What to expect when you're expecting (14 page)

Combination practice
. A group practice that includes one or more obstetricians and one or more nurse-midwives is considered a combination practice. The advantages and disadvantages are similar to those of any group practice. There is the added advantage of having at some of your visits the extra time and attention a midwife may offer and at others the extra medical know-how of a physician’s extensive training and expertise. You may have the option of a midwife-coached delivery, plus assurance that if a problem develops, a physician you know is in the wings.

Maternity center–or birthing center–based practice
. In these practices, certified nurse-midwives provide the bulk of the care, and physicians are on call as needed. Some maternity centers are based in hospitals with special birthing rooms, and others are separate facilities. All maternity centers provide care for low-risk patients only.

The advantage of this type of practice is obviously great for those women who prefer certified midwives as their primary practitioners. A potential disadvantage is that if a complication arises during pregnancy, you may have to switch to a physician and start developing a relationship all over again. Or, if a complication arises during labor or delivery, you may need to be delivered by the doctor on call, who may be a complete stranger. And finally, if you are delivering at a freestanding maternity center and complications arise, you may have to be transported to the nearest hospital for emergency care. A big advantage is likely to be the bottom line: CNMs and birthing centers usually charge less than physicians and hospitals.

Independent certified nurse-midwife practice.
In the states in which they are permitted to practice independently, CNMs offer women with low-risk pregnancies the advantage of personalized pregnancy care and a low-tech natural delivery (sometimes at home, but more often in birthing centers or hospitals). An independent CNM should have a physician available for consultation as needed and on call in case of emergency—during pregnancy, childbirth, and postpartum. Care by an independent CNM is covered by most health plans, though only some insurers cover midwife-attended home births or births in a facility other than a hospital.

When you have a good idea of the kind of practitioner you want and the type of practice you prefer, where can you find some likely candidates? The following are all good sources:

Division of Labor

Though not yet common practice nationwide, there’s a trend that might be coming to a hospital (and an ob practice) near you. Some obstetricians, tired of running from long office hours to long overnights in the hospital delivering babies—and concerned that fatigue can affect the quality of care they provide—are looking for a better way. Enter the ob hospitalists, also known as laborists—obs who work exclusively in the hospital, only attending labors and delivering babies. These laborists don’t have an office and don’t follow patients through pregnancy.

If your practitioner tells you there’s going to be a laborist at your birth, don’t worry. But do take some steps to make sure you’re comfortable with the arrangement. First, ask your practitioner if he or she and the hospital laborists have worked closely together in the past (and make sure their philosophies and protocols are similar). You might also want to call the hospital to ask if you can meet the staff docs before labor, so that you’re not being attended by a complete stranger during childbirth. Make sure, too, that you arrive at the hospital with extra copies of your birth plan (if you have one) to hand out, so whoever is attending you is familiar with your wishes even if he or she isn’t familiar with you.

If you’re uncomfortable with the whole arrangement, think about switching practices sooner rather than later. Remember, though, that if you’re with a multiple-doc practice already, there’s a good chance your “regular” ob won’t be on call the day you go into labor anyway. Keep in mind, too, that because hospitalists focus solely on deliveries, they’re extra-prepared to give the best possible care during labor. And extra-rested, also, because they work on shifts instead of around the clock.

Your gynecologist or family practitioner (if he or she doesn’t do deliveries) or your internist, assuming you’re happy with his or her style of practice. (Doctors tend to recommend others with philosophies similar to their own.)

Friends or coworkers who have had babies recently and whose personalities and childbearing philosophies are similar to yours.

An obstetrical nurse who practices locally.

The local medical society, which can give you a list of names of physicians who deliver babies, along with information on their medical training, specialties, special interests, type of practice, and board certification.

The American Medical Association (ama-assn.org) can help you search for a doctor in your area.

The American College of Obstetricians and Gynecologists Physician Directory has the names of obstetrician-gynecologists and maternal-fetal specialists. Go to acog.org, or call 202-638-5577.

The American College of Nurse-Midwives if you’re looking for a CNM. Go to acnm.org or mybirthteam.com, or call 240-485-1800.

The local La Leche League, especially if you’re strongly interested in breastfeeding.

A nearby hospital with facilities that are important to you—for example, birthing rooms with whirlpool tubs, rooming-in for both baby and dad, or a neonatal intensive care unit—or a local maternity or birthing center. Ask them for the names of attending physicians.