Lauren Miller Brown, birth and postpartum doula, childbirth educator, trained homebirth midwife, and massage therapist, @laurrielou

Deciding where you’ll get your prenatal care might not be something you spend a lot of time thinking about. You just make an appointment with the OB/GYN you’ve always seen, right? That’s definitely one option, but you may want to consider widening your net for a few big reasons. 

Does your provider make you feel supported, heard, and safe? Do you feel comfortable with the birthing locations that are available to you? If your answer isn’t “yes” to either of these questions, know that you don't have to settle for the status quo; you should feel empowered to change care providers and care settings whenever something doesn’t feel right.

We’ll break down the differences between OB/GYNs and midwives, and your options for giving birth: at home, in a birthing center, or at a hospital. 

(Tip: If you’re not sure what you want, consider writing down what’s most important to you when it comes to prenatal care, birth, and your postpartum experience. Then, when you talk to potential care providers, you can see if your values align.)

First, an overview of who’s who in the birth world. 

Certified Professional Midwives (CPMs) and Licensed Midwives (LMs)

CPMs and LMs specialize in holistic, comprehensive prenatal care and homebirth midwifery services.  They have to graduate from a MEAC accredited (midwifery education accreditation council) school and pass the NARM (North American Registry of Midwives) exam. Midwifery care is designed to provide supportive and integrated healthcare for the birthing person and baby. Prenatal appointments are generally longer than with an OB or midwife in a hospital, and cover a range of different topics — from a comprehensive dive into nutrition and lifestyle to your thoughts, feelings, and plans around birth and your postpartum time. One of the most integral parts of midwifery care is the care you receive after you birth your baby; midwives usually come to your home four to six times before the six-week mark.

Certified Nurse Midwives (CNMs)

CNMs are Registered Nurses (RNs) and have additional education in midwifery (masters or doctoral). They are licensed to work inside hospitals or at an independent birth center, and they can choose to have their own home birth practice. CNMs can provide most of the care that an OB/GYN would, performing pelvic exams, writing prescriptions, placing IUDs, and more. If you’re seeing a CNM in a hospital setting, you may find that they are more supportive of low-intervention birth options.

You can work with a midwife regardless of where you decide to have your baby — at a hospital, birth center, or at home.

Obstetricians/Gynecologists (OB/GYNs)

OB/GYNs are doctors who specialize in pregnancy, childbirth, and postpartum, though they can have a range of subspecialities including maternal-fetal medicine (a focus on high risk pregnancies) and reproductive endocrinology (a speciality in fertility). OB’s can perform surgeries like caesareans and handle more complicated pregnancies and births. 

OB/GYNs only work in hospitals - so they are not available if you want to give birth at a birth center or at home.

Now, an overview of the differences between giving birth in a hospital, at a birth center, or at home.

Hospital Care

Depending on the practice you choose, you can often decide to see a mix of the providers on staff, which may include OBGYNs, Nurse Practitioners (NPs), Certified Nurse Midwives (CNMs), and/or Labor and Delivery nurses. Alternatively, you may have the option to choose one provider and see them throughout your pregnancy. Most hospitals don’t guarantee that you see your specific care provider during labor and delivery —  for the most part, your labor is assisted by whomever is on staff and available when you’re admitted. 

Hospital care is incredibly important for higher-risk pregnancies or if you know that you want to get pain medication during labor and birth. A hospital birth usually means:

• When you arrive, time will be spent in triage getting your vitals taken and you’ll have a vaginal exam before you’re admitted to check how far along you are in your labor. 

• Many safety protocols, such as the use of IV fluids, pitocin (in the case of postpartum hemorrhaging), continuous fetal heart rate monitoring, vaginal exams, and rupturing the bag of waters (amniotic sac), if necessary. 

• That time is a big consideration. You might be encouraged to use an intervention if your labor stalls.

• Various levels of technology are integrated into care, so you may want to take into consideration how conservative your hospital is. You can ask about rates of intervention, C-section, and use of epidurals.

• Labor and birth positions may be restricted depending on the hospital and/or interventions used. 

• You can typically have a support person, as well as a doula at your birth, but during COVID-19, all hospitals are only allowing one support person per patient. Some doula support may still be possible; many doulas are currently supporting laboring people at home and then providing virtual support once the clients are in the hospital setting.

Interventions:

The hospital is the place you’ll want to receive care if you have a more complicated pregnancy, or need or want interventions. This includes pain medication (like an epidural or fentanyl), pitocin to augment labor, Cesarean section, or NICU care during labor/birth/postpartum.

Note: 

Some homebirth midwives are now offering an option called ‘Integrated Midwifery Care.’ With this option, you can work with a homebirth midwife concurrently throughout your pregnancy alongside your hospital provider. You get the benefits of midwifery care (longer and more in-depth appointments, focus on nutrition, and several early postpartum appointments) while also giving birth in a hospital. The midwife would typically join you at the hospital for your birth, like a doula would (this is limited right now because of COVID-19). 

Payment: 

Health insurance for pregnancy, labor, delivery, and newborn baby care became mandatory in 2014 under the Affordable Care Act. However, it’s important to check your individual benefits for labor and delivery, as these can vary dramatically from person to person. 

Birthing Centers

A birth center typically provides comprehensive midwifery care in a safe, home-like environment to low-risk pregnant people. Prenatal care is given by Certified Nurse-Midwives (CNMs) or Certified Professional Midwives (CPMs). At a birth center you could have several private, in-person prenatal appointments, as well as group prenatal appointments. At a birthing center, you can expect:

• a licensed midwife to be present during the entire labor, monitoring the safety and wellbeing of you and baby, while also offering guidance, support, and care. Your care will be based on your expressed preferences, rather than protocols. 

• encouragement to try many labor and birth positions. As long as the birthing person and baby are in good health, time is less of a consideration and you’re supported to proceed at your own pace. 

• options like waterbirth and nitrous oxide for labor support. You can also have a support person and a doula present at the birth (even during COVID-19). 

• a licensed birth assistant or second midwife to arrive for the birth and remain throughout the immediate postpartum period.

Interventions: 

Birth centers offer inducing by means of a foley balloon catheter and rupturing the membranes (opening the bag of water) if necessary. They are equipped to handle many birth and postpartum complications including postpartum hemorrhaging, and administering the same drugs that the hospital does, when appropriate. Midwives are also trained and highly skilled in neonatal resuscitation. They are not trained in performing surgery, namely for cesarean births - but can provide suturing when needed.

Important note:

If it is necessary to transport you to a hospital, your birth team and midwife will go with you and stay with you while you’re at the hospital. However, during COVID-19, only one support person will be permitted to accompany you, meaning your midwife and/or doula will only be able to provide virtual support. 

Payment: 

Most birthing centers are covered by some health insurance companies.  The cost for prenatal care, the birth, and postpartum care without insurance is usually around $8000 without insurance. 

Home birth

Until the invention of modern medicine, all women gave birth at home. Today, home birth remains a viable option for low-risk pregnant people. If you choose to plan a home birth with the assistance of a midwife, that midwife will most likely be a Certified Professional Midwife (CPM) as well as a Licensed Midwife (LM) of your state. There are also some Certified Nurse Midwives (CNMs) that have home birth practices. There are a number of similarities between birthing at a birthing center and birthing at home, namely the continuity of care, freedom to choose birthing positions, application of little or no interventions, and the option to have a water birth. A few additional highlights of home births include:

• a comfortable, safe and familiar environment for the entire labor and birth. Studies have shown that “low risk birthing people who plan home births have fewer interventions without an increase in risk to mothers and babies,”, Genedine Simkins, CNM, MSN, executive director, Midwives Alliance of North America.

• the ability to be planned or unplanned, assisted or unassisted. As a pregnant person you can plan to have a home birth with the assistance of a birth team that includes a medical professional like a CNM, CPM, or LM, as well as a doula. Or you can have an unassisted home birth that doesn't include a medical professional.

• You will need to purchase a birthing kit, as well as gather home birth supplies to prepare for your home birth: You can expect that your midwife will give you a list of supplies to gather like towels, washcloths, baby blankets, and a home birth supplies kit similar to one from Radiant Belly. 

Important Note:

As with a birth center, if it is necessary to transport you to a hospital, your birth team and midwife will go with you and stay with you while you’re at the hospital. However, during COVID-19, only one support person will be permitted to accompany you, meaning your midwife and doula will only be able to provide virtual support. 

Interventions:

The following interventions are available at home: foley balloon catheter, an IV and IV fluids, antibiotics, artificial rupture of membranes, oxygen, pitocin and other medications to prevent postpartum hemorrhage, neonatal resuscitation, and sutures. 

Payment: 

The cost of a home birth in the United States can be anywhere between $4500-$8000. Some insurance companies do cover home birth costs, since CPMs and CNMs can be considered out-of-network care providers. Some midwives offer a sliding scale, as well as a payment plan to fit families’ budgets. 

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In the Bay area (and virtually right now!), you can learn more about building your birth team and about your birthing options by attending the “Pregnant! Now What?  Birth Options in the Bay Area in the time of COVID-19” class offered through Natural Resources. and taught by Lauren Miller Brown, birth and postpartum doula, childbirth educator, trained homebirth midwife, and massage therapist.