (water breaking, release of waters) can happen before or during labor. Once it happens, there can be additional concerns about increased risk of infection. Some providers have very firm guidelines about transferring to the hospital after a certain point after ROM. Some providers have the option of IV antibiotics at an out-of-hospital birth, which can provide additional options to help reduce the need for hospital transfer for prolonged ROM.
8. Do you attend breech, twins, or VBAC births? If so, under what circumstances?
Contemporary recommendations continually fluctuate on the best practices for breech, twins, or VBAC (vaginal birth after cesarean). There is ample evidence pointing to the long-term risk of cesarean births for the mother, but there is also evidence that the risks for vaginal birth are higher for the baby. Each mother needs to evaluate her own situation to decide whether a vaginal breech birth is something she would want, as well as whether she would want that option in an out-of-hospital setting. Current training practices for obstetricians have focused solely on surgical solutions, so vaginal breech birth in a hospital setting is a rare option. It’s important to know how a midwife would handle a breech birth, and, if she doesn’t attend breech births, what practitioners she recommends.
Some midwives have experience with attending twins births and feel comfortable handling the birth on their own. Some prefer that you consult with the back-up practitioner.
VBAC recommendations continue to fluctuate, but many women who have previously had cesareans seek midwifery care for a VBAC, and most are successful. In my own experience with VBAC, the cesarean rate for the clients attempting VBAC is roughly the same as all of my other clients (5-8%). Hospital VBAC success is lower. ACOG estimates that about 60-80% of women who attempt VBAC should be able to have a vaginal birth, but only about 4-22% actually do. Virginia’s VBAC rate is 10.2%
Ascertaining your midwife’s skill level and experience with each of these situations is important. And if she is not comfortable with any of the three types of births, what is her referral practice?
9. What medications do you carry?
This will vary state to state based upon the state’s regulations for the midwife. In states where midwives are not allowed to carry medications, the midwives sometimes work with physicians who can assist with access to medications.
10. Do you use herbs, essential oils, and homeopathics?
Each midwife will have her own philosophy about herbs, oils, and homeopathic remedies. Some midwives have a lot of knowledge, skill, and experience with these modalities, while other midwives do not. Depending on the relative importance of this to you, it may be good to know your midwife’s experience with these options.
11. What is your relationship like with the medical community?
As midwifery care continues to grow, medical communities are finding ways to work with midwives in terms of transfers, back-up care, and supplemental care. Some midwives require that the mom finds her own back up care and some midwives have long standing relationships with physicians and hospitals. Regardless of your feelings or your midwife’s feelings about hospital birth, the fact is that out-of-hospital birth is safest with the option for a smooth hospital transfer when needed. Having a good relationship with the medical community can go far to facilitate a coordinated and efficient hospital transfer.
12. Have you ever lost a mom or a baby or come close to losing a mom or baby? What did you learn from that experience? How do you support moms through a traumatic birth, miscarriage, or stillbirth?
This is a difficult topic. No one wants to consider that a pregnancy may result in a stillbirth or other medical emergency. And yet it sometimes happens, in hospitals, at home, and in birth centers. It’s an unfortunate reality in rare situations, although it is more common that women can experience an early pregnancy loss (miscarriage). What kind of support would your midwife offer you if you were to miscarry? If you were to lose a baby, or face a life-threatening situation yourself, it’s important to know that how the midwife would handle the situation best matches what you would want.
13. Are you on a call schedule? Who will be on call for me? Who covers for you if you are not able to be at my birth?
The bigger the practice, the more chance of a call schedule for the midwife. Typically you will have at least one appointment with an alternate midwife. If there is a call schedule, how many midwives are in the call rotation? If it’s just two, you may be able to get to know both of the midwives pretty well. If it’s more like 4-6 midwives, it may be more of a challenge to feel a continuity of care.
14. Who assists you at births? What kind of training do they have? How long have they worked with the midwife?
Some midwives train birth assistants, apprentice-style, to serve with them at births. Others hire registered nurses (RNs) to serve as birth assistants, which is the case at the Premier Birth Center, where I practice. Other midwives allow you to shop around and choose your own birth assistant, and typically the midwife will have a list of birth assistants she has worked with in the past. It’s important that they have experience working together.
15. Do you have practice guidelines, protocols, and informed choice documents that I can see? What’s your typical prenatal care like? What would make me “risk out?”
Most midwives have practice protocols and informed choice forms. Some states require midwives to hand out certain informed choice forms. NARM requires all CPMs have practice guidelines and an informed disclosure for home birth. If you are considering hiring a CPM, she should be able to give you those documents on the spot. If you are planning a birth center birth, the birth center (especially a CABC accredited birth center) should have a Policies & Procedures Manual that details the care they provide. Seeing a midwife’s practice guidelines, protocols, and informed choice documents can give you insight into the care you would receive with that practice.
16. Do you keep practice statistics? How often do your clients transfer to the hospital and why do they transfer?
Some states also have this data available online. Contact your state department of health. These statistics will give you a good sense of how often a mother has to transfer from the birth center or from the home. Some midwives are more conservative than others in terms of deciding to transfer, so it’s good to have a discussion with the midwife to find out why she most often has made the decision to transfer.
17. How would you describe your care?
This will give the midwife a chance to share her perspective on what kind of care she offers. You can probably get a feel for her practice style just from the answers to her other questions, but asking her to describe her care gives her a moment to pause and really think about her style and what she’d like you to know about her.
18. What does birth look like with your practice?
Ask the midwife about her protocols for monitoring you and the baby. Out-of-hospital providers almost always use a Doppler or a fetoscope for monitoring your baby’s heartbeat. Hospital-based providers are more likely to prefer continuous electronic fetal monitoring, although some will be able to offer intermittent electronic fetal monitoring. Some midwives rarely do cervical exams, while some will usually do an initial cervical exam when they arrive at your birth, and then may check periodically during your labor. Some midwives offer warm compresses and oils for perineal support, while other midwives prefer a more “hands-off” approach. Some midwives encourage the parents to catch their own baby, while others are not as comfortable with that idea.
19. Do you offer water birth?
Many, but not all out-of-hospital midwives attend water births. Hospital-based providers will often support the use of water for pain relief during labor, while not supporting the actual birth of the baby in water or not supporting water labor after rupture of membranes. If the midwife does support water birth or water labor, does she offer birth tub rentals? If you’re giving birth at a birth center, be sure to ask about their birth tubs. How are they cleaned? How do they verify cleanliness (taking laboratory cultures on a regular basis, for example)?
20. Do you offer other services besides midwifery care?
Some midwives offer birth pool rentals for moms who want a water birth. Childbirth education classes, lending libraries, and a selection of supplements or teas might be offered through the midwife as well. Some midwives also offer placenta encapsulation or work with local encapsulation providers, if that is a service you would want.
Trust your instincts and trust the midwife’s instincts.
I’ve been interviewed by hundreds of women. Sometimes, we’re a good fit and sometimes, we’re not a good fit. If someone doesn’t want to move forward with my practice, I don’t take offense. I trust that a woman knows her own needs and will find the right midwife to serve her.
Sometimes, I meet someone and know instantly of a midwife who would serve her better than I, and I recommend she contact that midwife for an interview. During the interview, the midwife is interviewing you as well. It should be a good fit for you both. Don’t take offense if a midwife says to you, “I just don’t think we’re a good fit,” and refers you to another midwife. She does this because she wants you to receive the best individualized care, and she knows that the quality of the care depends on the quality of the relationship between the client and the midwife.
Do some soul searching.
The midwife you choose will become a big part of your pregnancy, birth, and postpartum experience. Before you start looking for a midwife, step away from the computer and really think about the type of person you want to have caring for you during this process.