Who you choose to provide your care in labor is one of the most important decisions you have to make during your pregnancy. You need to be aware of your choices, and how it will affect your labor. There are two main categories of care providers—doctors and midwives. Each of these groups can be broken up into different types. Most doctors who attend births will be obstetricians, but some Family Practitioners also attend births. Variations of midwives include Certified Nurse-Midwife (CNM—a registered nurse who has gone on to attain a degree in midwifery), Certified Professional Midwife (CPM—a woman who has completed a rigorous course in midwifery and become certified), and Direct-Entry Midwife (DEM—a woman who has become a midwife without getting a degree in nursing; occasionally referred to as a “lay midwife”). For more information on labor and birth practices, see my posts on “Safe Motherhood” which was taken from the World Health Organization’s report on Care in Normal Birth. It details practices which are demonstrably useful and should be encouraged, practices which are clearly harmful or ineffective and should be eliminated, practices for which insufficient evidence exists, and practices which are frequently used inappropriately.
Obstetricians tend to view pregnancy as a medical condition, and labor and birth as pathological events which must be closely monitored to keep mother and baby safe from adverse events. Midwives tend to view pregnancy as a natural condition, and labor and birth as normal events which are generally safe in and of themselves, and need only slight monitoring to ensure that everything is going well. Obviously, as with all professions, there will be some overlap—some obstetricians who view pregnancy and birth along the midwifery “model of care” viewpoint, and vice versa—but the general rule holds true. Family practitioners tend to fall in the middle—less likely to use technology and intervention than obstetricians, but more likely to do so than midwives.
Your choice of care provider many times will automatically choose your place of birth, or at least greatly limit your choices. Contrariwise, your choice of hospital will limit your choice of doctors, because doctors only practice in hospitals in which they have privileges, and a given doctor may not have privileges in a certain hospital. In this area, doctors attend hospital births while midwives attend home births. (If you know of any exceptions to this rule, or of any birth centers, please contact me, so I can correct this information.)
Two other groups of people are also important to consider: labor nurses and doulas. It is important that you have a nurse who supports you in your choices. I have read far too many “bad birth stories” in which the mother’s chief complaint was an unsympathetic or downright overbearing nurse. In general, nurses will have to follow the policy of their employer (the hospital), and may be unwilling (or unable) to make any exceptions to the “standard operating procedure.” However, there are some nurses who have said or done things that were unprofessional, for instance, mocking a woman who wanted to avoid an epidural, or belittling her choice. Most nurses are not this way; most nurses entered the profession because they are caring and compassionate and want to help people. If, however, you get a nurse that you just don’t get along with, you need to know that you have the right to ask for a nurse who is more supportive of your choices.
Doulas are women who are specially trained to assist a woman in labor. There are many certifying organizations (DONA, ALACE, and CAPPA), but not all doulas are certified. While certification is evidence of a certain amount of training and education, many uncertified doulas are just as educated and skilled. “Why should I hire a doula when I’ll have a hospital full of nurses?” Frankly, most hospitals have as few nurses as they possibly can have to monitor the number of women they expect to have laboring at any particular time. This means that much of a nurse’s time will be spent monitoring women from a central location, charting progress, and going from one woman to another. Most of the time a nurse spends in your room will be spent assessing your labor and writing it down. Studies show that the average nurse will spend 15 minutes of her 8-hour shift actually offering comfort measures or emotional support. This is where a doula can fill the tremendous gap left by the industrialization of birth. Doulas do not take the place of the father; rather, they help support both parents, and often can suggest something that your husband would not have thought of to ease your labor or improve your experience. Studies show that having a doula shortens the length of labor, and also reduces the rates of C-section, epidural and other pain medications, Pitocin, and forceps use. When you choose a doula, make sure that you get along with her (some personalities just don’t mix), and try to interview several women so you get an idea of the similarities and differences of each woman so you can make the best choice.