Birth pregnancy and depression. Choosing a caregiver by Ina May Gasgkin

Choosing a Caregiver.
P:305-307.
Exerpt from Ina May’s Guide to Childbirth. By Ina May Gaskin.

One of the greatest influences on what happens to you during labour (especially as this relates to medical interventions, procedures, and medications) depends upon whom you choose to be your caregiver.
In North America there are three separate professions that provide maternity care: midwives, family doctors, and obstetricians.
Midwives are specialists in normal pregnancy and birth. Midwifery care is individualised and focuses on minimising the use of obstetrical intervention when possible. Midwives provide all the prenatal care healthy women need. The midwifery ideal is to work with each woman and her family to identify her unique physical, social, and emotional needs. Midwifery care is associated with fewer episiotomies, fewer forceps and vacuum-extractor deliveries, fewer epidurals, and fewer cesariean sections. Midwives are trained to identify the small percentage of births in which complications develop and to refer these to obstetricians.
In the United States, there are three basic categories of midwives. Certified nurse-midwives (CNMs) are registered nurses and have completed additional postgraduate training at an institution accredited by the American College of Nurse-Midwives (ACNM). Direct-entry midwives are those who did not become registered nurses as a step toward midwifery training. There are two varieties of certified direct-entry midwives in the United States: certified professional midwives (who are certified by the North American Registry of Midwives) and certified midwives, who are certified by the ACC, the credentialing arm of the American College of Nurse-Midwives. In several states, another variety of direct-entry midwife is licenced to practice; usually these midwives are called “licensed midwives.” Not all midwives are certified or licensed.
Most of the home births in the United States are attended by some variety of direct-entry midwife, with approximately 8% of home births being attended by certified nurse-midwives. Birth centres are staffed by all varieties of midwives. The bulk of certified nurse-midwives work in hospitals.
About 30% of family doctors practicing in the United States provide maternity care. These general practitioners tend to be somewhat more prevalent in rural areas. Many do not have surgical privileges and like midwives, must refer to an obstetrician if a cesarean becomes necessary. It would be a mistake though, to consider care by family doctors or midwives inferior to that offered by obstetricans simply on the grounds that obstetricians need not refer care to a family physician or to a midwife if no complications develop during a course of labour. Several studies have found that family doctors tend to have lower rates of obstetrical intervention than obstetricians.
Some family physicians practice more within a midwifery mode because part of their residency training involved teaching by certified nurse-midwives. Other family doctors practice much like obstetricians, since in many states most receive the bulk of their obstetric training from obstetricians.
Obstetricians are doctors who have specialised in obstetrics. Their medical training is focused on detecting and treating the pathological problems of pregnancy, sometimes labour and birth. As surgeons, they perform cesarean sections and forceps and vacuum-extractor births. In North America, for historical reasons, they far outnumber midwives and family physicians who provide maternity care. In part because of their numbers and long-held dominance over the other two professions, they design most of the hospital maternity-department rules and routines. They usually determine the role played by family doctors in maternity care.
Obstetricians are trained to detect pathology. When they detect it, their training focuses on intervention and treatment. Looked at from a world perspective, the role of obstetricians in North America is unusual, since in North America, obstetricians serve as caregivers for healthy pregnant women, as well as for women who are ill or high-risk. When obstetricians provide maternity care for healthy women, they often apply interventions that are appropriate for complicated pregnancies, to all women. In most countries, obstetricians focus on providing care to women who are ill or who have develped a complication.

Interviewing a Caregiver.
P 307-310.

As I’ve mentioned before, it is not possible to determine solely by licensure, certification, gender, profession, or outward appearance the philosophy of practice of any given practitioner. Not all midwives work within the midwifery model of care; not all doctors work entirely within the limits of the medical model of care. Women are not necessarily more sensitive than men when it comes to providing maternity care.
What I’m saying here is that you need to be a smart shopper. One of the best ways to educate yourself about the care possibilities in your area is to interview several practitioners. Notice how you feel during and after your talks with them. Keep in mind that some practitioners may tailor their answers to match what they think are your prejudices. You might ask for instance: What is your practice concerning eipisiotomy on first-time mothers? How often does this happen?
Respect your own intuition. If you get “good” answers from a given practitioner but you just don’t feel comfortable with that person, you will probably be wise to continue looking for a good match.
What follows is a list of specific questions that you might ask.
Home-Birth Midwife.
How, when and where did you receive your midwifery education?
Are you certified or licensed?
What physician collaboration or backup do you have?
Do you maintain statistics from your practice? May I see them?
How many women are due within a month of my due date?
Do you work with a partner? If so, what are her qualifications?
What is your plan if someone else is in labour when I am?
Do you use pharmaceutical products to induce labour?
What prenatal tests do you require?
What are your recommendations about my diet during pregnancy?
(You should be wary of anyone who recommends a weight gain of less than twenty five or thirty pounds. If you are overweight, you should not be encouraged to lose weight or to avoid gaining beyond a certain number of pounds. Watch out for practitioners who recommend salt restriction.)
Do you carry an oxygen tank to births?
What methods do you suggest to alleviate labour pain?
Is your certification in neonatal resuscitation up to date?
To what hospital do you transport if this becomes necessary? Who will go with me?
How often will you make postpartum visits?
Do you participate in regular peer review?

Hospital-Based Midwife.
How many women do you have to care for at once?
Who will care for me if you aren’t at work when I go into labour?
What prenatal tests do you do routinely?
What procedures do you do routinely for women in labour?
Are you open to my having a doula, in addition to my husband/partner?
May I drink and eat during labour?
Can I have intermittent monitoring rather than EFM?
What methods do you suggest to alleviate labour pain?
Are there tubs or showers at the hospital? Is it likely that I can use one?
Is there a time limit on labour?
Can you put my baby on my chest (skin-to-skin contact) after birth?
Will you wait to clamp the umbilical cord until it has stopped pulsating?
What kind of postpartum care do you do?
What is your induction rate? What methods do you use?

Obstetrician or Family-Practice Doctor.
How likely is it that you’ll be present when I give birth?
If not, who will be there instead?
Can I meet all of your partners?
What is your policy on ultrasound?
What forms of pain relief do you recommend?
How many women in your practice give birth without pharmacological pain relief?
What do you think about doulas?
How often am I likely to see you while I’m in labour?
What prenatal tests do you do routinely?
What labour procedures do you do routinely?
What methods do you suggest to alleviate labour pain?
Can my baby’s heart rate be intermittently monitored by the nurses?
Do you perform episiotomies routinely? How often do women in your care give birth without episiotomy?
Can I drink and eat in labour?
If I go into labour, check in to the hospital, and my labour slows down before I get very far, can I go home?
Can I walk around in labour?
Is there a time limit for labour? How long can I push?
Can I choose the position for giving birth? Can I give birth on my hands and knees if I like that position?
What is your cesarian rate?
This may seem a personal question, but (if female) can I ask if you ever gave birth vaginally?
This may seem a personal question, but (if male and a father) can I ask if any of your children were born vaginally?
What is your forceps and vacuum-extraction rate?
Will you cut the umbilical cord after it quits pulsating?
Can you put my baby on my chest (skin-to-skin contact) after birth?

Doula.
What training have you had?
Do you have any other responsabilities that might keep you from being available when I’m in labour?
Can you provide references?
How many clients have you already worked with?
Can you tell me the range of situations you’ve worked with?

Remember that a postpartum doula’s job is to care for you so that you can focus on your baby’s care. She may do housework or cooking. You want a mature person who will truly listen to you, someone who will be calm even if you are feeling overwhelmed and stressed.

If any of the above questions provokes resentment, sarcasm, hostility, scare tactics, or vague or patronising answers, keep shopping. You would likely not put up with such treatment in a restaurant, and finding the right caregiver for you during pregnancy and birth is a far more important decision to make than where you eat a meal.


Notes and references for this chapter on page 310 of “Ina May’s Guide to Childbirth”.