Know your Midwife

It is so important to know what you’re getting into before you’re in labor!  Interview any OBs, midwives, hospitals, and birth centers you are considering and make the best decision for you.  Also, a great new website, The Birth Survey, provides consumer reporting for doctors, midwives, and hospitals (at this point you can take the survey, but the results are said to be formulated by Fall 2008).

Here are some questions to ask your Midwife to make sure you find one who is on the same page with your birthing beliefs.  These are taken from Gentle Birth Choices, written by Barbara Harper, 2005, p. 249 (a great book, also in my library).

1. What is your education and training as a midwife?
   It is good to discern if you are hiring a certified nurse-midwife (CNM), a certified professional midwife (CPM), or a direct-entry midwife.  Find out what their training or midwifery school was like.  The three groups represent vast differences in educational experience but not necessarily in the way they practice.
2. What kind of testing or licensing procedure did you go through to become a midwife?
3. How many years have you been practicing?
   Do you want to trust a midwife who is just starting out in independent practice or do you continue your search for a more experienced midwife?  Find this out right away.
4. What is your general philosophy about pregnancy and birth?
   Midwives in general hold the philosophy that normal birth is not a medical event and needs to be respected for the creative process that it is.  I would be surprised if you found a midwife who viewed birth as a potential emergency to be prepared for.
5. Are you a mother yourself?  How old are your children now?
   If you are choosing a midwife with young children, how will she be able to attend your birth if there are family needs?  Are you open to her bringing her young children and perhaps nursing child with her to your birth?  Ask her to share her birth stories with you.  Many women become midwives after a not-so-wonderful birth experience.  Find out about your midwife’s births.  Some argue that midwives who have never given birth cannot be as good as those who have had children.  I don’t agree with this assumption; I know some wonderful, talented, caring midwives who have not had the opportunity to give birth.
6. Do you work alone or with a partner or assistant?  If you work with someone, what is his or her experience?
   It is important to meet all the people who will have any responsibility concerning your prenatal care, labor, or birth.  Some midwives take on apprentices or students.  Find this out in the beginning.
7. How many births have you attended as the primary caregiver?
   How long has your midwife been in independent practice?  Has she always worked with an experienced partner?  You may ask for references from former clients.  Some midwives provide a chance for past clients and future clients to meet each other at informal classes or support groups.
8. Do you attend births in a birth center or hospital?
   Perhaps this midwife has hospital privileges or attends births at home or in a birth center.
9. How many births do you typically attend each month?
   For a home-birth practice, the most births that one midwife with one assistant can possibly attend is six to eight per month.  If she tries to attend more, there could be two women in labor at the same time, leaving one with no coverage.  Midwives in birth centers can handle many more births per month because they can attend more than one laboring woman at a time.
10. Who takes over for you if you go on vacation or get sick?
    A very important consideration is who will take over the midwife’s practice if she is unable to continue or needs to leave for a certain period of time.  Make these plans with your midwife early on in your pregnancy.  Know that if you will be covered if anything happens to your midwife.
11. Do you have guidelines or restrictions about who can give birth at home?
12. Are these your policies or those that the state licensing requires?
    A midwife should have the same screening criteria as a doctor screening for risk factors.  Depending on licensing status, some midwives must refer to a physician for cases of breech or twins or even VBAC.  Other states have less restrictive or no guidelines.  This must be discussed.
13. Do you require that I see a physician during my pregnancy even if everything is all right?
    A visit to a backup physician is usually in order just so you can meet and he or she can establish a chart on you.  If your midwife does not have an active relationship with a backup physician, it may be your responsibility to obtain a doctor and see him or her.
14. What are your fees and what do they include?
    Just as with a doctor, most midwives’ fees cover all prenatal care, birth, newborn assessment, home care, and follow-up for six weeks.  Any lab tests, diagnostic tests, or extra doctor’s visits are not included.  Also not included are the costs of a hospital transfer, including ambulance, hospital, and doctor’s fees.
15. Can you submit your charges to my insurance company?
    Many CPM and CNM services are covered by health insurance plans or state-funded Medicaid programs.
16. What payment arrangements do you make?
    Most midwives will make an affordable arrangement to take payments throughout pregnancy.  Many even have payment forms and billing systems on their computers.  Payment of services in full is usually required before the birth.  Be considerate about the midwife’s bill and make clear and early arrangements for payment.
17. How often will I see you?
    Visits are scheduled once a month until the seventh month, every two weeks until thirty-six weeks, and once a week after that.  Extra appointments can be scheduled at any time between regular visits.
18. What are your guidelines concerning weight gain, nutrition, and exercise?
    Nutritional status will be monitored throughout pregnancy.  Most midwives focus on the importance of a healthy balanced diet and work with women to get the most out of what they eat.  Many midwives have special education in the use of herbs, food supplements, and homeopathy for pregnancy.
19. Do you require that I take a childbirth education class?  Do you teach a childbirth preparation class?
    Midwives will often teach their own preparation classes.  Some midwives feel that they give so much individualized attention that couples do not need extra classes to prepare for birth.
20. If I am planning a home birth, do you visit my home before I go into labor?
    Midwives generally make at least one home visit before they come to the house for labor.  They assure that the home is adequate and clean, and they help plan any necessary details with the couples, such as where the birth pool should go.
21. When should I call you after my labor begins?
    Each midwife sets her own protocols about when and the reasons why to call after labor begins.  Generally midwives want to know as soon as contractions begin so they can plan their day (or night).  Some midwives will have apprentices who come right away, others arrive when they are needed.  Most encourage women to enjoy the early stages of labor and to get plenty of rest and eat if they are hungry.
22. How do you handle emergencies?
    Ask very carefully just what kind of emergencies she is prepared to deal with and has dealt with in different situations.  A very experienced midwife may have different answers from someone just graduating from midwifery school, but their protocols should be very similar.
23. In what situations would I need to go to the hospital?
    Find out exactly why you might be transported.  Transports can sometimes be an emergency, but more than likely they are for women who have been laboring for more than a day and become exhausted.  Find out what your midwife’s transport rate is and evaluate it.  Most home birth midwives and birth centers have a rate of less than fifteen percent.
24. Would you stay with me in the hospital?
    Most midwives can accompany their clients into the hospital and stay with them, but in some states where midwifery is still illegal, the midwife cannot come into the hospital and admit that she has been attending a home birth.  Find out if your midwife has a good working relationship with a local hospital.
25. What is your experience with water for labor and birth?
    Midwives traditionally have used water for pain relief during labor.  Many are now advocating its use by all of their clients.   It is difficult to find a midwife today who doesn’t use water in labor or for birth.
26. Can I give birth in water?
    Ask if your midwife has access to a birth pool for her clients or if she knows where you can rent or purchase one.  Find out if she truly supports the option of waterbirth.  I have talked with many women who have said that their midwives talked about waterbirth prenatally and even encouraged water labor, but then asked the mother to get out of the birth pool at the last minute.
27. How ‘hands off’ are you during a birth?
    Is your midwife is willing to “allow” the family to conduct the birth under her supervision?  Ask if she is willing to give you complete control.  Will she encourage or instruct you and your partner when and how to catch the baby?  Will she leave you alone in another room if that is what you want?  How involved can your children be in the labor and birth?
28. What is your experience with breech births?  How many have you attended?
    Breech may be beyond the scope of practice for some licensed midwives.  Others handle it just like any other birth and specialize in breeches, especially in water.
29. What in your experience with twins?  How many have you attended?
    Twins may also be beyond the scope of practice.  Find this out before you make further plans. (It is also illegal to have twins anywhere but in a hospital in Colorado)
30. Do you cut episiotomies and suture perineal tears?
    Home-birth can birth-center midwives usually have an episiotomy rate of close to zero, but tears do sometimes happen during birth.  Unless your midwife sutures well, you may need to travel to a hospital if you need stitches.  This might influence your choice of practitioners.
31. What is your experience with a VBAC?
32. Will you attended a VBAC at home? in the hospital?
    Many midwives cannot legally attend a first-time VBAC at home because of licensing restrictions.  Some are willing to look the other way in order to give the woman a chance.  This is a very serious consideration that requires much discussion with your midwife.
33. Have you ever had to resuscitate a baby?
    Assess the resuscitation skills of the midwife.  Midwifery organizations and nursing schools teach courses in neonatal resuscitations, and your midwife should have a current certificate.  As to see it.  Ask if her resuscitation course focused on the latest information about the consciousness of newborns.
34. What kind of equipment do you bring to a birth?
    Find out what kind of drugs, oxygen, resuscitation equipment, intravenous (IV) equipment, and other emergency equipment your midwife keep sin her bags.
35. Do you examine the baby after birth?
    Midwives perform a normal newborn exam on the baby usually an hour or two after the baby has been born and breast-fed.  Assess from the midwife what her routines are for newborn exams and what she uses for eye drops and vitamin K.  She may use alternatives such as oral vitamin K.
36. Will you help me with breast-feeding?
    Midwives should be on call twenty-four hours a day, seven days a week, for all problems after birth, especially breast-feeding.  Many even have special classes or private sessions to evaluate breastfeeding readiness and answer any questions.  Some have great relationships with lactation conselors or consultants for more difficult problems.  Babies born without medications usually have an easier time breast-feeding, but that doesn’t mean every mother automatically has an easy time.
37. How often do you come to see me after I give birth?
    Home-birth midwives generally come back for follow-up visits after twenty-four hours, two days, five days, and ten days.
38. Do you provide or know of anyone who will help new mothers after birth?
    Some home-birth services provide a postpartum doula or can recommend one for help after the baby’s birth.  There is generally an extra charge that is well worth every penny.
39. Do you have a pediatrician you work with or recommend?
    Some naturopathic doctors who attend home births automatically become the pediatrician.  Midwives often have collaborative relationships with pediatricians who support home birth and possibly delayed immunizations or not immunizing at all.  Interview pediatricians the same way you would your provider.
40. How do you feel about circumcision?
    I don’t know of very many midwives who will present both viewpoints about circumcision unless their clients are Jewish or Muslim.  If there is a religious consideration, the thoughtful midwife will support her clients’ decision.