By Jamie Guertin, DNP, CNM

Too often, patients and families choose a provider for pregnancy care because the birth provider is in their insurance network, a friend recommends the provider, office, or hospital, or because the provider results at the top of an internet search in the community.

Unfortunately, these common decision pathways neglect an important set of questions every family needs to consider when choosing their birth provider. Many of these questions can start before you become pregnant.

As a certified nurse-midwife for more than a decade, I’ve seen the positive difference these questions make in patient satisfaction, shared decision-making, and, ultimately, a better birth experience. Use this background education and these simple, but imperative questions to choose your birth provider.

• What types of providers offer pregnancy care and attend births?
• What are the benefits of each provider type?
• Which providers are available where I live?
• Would I prefer to birth at the hospital, a birth center, or at home?
• What expenses does my insurance cover and what other expenses do I need to plan for that aren’t covered by my plan?
• What types of providers offer pregnancy care and attend births?

Obstetricians/gynecologists (OB/GYNs), midwives, and family practice physicians are all trained in pregnancy, birth, and postpartum care. The fundamental difference between physician and midwifery care is the lens that each profession uses to view pregnancy, birth and postpartum periods. Midwifery has always viewed these period events as normal events in a woman’s life. Physicians train to treat medical conditions instead of looking to support normal physiologic processes, and while physicians are necessary in high-risk pregnancy care and management, most pregnancies are low to moderate-risk and require support, education, and encouragement, not treatment and intervention.

Although midwives attend 14% of vaginal births in the United States each year, midwifery remains misunderstood, unappreciated, and undervalued in the United States despite a long track record of safe care with better outcomes in pregnancy and birth care (American Midwifery Certification Board, 2020). It is important to know that midwives have three different training pathways and are licensed as certified nurse-midwives (CNM), certified midwives (CM), or certified professional midwives/licensed midwives (CPM or LM). Community or lay midwives are common in many communities but do not always have training through a degree or certificate program. In 2010, the International Confederation of Midwives established a minimum education and training standard for midwives; both CNM and CM training pathways exceed these standards in the United States (American College of Obstetricians and Gynecologists, 2015).

Ask:

• Which of these providers do I want to support my pregnancy and birth care?
• What are my own beliefs about pregnancy, birth, postpartum, and breastfeeding?
• Do I believe normal or low-risk pregnancy, birth, or postpartum periods require interventions or support?
• Am I more comfortable with a certain training pathway than another? If yes, why am I more comfortable with that type of philosophy, training, or provider?

What are the benefits of each provider type?

Many studies have evaluated the stark differences between midwifery and physician care. When compared to care from a physician for birth, midwifery care is associated with lower rates of induction, lower rates of epidural use, higher chance of vaginal birth (including vaginal birth after cesarean), fewer interventions during labor, lower rate of preterm birth, a higher chance of successful breastfeeding and a higher rate of satisfaction, sense of control and confidence during birth and care (National Partnership for Women and Families, 2024; Sandall et al., 2016). Care from a physician is associated with a higher risk of cesarean birth, operative vaginal birth (the use of forceps or vacuum), induction of labor, episiotomy (a cut into the vaginal tissues during birth), use of epidural anesthesia, perineal lacerations (a tear in the vagina, perineum, or anus), continuous fetal monitoring, use of any pain medication and admission for the baby to the neonatal intensive care unit (Smith et al., 2016).

Although the benefits of midwifery care are notable, a key difference between midwives and OB/GYNs is that midwives are not trained as surgeons and do not perform surgery. All midwives who perform birth in or out of the hospital have practice collaboration plans to consult, co-manage or refer care to an OB/GYN should a patient have or develop high-risk medical conditions or require a cesarean section during their pregnancy or labor care. An OB/GYN is absolutely needed to manage or co-manage a high-risk pregnancy or for any planned or unplanned cesarean birth.

Family physicians offer the benefit of continuity of care through the pregnancy, birth and postpartum periods for the woman and the newborn baby, but only 6% of family practice physicians choose to offer this care to their patients (American Academy of Family Physicians, 2022). In studies that compare midwifery care to family practice physician care, midwifery care has been associated with lower rates of interventions and cesarean section, and higher rates of spontaneous vaginal birth and patient satisfaction levels about shared decision-making, emotional support during birth, and care that felt personalized to the patient and the family (Janssen, 2007; Declercq, 2006).

Between the three types of providers, midwifery care has the most data to support the best outcomes, but not everyone has access to a midwife in their community.

Ask:

• Which provider would best support my needs, preferences, or wishes during my birth?
• Is there something that happened during your prior birth that you would like to avoid or lower the risk of in a future birth? (example: an episiotomy, third-degree laceration, or induction of labor)
• Did I have a cesarean birth in the past? If yes, why was the cesarean birth performed and do I want to have a trial of labor after cesarean for a future birth?
• Does my current family practice physician offer pregnancy or birth care? Am I interested in using them as my birth provider or my baby’s provider after birth?

Which providers are available where I live?

To fully answer the question, you need to research your community and towns nearby. It’s best to research all options for birth providers in your area and decide which provider you think is best for you. It’s helpful to rank the options too. For example, if there are a few midwives or OB/GYNs to choose from, which is your first choice, second choice, etc.

To ensure you capture all the providers, I recommend these tips for your research:

1.     Complete an internet search or social media search with “OBGYN + [your town or community]”, “certified nurse-midwife + [your town or community]”, and “certified professional midwife + [your town or community]” (add birth center or home birth to your searches if you are interested in these birth options).

2.     Complete an internet search or social media search with “birth collective + [your town or community]” or “doula + [your town or community]”. Collectives and doulas often share information about birth in their communities or promote providers that are doing a great job. Send direct messages to these groups and they will connect you to local resources quickly.

3.     Check if your state offers a webpage for preconception or pregnancy education (usually found on the state’s webpage). Search for “Texas + state pregnancy resources” or “Colorado + state pregnancy education”.

4.     Use the ACNM’s search engine: Find A Midwife

5.     Visit amidwifenation.com/state-resources to learn more about birth resources in your state or community.

Ask:

• What type of providers are available in my community?
• Do these providers attend births in hospitals, birth centers, the home, or a combination of these options?
• What do people in the community have to say about providers in my community?
• Which providers do local doulas or birth workers recommend for pregnancy and birth care?
• Am I willing to drive 30-60 miles to seek care from a provider that I think would provide better care than a provider that is closer to me?

Would I prefer to birth at the hospital, a birth center, or at home?

Depending on where you live, you may not have an option about where to birth or you may have many options. It’s best to research what each birth environment offers than compare each birth environment to what your community offers and what your birth preferences are.

Birth in the hospital accounts for 98% of births in the United States, but hospital birth is often fraught with many interventions for the mother and the baby. While many hospitals are moving towards better support for physiologic birth, the hospital is an environment where you will have to advocate for fewer interventions. If you are looking for assistance and support during pregnancy care or navigating hospital care during your birth, doulas are a wonderful solution and offer flexible options to support

Birth centers are a valuable option between the hospital and the home. About 20,000 babies (0.5% of births) are born in birth centers each year and there are over 400 birth centers across the United States (Alker, 2024). Birth centers support physiologic birth practices and aim to support labor and birth with the fewest interventions needed. If your birth is uncomplicated, many birth centers discharge the mother and baby home within about 8 hours after birth with close follow-up in the next days and weeks. If you need to transfer to a hospital during labor or after birth, birth centers have well-defined policies to guide transfers so that transfers are safe and efficient.

Home birth is truly undervalued and misunderstood in the United States, but home birth rates are on the rise. In 2021, 1.41% (51,642 babies) of births were at home – a 22% increase from 2020 to 2021 (National Center for Health Statistics [NCHS], 2021; NCHS, 2022). I chose to have a home birth for my fourth baby with a certified nurse-midwife after three births in the hospital because I wanted to be at home with my husband and 3 small children during and after the birth while experiencing minimal interventions. It was truly a wonderful experience and remains an option I recommend for any low-risk pregnancy to consider.

Ask:

• Do I want to birth at home, in a birth center or in a hospital?
• If I had my birth in the hospital for my first birth, am I open to a birth center or home birth for my next birth?
• If I needed to transfer care from home or a birth center to a hospital, do I understand what the transfer process entails?
• If you are planning a vaginal birth after a cesarean (VBAC), ask your provider what percent of women try for a VBAC in their practice and what percent of those women achieve a VBAC? (This is a great measure of how the practice either supports or does not support VBAC!)
• If you are planning a hospital birth, what is the primary cesarean section rate for your provider or your hospital? What is the repeat cesarean section rate for your provider or your hospital (this is the percentage of women who choose to have another cesarean section)? (These questions tell you how well the provider or the hospital supports physiologic birth.)

What expenses does my insurance cover and what other expenses do I need to plan for that aren’t covered by my plan? What additional expenses or support are important to me in my birth care?

Insurance coverage is important to understand, but it’s hard to understand policy coverage, additional fees, and bills to expect. You need to call your insurance company and ask them questions ahead of time. Often, you need to call more than once to ask the same questions to a few different people to get the full picture of your coverage. Hospitals are harder to get estimates from than birth centers or home birth midwives. Some insurance companies, including Medicaid, do cover some home birth and birth center costs but this varies from state to state.

Regarding costs for pregnancy and birth care, $3,000-$4,000 in savings will cover the average cost of care. In 2022, the Kaiser Family Foundation reported the average cost was $14,768 (with $2,655 paid out-of-pocket) for a vaginal birth and $26,280 ($3,214 paid out-of-pocket) for a cesarean birth. Cost is often less with birth centers and home birth care compared to hospitals because interventions are far fewer.

Additional costs to consider include hiring a pregnancy, labor, or postpartum doula ($400-$2,000) or a lactation consultant ($100-$400). These professions are incredibly supportive and valuable to a postpartum mother and baby but are often not included or covered in insurance policies.

Ask:

• Do I have a copy of what my insurance covers for pregnancy, birth and postpartum care?
• Do I have the phone number of my insurance company to ask about my policy and expected/covered costs?
• Does my insurance cover birth center, home birth, doula support, or lactation consultant care? If so, what kind of cost is reimbursed, or what kind of benefit is provided?
• What is my state’s global fee for pregnancy care? (Do an internet search for “global maternity fee + [your state]”. This fee will give you the average cost for birth in your state.)
• What is the difference in cost between a home birth, a birth center, and a hospital birth for me?
• If the cost difference is less, would I consider a different birth provider or place for my birth?
• How much would my care cost if I paid cash compared to using my insurance plan? (Cash will almost always cost less money than using your insurance plan.)
• Based on my current finances, do I need to start an emergency fund or set aside extra money for my pregnancy and postpartum care?
• Is it important to me to save for doula or lactation support? If yes, how much do these professions charge in my community?

What happens if I need or want to change providers during my care?

Regardless of why you want to change providers during pregnancy care, this is generally easy to do if you have other providers in your community that attend birth. If you live in a maternity care desert, options may be very limited for your pregnancy or birth care and you may only have one option.

Families choose to change birth providers most often because there is a disagreement about philosophies regarding birth, miscommunication or poor communication, frustrations about inadequate front office staff or callbacks, or low patient satisfaction regarding after-hour needs, questions, or concerns.

Ask:

• Would I feel comfortable changing providers during my care?
• If I needed to change providers, which provider is my second or third choice?
• Are there providers that I could transfer my care to in my community or am I in a maternity care desert?

One last question…What areas do you need to learn more about or do research for your care?

I always offer this insight to my clients and families: Every pregnancy, birth, and postpartum experience is a little different than the one before. The best thing that you can do to prepare for birth is to do your research, learn about the options, decide which is best for you, and ask many questions along the way to ensure that the communication between you and your birth provider team is clear, supportive and transparent. What else do you need to learn to get the best care and to get better outcomes in your pregnancy care and birth for you and your baby?

Recommended Resources

References

Alker, J. (2024, August 19). Birth centers offer potential to transform maternity care through community-led approaches that focus on families of color. Georgetown University Center for Children and Families. https://ccf.georgetown.edu/2024/08/19/birth-centers-offer-potential-to-transform-maternity-care-through-community-led-approaches-that-focus-on-families-of-color/ 

American Academy of Family Physicians. (2022). Credentialing family physicians who provide maternity care. American Family Physician, 105(5), 456-457. https://www.aafp.org/pubs/afp/issues/2022/0500/p456.html

American College of Obstetricians and Gynecologists. (2015). ACOG endorses the International Confederation of Midwives’ standards for midwifery education, training, licensure, and regulation. https://www.acog.org/news/news-releases/2015/04/acog-endorses-the-international-confederation-of-midwives-standards-for-midwifery-education-training-licensure-and-regulation

American Midwifery Certification Board. (2020). 2020 demographic report. https://www.amcbmidwife.org/docs/default-source/reports/demographic-report-2019.pdf?sfvrsn=23f30668_4

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the second national U.S. survey of women’s childbearing experiences. Journal of Midwifery & Women’s Health, 51(4), 273-280. https://doi.org/10.1016/j.jmwh.2006.06.006 

Janssen, P. A., Carty, E. A., & Reime, B. (2007). Comparison of midwifery care to medical care in hospitals in British Columbia. Birth, 34(2), 140-147. https://doi.org/10.1111/j.1523-536X.2007.00164.x 

Kaiser Family Foundation. (2023). Health costs associated with pregnancy, childbirth, and postpartum care. Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/brief/health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/

National Center for Health Statistics. (2021). Changes in home births by race and Hispanic origin and state of residence of mother: United States, 2019–2020 and 2020–2021. National Vital Statistics Reports, 70(15). https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-15.pdf

National Center for Health Statistics. (2022). Home births in the United States reach highest level in 30 years. CDC Blogs. https://blogs.cdc.gov/nchs/2022/11/17/home-births-in-the-u-s-increase-to-highest-level-in-30-years

National Partnership for Women & Families. (2024). Collecting information about maternity care providers. Childbirth Connection. https://nationalpartnership.org/childbirthconnection/healthy-pregnancy/choosing-a-care-provider/collecting-information/

Sandall, J., Soltani, H., Gates, S., Shenna, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD004667.pub5

Smith, H., Peterson, N., Lagrew, D., & Main, E. (Eds.). (2016). Toolkit to support vaginal birth and reduce primary cesareans: A quality improvement toolkit. California Maternal Quality Care Collaborative. https://www.cmqcc.org

About the Author

Jamie Guertin, DNP, CNM

Dr. Jamie Guertin is a certified nurse-midwife practicing full-scope midwifery in Newport News, VA. She is passionate about fixing a broken maternal health system and started a platform called amidwifenation.com that aims to help people and midwives improve pregnancy, birth, and postpartum care. When she is not promoting maternal and infant health or midwifery, she is a wife, home-schooling mama to four little ones, an Air Force veteran, and a succulent enthusiast.

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