Your choice of a maternity care provider and birth setting can affect the kind of care you receive, the choices and options you will have during labor and birth, and the amount of involvement you have in decisions regarding your care.
Taking time early in your pregnancy to learn about different kinds of maternity care providers and birth settings can help you have a safe and satisfying birth experience.
An optimal provider and birth setting will offer you:
- Care that is consistent with the best available research on safety and effectiveness
- An environment and treatments that support or enhance, rather than interfere with, the natural process of pregnancy and birth
- Individualized care that takes into account your health needs and those of your baby, as well as your personal preferences and values
- Abundant support, comfort, and information
- Access, either directly or through an efficient referral mechanism, to treatments for complications, should the need arise.
The vast majority of women enter pregnancy healthy, with no major medical problems. If this is true for you, you can choose from the full range of providers and birth settings available in your area. If you have a serious medical condition or are at risk of developing such a condition, an obstetrician or maternal-fetal medicine specialist should be on your team and you should plan to give birth in a hospital.
The different types of midwives and physicians are explained below.
Midwives have been attending and supporting women during pregnancy and childbirth, and teaching other women to do so, for centuries. All midwives are trained to provide women with prenatal care, care during labor and birth, and follow-up care after the baby is born. In the United States today, midwives attend approximately one in nine vaginal births and about one in twelve of all births, primarily in hospitals.
Certified Nurse-Midwives and Certified Midwives
Certified nurse-midwives (CNMs) are registered nurses who have completed a graduate midwifery education program and become certified by the American Midwifery Certification Board (ACNM). Certified midwives (CMs) are a new type of midwife who receive the same training and accreditation as CNMs but who are not registered nurses. Both CNMs and CMs are specialists in the care of healthy women in pregnancy and childbirth. They also provide well-woman care, which includes gynecological checkups, pelvic and breast exams, Pap tests, and family planning services.
CNMs and CMs are able to attend births in hospitals, birth centers, or homes, and they typically have established relationships with doctors with whom they can consult as needed and who will assume care during pregnancy or labor if certain complications develop. Their services are usually covered by health care insurance policies. CNMs and CMs account for about 90 percent of all midwife-attended births.
Depending on their style of practice, a CNM or CM might be with you for your whole labor or might function more as physicians do, coming in periodically to check on you and then being present when you give birth.
Certified Professional Midwives
Certified professional midwives (CPMs) specialize in healthy pregnancy and natural childbirth. They attend births at home and, in some states, birth centers. They learn their profession by attending freestanding midwifery schools or through apprenticeship to other midwives, combined with reading and study. CPMs have nationally recognized credentials through the North American Registry of Midwives. The licensing of CPMs varies from state to state, and in some states this type of midwifery is illegal or unregulated.
CPMs may or may not have formal relationships with individual physicians and/or hospitals. It is important to carefully explore the issues of medical backup and emergency care with your provider, because you may need to arrange for physician or hospital backup yourself. (For information on who is a good candidate for home birth, see Choosing a Place to Give Birth.)
Insurance coverage of CPMs differs from state to state and insurer to insurer. It is more common where home birth midwives are licensed.
Some midwives are not certified and consider themselves “traditional,” “independent,” or “direct entry” midwives. Although many such midwives are experienced and practice safely, the lack of a national credential and, in most cases, a license to practice makes it difficult to evaluate their skill and safety record. If you are considering a midwife who is not certified, ask careful questions about the midwife’s training and experience and her arrangements for referral and transport if complications develop.
In the United States, physicians attend about 90 percent of all births. Here’s a look at the different type of physicians who commonly provide care to pregnant women.
A family physician is a medical doctor who is trained to provide basic, comprehensive care to people of all ages. Some family physicians provide maternity care and have hospital delivery room privileges. A few are trained to perform cesarean sections. These doctors often know the whole family, which can enhance planning for a woman’s care as well as the care of the baby after birth. Studies have shown that family physicians’ use of common interventions such as episiotomy, cesarean, and labor induction tends to fall between that of midwives and that of obstetrician-gynecologists.
Increasingly over the last several decades, obstetrician-gynecologists (OB/GYNs) have replaced family practice doctors in providing maternity care. OB/GYNs have completed a four-year medical and surgical residency program in obstetrics and gynecology after completing medical school. Because OB/GYNs are trained to diagnose and manage complications of pregnancy and birth, they are excellent providers for women or babies who have serious medical conditions. Women with such health problems may benefit from shared care with a midwife. OB/GYNs also provide care for childbearing women without specific medical concerns who either prefer to work with an obstetrician-gynecologist or must do so because of limited options.
OB/GYNs commonly provide prenatal check-ups and oversee labor but rarely stay with you throughout labor and may be present only at the time of birth. (During labor, your hands-on care is generally provided by labor and delivery nurses.) Because obstetrics is a surgical specialty, OB care typically involves much higher rates of intervention than midwifery or family practice–based care.
Maternal-Fetal Medicine Physicians
Maternal-fetal medicine physicians (MFMs) are sub-specialists in the obstetrics field who have additional training in complicated obstetrics. They often assume care of women with serious conditions such as diabetes or heart disease. These doctors usually practice in large academic medical centers or urban areas and see women only on referral from a physician or midwife. Many perform prenatal and genetic testing procedures and have expertise in the field of genetics. Frequently, they devise a plan of care in collaboration with a pregnant woman’s midwife or physician in her home community. If you are referred to a maternal-fetal medicine specialist, find out whether she or he actually attends births; many no longer do.
For guidance in finding and choosing a maternity care provider, see Questions to Ask When Selecting a Doctor or Midwife.