Thursday, August 5, 2010

How to find a midwife?


Many times, I get asked about how to find a good midwife, as in - what questions to ask when "interviewing" prospective midwives.

There is no easy answer to this. Many midwives could "pass" the typical questions that might come to mind, but that does not automatically mean that they are a skilled midwife.

Also, personality plays a huge part in this very personal choice, and unless a lady has had a natural, midwife-supported birth, she might not even know what type of support she is looking for during pregnancy and birth.

I have been very happy with all the midwives that have attended my various pregnancies, but I feel that each time I had to chose a new one, I knew a little bit better what I was looking for, and made a little better of a choice (although again, I felt very blessed by each and every one of them). Part of that is probably also me changing in regard to how I cope with pregnancy and labor over the years, and what may at one time have been a perfect fit no longer would be quite so perfect.

Across the board, generally speaking, I have found every midwife I have ever met or talked to to be more knowledgable than the majority of OBs, with only one exception of a lady who I considered a danger to both moms and babies. That being said, all midwives are most certainly NOT created equal, and there are questions one could ask to get a feel for the prospective midwife's philosophy on childbearing.

The thing that makes it hard to separate the "wheat" from the "chaff" is the fact that birth, by design, turns out fine the vast majority of the time whether or not a midwife is present, if mom is allowed to labor in her own timing and without interventions. The midwife is a "lifeguard" - ready to jump in if there is an emergency, but most often not needed.

Thus, even a midwife who has very little skill and/or confidence of how to handle emergencies that might arise, might have rates of wonderful births 90% or even 99% of the time. The only reason why I want a midwife to attend my birth (other than to offer emotional support and comfort) is for the 1% of the time, when her skill could mean the difference between transporting to the hospital or being able to stabilize the situation at home. It's not that some midwives don't want to learn and improve their expertise - it's just that so much of their knowledge (that has been passed down for centuries) has been lost and buried because of the choke hold that the medical establishment has had on the midwifery community. For example, in the state of Arizona, midwives are not allowed to attend women having a VBAC, twins, breech babies, and a whole list of other things. I'm not saying they don't do it, but you can see why such an environment would make it difficult to obtain the necessary training to attend these births.

Trying to extract information from a midwife about the percentage of her births that transferred to the hospital (most often for a Cesarean) and why they did it, or trying to figure out if these transfers could have been prevented, without coming across as rude, prying, offensive, or a know-it-all can be a bit of a tightrope walk. It really more comes down to reading between the lines, and judging by what a midwife isn't saying.

So yes, while there are some questions that can help in the decision making process, in the end you will just have to pray about it and rely on your gut instincts. If you are undecided between a couple of seemingly equal choices, have your husband be the tiebreaker - it is amazing how they sometimes see things and pick up on them that we might have overlooked.

Here, in no particular order, are some questions to get you thinking:

- What is your background, training, and experience?

- How many births have you attended as the primary caregiver since the completion of your training?

- Why did you become a midwife?

- What are your expectations of me regarding self-care in pregnancy? What are your views on nutrition, weight gain, etc.?

- How long do your appointments typically last? What is a typical appointment like? Where do appointments take place?

- What prenatal tests do you require? Which do you recommend? Can I opt out of any, or all?

- What are your views on pregnancy, labor, and birth?

- If you are planning on having a large family, what are her views on that? Is she comfortable with and knowledgable about caring for a "grand multipara"?

- How do I reach you? Are you on call 24 hours a day?

- Do you have a limit on the number of births you attend per month? What would happen if you had 2 births occur at once? Have you ever missed a birth? Do you work with a partner or assistants? (Note: A good midwife tries to work with a partner and/or assistants so that a double emergency where both the mother and baby need special care is not a problem).

- What is your definition of "high risk"? What conditions would you transfer me out to obstetrical care for during pregnancy ("risk me out")?

- Do you provide postpartum visits in the early days after birth? How many? How long do you provide postpartum care?

- What equipment do you normally use at births? How many times have you actually used them? What medications and equipment do you have for emergencies? What is your training in those? Are you certified in CPR?

- What complications have you seen and handled? How would you handle complications such as hemorrhage, cord around the baby's neck, baby not breathing spontaneously, shoulder dystocia, meconium, etc?

- What if I need stitches?

- How do you feel about circumcision/immunizations/etc?

- Do you have adequate medical backup? Do you rely on a particular doctor or hospital? Can I choose my own physician? (If you do not wish to be seen by male doctors, it is important to let the midwife know right away.)

- What medical complications require transport to the hospital? Will you be able to continue labor support should I need to go to the hospital?

- Do you do VBACs at home? If so, what is your outcome ratio? What are the risks of doing so? (Note: In states where midwives are not allowed to attend VBACs, twins, etc. they may not be forthcoming with this information for fear of being "turned in" and losing their license.)

- What is your fee and what services does it include? Which fees are separate (ask about prenatal care, lab work, newborn assessment, breastfeeding support, postpartum care, water tub rental, birth kit, etc.)? What about payment plans? Do you accept reimbursements from insurance companies? Which ones? (As a general rule, HMOs will not cover any part of a the midwife's fees, whereas most PPOs will reimburse her for up to 50% as an "out of network" provider.) What other costs might I encounter? (Note: In the case of transport to the hospital, physician and hospital fees will be additional.)

- Who will you bring to the birth? How long will you stay after the delivery? Do you do the clean-up?

- How do you handle PROM (premature rupture of membranes), going post-dates (approaching/exceeding 42 weeks), etc?

- What is your rate of transfers/C-sections/assisted delivery/episiotomies?

- What are complications rates? How many women end up with an obstetrician? How many for pain, exhaustion and failure to progress, how many for medical complications? What are the rates among first time home birth moms vs. repeat home birth moms?

- Have you ever lost a baby/mother? What were the circumstances? (IMPORTANT: Moms and babies have always died in labor, and will always continue to do so. It's part of life and death. Babies die at hospitals every single week, but we never hear about those cases. Any hospital in a large city like ours typically has one to two such cases every single week.)

Truth be told, I have asked very few midwives even just a couple of these questions. I prefer to get them talking without me prodding them, while I just listen and read between the lines.

If you have anything to add, please do so in the comments below.

17 comments:

  1. Great idea! Wish that many more woman would research before deciding. I have a wonderful midwife, and I am excited about my first homebirth coming up! I love the picture at the bottom:0)

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  2. Based on reading some of your past posts, you have shared that you feel a woman's job is to be a wife and mother, hopefully homeschooling. Yet you've also shared that you think it is perverted for women to go to male OB's, and you favor female midwives.

    I guess I'm wondering how your opinions on the place of a woman fit in to the expectation that there will be professional, experienced females to act as midwives for pregnancies. It seems a bit like a Catch 22, but maybe I'm misinterpreting your position? Either way, I couldn't agree more with seeking out midwives over OB's for the 99% of pregnancies that are normal and healthy.

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  3. I have had two births with midwives. We hope that that Lord blesses us with more children. My question is: If my midwife is excelent, has done great in an emergancy situation (my friend used her and had an emergancy that did not turn into a c-sec becasue of the midwife) but is openly gay, has a partner, would you still use her? My options are limited and love using a midwife but don't know what to do about this. What do you think?

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  4. My husband and I are a bit lost in all of this. Here in Australia homebirth is much harder to pull off and much more expensive. We simply don't have the money for some of the midwives around here. We found a woman that runs a free practice, she is very choosy on who she will take in, but she realizes there are people who can't afford a $5000 midwife fee, and does it as a ministry. Right now she is our only option, if we don't take her we go to the hospital, because I didn't make the cut into our only birthing center (only 1/3rd of women get in, they can only take 500 a year)

    But I have some reservations about this woman, the biggest one being, sometimes there are circumstances that mean you need to go to the hospital. Sometimes there ARE necessary c-sections or medical interventions. It's rare but it happens. She seems to deny this fact and insists every baby can be born at home, she has said that the only time she ever goes to the hospital is when the family call it, she will never do so.

    She appears knowledgeable in how to care for emergency situations within her limits, she is also a registered GP, but if we go with her my husband and I will have to make ourselves aware of when to draw the line if hospital birth is necessary and rely on our own judgment for that, and that scares me, not to mention the idea of researching everything that can go wrong.

    Do you think I'm better off doing the research and taking the risk with this lady, for the sake of a homebirth which I do want dearly, or should I go for the hospital, which is probably just as much of a risk, but hospital risks are less likely to kill me if something goes terribly wrong.

    But I hate hospitals, seriously... and the one I will be put into, because we don't have private health cover, is one I don't trust.

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  5. My husband and I so far have chosen to freebirth. We do have prenatal appointments with a midwife. Sometimes midwives can intervene or just stress women out just by their presence. Midwives can cause complications. We pray about whether or not we should have a midwife for each of our children. There are risks both ways. Sometimes midwives can be life savers. However it seems more dangerous to choose a hospital birth than choosing an unassisted birth at home. I think women should consider free birth before giving up homebirth or having a lesbian midwife. ~Kathleen
    www.diyhomelife.blogspot

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  6. Courtney, one can be a midwife and a stay at home mom at the same time. My own mother managed to do it, though granted she only had 5 children in total, and they were spaced out. I would even sometimes go along with my mother to births, and they were always a good, educational experience.

    Zsuzsanna, I would also ask if the midwife has had homebirths herself. Sure, it sounds like a no-brainer, but there's a midwife in Texas (that my mother does not particularly care for, lol) who has had 3 children, and all elective c-sections! I think it's important for them to practice what they preach.

    I think the vaccination question is an excellent one. None of my brothers or my sister have ever been vaccinated due to my mother's strict stance against them.

    I asked my mother a while ago how many episiotomies she has done, and throughout her 17 years as a midwife, she said she has only had to do about 3. Like c-sections, they are often overdone.

    I could type so much more about my mother's midwifery and your questions, but I am a bit crunched on time. I will say, however, she has had many, many clients who are Independent Fundamental Baptists, and they continue to come back to her with each pregnancy.

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  7. Totally off subject, but I was wondering if you could tell me what methods your husband used/uses to memorize the Bible ^_____^

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  8. abba12, I'm in Australia too. I can't help you out with your midwife question but have you considered using a hospital but employing a doula?

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  9. Hello Zsuzsanna!

    It's been a long while since I've caught up on your blog and I'm enjoying your writing.

    Since you brought up the midwife questions and you're so close to the blessed arrival, I have a silly/fun question for you: how do you decide the names of your children? Do you leave it up to your husband, decide together, you alone? Do you wait until you see the babe? (Well, clearly that's a need to know before bestowing a name!) I do so love your children's names and they fit their personalities so well, I'd love some insight into how the elder ones got theirs and this new one will.

    And a congratulations that things are progressing along so nicely. I'm praying for you as things near.

    Mindy

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  10. Cortney,

    women have attended other women's births for thousands of years, and midwives were used in Bible times even all the way in the beginning in the book of Genesis. During the same time that home births were the norm, it was also the norm for women to stay home and not work outside the home. So obviously, being a stay-at-home mom/wife and being a midwife are not mutually exclusive.

    Ideally, natural out-of-hospital births would be the norm, not the exception. In a perfect world, all girls would grow up in an environment where they learn and witness that birth is natural, and where the knowledge how to help those who might be encountering health issues/threats is passed down from one generation of women to the next. If all the ladies in my circle of friends or even on my street had that knowledge, I would not need a midwife, I would simply call on my friends when I'm in labor. Hence the name, midwife, which means "among the wives".

    Also, not all women are able to have children, or to have as many as other women do. Even so, children grow. I would love to one day become a midwife myself when my children are old enough to be left home by themselves if I get called out in the middle of the night.

    Anonymous,

    no, I most certainly would NOT use a gay midwife. There are 2 reasons for that:

    1. The same reason why I would never use a male OB: I don't want to expose myself to someone who is attracted to my gender.

    2. The main reason: based on what the Bible teaches, I firmly believe that EVERY homosexual is a violent perpetrator. They are not just perverted in their own private way that doesn't affect me - they violate (or wish to violate) others.

    I would rather have an unattended birth than one attended by such a person.

    abba12,

    I'm sorry to hear of your situation. I have been reading a bit about the increasingly hostile environment towards midwives in Australia.

    Personally, I would rather go with that lady midwife than go to the hospital. I actually like the fact that she does not force parents to go to the hospital, but rather leaves that choice to them. It doesn't mean she won't suggest doing so, or give her opinion - but at the end of the day, the parents have to make that decision. Only a midwife who is very knowledgeable, and thus confident that such situations are highly unlikely to even arise, would be relaxed enough to do so.

    If you are concerned about the safety of this, you could ask her about her rate of complications/transfers.

    Yes, C-sections are sometimes necessary, but I think those are less than 1% of births. The reason why hospitals think the rate is higher is because they create/allow problems that then need the "big guns" to treat them.

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  11. Kathleen,

    I am aware of the unassisted/free birth movement, but personally, I feel safer and better cared for with a midwife. That being said, that's just me, and other ladies might feel just the opposite. A dear lady I know has given birth to all of her six children unassisted at home, with never a problem. It's not that she is against midwives, I think they have just never been able to afford one (plus, midwifery is illegal in the state where she lives).

    In any case, I think that women who are conscious about staying healthy are much better of giving birth at home unassisted than to go to a hospital. If my choices were between going to the hospital or giving birth unassisted, I would choose the latter in a heartbeat (unless it were a life and death emergency, of course).

    The Bible makes it clear that God is the one who takes children out of the womb.

    Stellar,

    thank you for your great input! Good point about the midwives personal birth history!

    Augustine,

    you can read about that here:

    http://www.faithfulwordbaptist.org/page8.html

    Alice,

    great point! Anyone considering a hospital birth should most certainly look into having a doula! Going to the hospital without a doula is like going to court without an attorney.

    Mindy,

    thank you for your kind comment. Good question about the kids' names. Our general "policy" is that either of us can make name suggestions, and we keep doing so until we find one we both like. Each of us has "veto" power to veto any weird names should one person just really like a name that other person absolutely hates.

    Solomon was pretty much my husband's choice only, I agreed to it only because he promised we would never use any weird nicknames for him. Isaac was chosen because out of all the names we liked, it was the only one that Solomon (16 months old at the time) could pronounce, and we wanted a name that he could say. To this day, all other babies have learned Isaac's name first, because apparently it is so easy for them. It also fits him very well, because it means "laughter", and he has been laughing out loud since the day he was born and is generally a very jovial type of person. John was named on the evening of the day that he was born (he was born in the morning), because we could not think of anything fitting sooner. We chose Miriam and Becky's names before they were born, but the names are never really set in stone until after the baby is born and we see that it "fits". Plus, we don't find out the gender until they are born, which makes us less motivated to want to find a name ahead of time.

    No names for this latest baby yet. My husband and I both have one boy's name each that we like, but we each hate and veto the other person's choice, so we will have to come to some sort of agreement. :)

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  12. You know, it's so interesting (I know, I've commented already tonight, but bear with me, I just love names) but I've always thought that John's name fit him very well--wise little John, an old soul (You'd have to check with your husband, but I believe he was the eldest lived apostle) who notices so much and says such wise things for his age. When you say he was a morning baby it makes me think of John, running to see Christ resurrected, in such complete love and faith that beautiful morning when even Peter was frozen in awe. Maybe you need a Peter? ;)

    I suppose since you were blessed with boys in a row it was a dream come true to finally use a female name!

    The Lord be with you and your family,

    Mindy

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  13. P.S. My guess was that Solomon was named for the Song of Solomon, such a beautiful celebration of love, it seems the perfect name for two newlyweds with stars in their eyes naming their first baby.

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  14. Hi, thanks for the useful information you provide on your blog. We're expecting our first child in June 2013. I would really like to use a midwife. In your pregnancies when do you typically get your first ultrasound? I'm 6 weeks/5 days right now and I'd like to be sure the baby is okay but I'm also a little nervous that the ultrasound this early could cause damage.

    Thank you!
    Renee

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    1. Renee,

      Congratulations! What a special time that first pregnancy is! I know you are excited to "meet" your baby, but I would strongly caution you against first-trimester ultrasounds, unless there is a serious medical indication. Even after that, I personally do not subscribe to routine ultrasounds, only if one becomes medically advisable (rarely).

      You can find more information online about the effects of u/s on the developing baby during the first trimester.

      Also, if there WERE a problem, it's extremely rare that anything could be done about it in utero. All it means is that you will be encouraged to "terminate" the pregnancy, and no matter how adamantly refuse, that would be more stress than any mom should have to be put through.

      I think in our "have it now" society, we have forgotten how to wait to open our Christmas presents, so to speak.

      Blessings,
      Zsuzsanna

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  15. Hi Zsuzsanna,

    Um, I am a little confused. You said it is illegal for midwives to attend women having VBACs in Arizona, so how on earth can a woman having a homebirth, like yourself, have a midwife to assist with the birth, even though it is a VBAC? Because if it is a illegal, then midwives are always breaking the law, by going to help women birth their babies vaginally at home. So, I am rather confused, how it ca be illegal, yet you have ad midwives assist you at home for VBACs?

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    1. I have never yet had a C-section, therefore none of my births are VBACs. Also, just because something is against the law, does not make it wrong, just as not everything that is legal, is right (just think abortion). Many midwives choose to ignore the law and attend VBAC moms because they want them to have healthy, safe, sustainable deliveries (automatic repeat C-sections are none of these), even if they have to break the law to help women. Just as the midwives in the days of Moses did.

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