Choosing your health care provider for pregnancy

The person you choose for your health care during pregnancy can make a big difference in the type of childbirth you have. The nature of your pregnancy — determined by your age, the outcomes of your past pregnancies, and health conditions that make pregnancy and childbirth particularly risky for you — may dictate which type of health care provider is best for you. But your personal preferences matter, too.

In the United States, doctors deliver about 90 percent of babies, while midwives deliver about 8 percent. In Europe, by contrast, midwives assist at more than 70 percent of normal vaginal births. Before picking your pregnancy care provider, consider all of your options — family physicians, obstetricians, maternal-fetal medicine specialists and midwives.

Where to start

Finding the right health care provider for your pregnancy and childbirth can be a daunting process. To identify potential providers:

• Ask family and friends for recommendations.
• Consult with your regular doctor and other medical professionals.
• Contact your county medical society for a list of the providers in your area.
• Contact the hospital you prefer and find out who its maternity care providers are.

As you study your options, consider these questions:

• Is the health care provider's office a convenient distance from your home or work?
• Can the health care provider deliver your baby in the place you want to give birth — at a particular hospital or birthing center?
• Does the health care provider work in a solo or group practice? If it's a group practice, can you usually see your chosen health care provider or will you see all members of the group?
• Who will replace your health care provider if he or she isn't available in an emergency or when your labor begins?
• How much do the health care provider's services cost? Is the cost covered by your insurance company?
• What level of expertise does your pregnancy require? Will your health care provider meet that need?
• How much do you value the opportunity for your health care provider to serve the entire family?

Family physicians: Primary care for all ages

Family physicians provide care for the whole family through all stages of life, including pregnancy and birth. They have training in various fields of medicine, including obstetrics, pediatrics, internal medicine, gynecology and surgery. Training and experience qualify them to manage most pregnancies, including minor surgical procedures for vaginal delivery. Some perform Caesarean births, but most do not.

Family physicians may work solo, or they may be part of a larger group practice that includes nurses and other medical professionals. They're usually associated with a hospital where they can perform deliveries.

You might choose a family physician if:

• You and your doctor don't foresee any problems with your pregnancy
• You want your doctor to be involved with all members of your family
• You want continuity in care from prenatal appointments throughout childhood and beyond

Obstetrician-gynecologists: Traditional caregivers for pregnancy and birth

Doctors who specialize in obstetrics and gynecology are commonly referred to as ob-gyns. Besides providing prenatal care and delivering babies, they specialize in the care of women in general, overseeing prevention and treatment of conditions affecting a woman's reproductive organs, breasts and sexual function. Because of their emphasis on women's health, ob-gyns serve as the main health care provider for many women. They're trained to handle all phases of pregnancy, from preconception planning to postpartum recovery.

Ob-gyns often work in a group practice that may include recent graduates from medical school (residents), nurses, certified nurse-midwives, physician assistants, dietitians and social workers. They may be based in a hospital or clinic.

You might choose an ob-gyn if:

• You have a high-risk pregnancy. You may be high risk if you're over age 35 or you develop diabetes (gestational diabetes) or high blood pressure (preeclampsia) during pregnancy.
• You're carrying twins, triplets or more.
• You have a pre-existing medical condition, such as diabetes, high blood pressure or an autoimmune disorder.
• You want the reassurance that if a problem does arise — such as the need for medical interventions or a Caesarean birth — you won't need to be transferred to a different care provider.

Maternal-fetal medicine specialists: Advanced care for high-risk pregnancies

These doctors, also called perinatologists or high-risk obstetricians, are trained in the care of very high-risk pregnancies. They concentrate exclusively on pregnancy and the unborn child, dealing with the most severe complications that arise. When women with major medical problems become pregnant, their physicians often consult with maternal-fetal medicine specialists in order to optimize care for both the mother and her fetus. Most women don't need the services of a maternal-fetal medicine specialist because most pregnancies are fairly routine.

Maternal-fetal medicine specialists often work as part of a group practice, functioning mainly as consultants rather than primary obstetric care providers. They're often associated with a hospital, university or clinic.

You might choose a maternal-fetal medicine specialist if:

• You have a severe medical condition complicating your pregnancy, such as an infectious disease, heart disease, kidney disease or cancer
• You've previously had severe pregnancy complications or recurrent pregnancy losses
• You have a complicated family medical history, which may require your baby to undergo sophisticated prenatal diagnostic techniques or interventions, such as chorionic villus sampling or fetal surgery
• You're a known carrier of a severe genetic condition that may be passed on to your baby
• Your baby has been diagnosed before birth with a medical condition, such as spina bifida

Midwives: Attentive caregivers in low-risk pregnancies

Midwives provide preconception, maternity and postpartum care for women at low risk of complications during pregnancy. Throughout much of the world, midwives are the traditional care providers for women during pregnancy. In the United States, the use of midwives is steadily increasing. In general, midwives follow the principle that pregnancy and birth are normal, healthy, personal events until proven otherwise. As a result, midwives generally take a lower-tech approach than obstetricians and other doctors typically do.

Midwives vary in the amount of formal training they've received and the services they offer. Midwives are often classified according to their training:

• Certified nurse-midwives. These are registered nurses who have completed advanced training in obstetrics and gynecology and have graduated from an accredited nurse-midwifery program. They are certified by the American College of Nurse-Midwives (ACNM), for which they must pass several exams. Certified nurse-midwives are licensed in all 50 states and the District of Columbia. Some can prescribe medications. Most can recommend diet, exercise and lifestyle changes.
• Direct-entry midwives. These midwives don't have a nursing degree but may be trained in other areas of health care. They may have training through self-study, apprenticeship, a midwifery school or a college- or university-based program separate from nursing. They may be licensed, certified or neither. Different states have different licensing requirements. Some states have very strict standards. Others don't regulate midwives at all.
• Certified midwives. These direct-entry midwives are certified by the ACNM, for which they must pass the same exams required of certified nurse-midwives. This is a fairly new certification and is currently licensed only in the state of New York. However, other states and midwifery organizations may use the same designation for individuals whom they have licensed. Although this may sound confusing, most certified midwives are happy to explain their certification.
• Certified professional midwives. These direct-entry midwives have been certified by the North American Registry of Midwives, an international certification agency created by the Midwives Alliance of North America.
• Lay midwives. These caregivers are uncertified or unlicensed midwives who generally have had only informal training.

Most midwives in the United States today are certified nurse-midwives or certified midwives.

Midwives may practice solo but often are part of a group practice, such as a team of obstetric care providers. Most midwives are associated with an ob-gyn in case problems occur. The majority of certified nurse-midwives attend births in a hospital or birthing center. Direct-entry midwives are more likely to deliver at home.

If you're considering a midwife, check to see that he or she has a backup arrangement with a hospital so that you'll have access to obstetric skills and equipment in case of pregnancy or birthing problems. If you're not giving birth in a hospital, create an emergency plan that includes such details as the name and number of your midwife's backup doctor, the hospital you'll be taken to, and how you'll get there.

You might choose a midwife if:

• You're free of health problems and you expect to have a low-risk pregnancy
• You want someone who can spend a significant amount of time discussing your pregnancy with you
• You prefer a more personalized approach to the birthing process
• You desire a less regimented birthing process
• You desire fewer interventions

Who is right for you?

In the end, it's most important to find someone you can rely on and confide in over the next nine months. As you meet a potential health care provider, think about these issues:

• Does he or she listen to your concerns and provide helpful answers to your questions?
• Does he or she seem open to and comfortable with your philosophy regarding pregnancy and childbirth?
• Will he or she keep you informed and allow you to participate as you wish in medical decisions affecting you and your baby?

Choose someone you trust to safely guide you and your baby through the birthing process. Then, remember that you chose your health care provider for a reason, and allow him or her to give you the best possible care.