Types of health care providers

Obstetrical care is offered by family physicians, obstetricians-gynecologists, maternal-fetal medicine specialists and midwives.

Family physicians

Family physicians provide care for the whole family through all stages of life, including pregnancy and birth.

Training for family physicians:

• Medical school followed by at least three years in training at a hospital or another patient setting (residency).

• Study and work in various fields of medicine, including obstetrics, pediatrics, internal medicine, gynecology and surgery.

• Certification by the American Board of Family Practice, for which they must pass an extensive exam.

• Training and experience that allows them to manage most pregnancies, including minor surgical procedures for vaginal delivery. Some perform Caesarean deliveries, but most do not.

Practice. Family physicians may work solo, or they may be part of a larger group practice that includes other family physicians, nurses and other medical professionals. They're usually associated with a hospital where they can perform deliveries.

Advantages. If you've been going to your family doctor for a while, he or she will probably know you well. Your doctor will probably be familiar with your family and medical history. Thus, a family doctor is likely to treat you as a whole person. Your pregnancy is seen as part of the larger picture of your life. Also, a family doctor can continue to treat you and your baby after birth.

Issues to consider. Family physicians can cover most of the range of obstetrical care. But if you've had problems with pregnancy before, your family physician may refer you to a specialist in obstetrics or use a specialist as a consultant or backup. The same may be true if you have diabetes, high blood pressure, heart disease or another medical problem that may complicate your pregnancy. If you have a family history of a genetic problem, your doctor may refer you to a geneticist or genetics counselor.

It's possible that your family physician may not be available at the time of your delivery. If so, you may be giving birth with a doctor you don't know. One way to get around this is to meet your doctor's backup before your due date.

You might choose a family physician if:

• You and your doctor don't foresee any problems with your pregnancy.

• You want your doctor to be involved with all members of your family.

• You want continuity in care from prenatal appointments throughout childhood and beyond.

Who's making deliveries?

According to the Centers for Disease Control and Prevention, here's who delivered America's babies in 2001:

• Physicians (including family physicians and ob-gyns) delivered 91 percent of all births, which is down from 99 percent in 1975.

• Midwives attended 8 percent of births, which is up from 1 percent in 1975.

• Almost 95 percent of midwife-attended births were by certified nurse-midwives.

And here's where the deliveries occurred:

• 99 percent of births were in hospitals.

• Of the 1 percent out-of-hospital births, 65 percent were in a residence, and 28 percent were in a free-standing birthing center.

(Source: Centers for Disease Control and Prevention, "Births: Final Data for 2001.")

Obstetricians-gynecologists

Doctors of obstetrics and gynecology are commonly referred to as ob-gyns. They specialize in the care of women during pregnancy and in general, including care of a woman's reproductive organs, breasts and sexual function. Because of their emphasis on women's health, ob-gyns serve as the main health care provider for many women.

Training for obstetricians-gynecologists

• Medical school followed by a four-year residency.

• Focus on obstetrics, gynecology, infertility and surgery.

• Preparation to handle all phases of pregnancy, including before conception, during pregnancy, labor and childbirth, and postpartum.

• Training in preventive medicine, which includes regular checkups and exams to detect problems before you become sick.

• Training in diagnosing and treating menstrual and hormonal disorders, gynecologic infections, vulvar and pelvic pain problems, as well as in performing pelvic surgery.

• In many cases, certification by the American Board of Obstetrics and Gynecology. To be certified, a doctor must pass written and oral tests.

• In some cases, a role as a teacher and researcher at a medical school or teaching hospital.

Practice. Ob-gyns often work in a group practice consisting of various medical professionals, including recent graduates from medical school (residents), nurses, certified nurse-midwives, physician assistants, dietitians and social workers. Ob-gyns may work in a clinic or hospital setting.

Advantages. If you already see an ob-gyn you like for your general health care, he or she may be a natural choice for continuing to provide care during your pregnancy and childbirth. Many women choose an ob-gyn for obstetrical care because if a problem or complication arises during pregnancy, they won't have to switch health care providers. An ob-gyn can, if necessary, perform an episiotomy, forceps delivery or Caesarean delivery.

Issues to consider. An ob-gyn can meet all the needs of most pregnant women, except perhaps for those with extremely high risk pregnancies. In such a case, your ob-gyn may refer you to a maternal-fetal medicine specialist, while ideally remaining involved in your overall care.

As with a family physician, your ob-gyn may not be available when you're ready to give birth. For this reason, you may wish to meet the other health care providers who may deliver your baby if your doctor isn't available.

You might choose an ob-gyn if:

• You have a high-risk pregnancy. You may be high risk if you are over the age of 35 or you develop diabetes during pregnancy (gestational diabetes) or high blood pressure during pregnancy (preeclampsia).

• You're carrying twins, triplets or more.

• You have a pre-existing medical condition, such as diabetes, high blood pressure or an autoimmune disorder.

• You want the reassurance that if a problem does arise, such as the need for an operative vaginal or Caesarean delivery, you won't need to be transferred to a different care provider.

Maternal-fetal medicine specialists

Maternal-fetal medicine specialists are trained in the care of very high-risk pregnancies. They concentrate exclusively on pregnancy and the unborn child, dealing with the most severe complications that arise.

Training for maternal-fetal medicine specialists

• Medical school followed by four years of residency.

• Three-year fellowship focusing on obstetrical, medical and surgical complications of pregnancy.

• Preparation to provide care for women with high-risk pregnancies.

• Training to provide consultation for family physicians, ob-gyns, certified nurse-midwives and other specialists.

• In some cases, a role as a teacher and researcher at a medical school or teaching hospital.

Practice. Similar to other doctors, maternal-fetal medicine specialists often work as part of a group practice. They may be part of a group of obstetrical consultants. They're often associated with a hospital, university or clinic.

Advantages. This highly specialized doctor will be familiar with the complications of pregnancy and adept at recognizing abnormalities. When women with major medical problems become pregnant, their physicians often consult with maternal-fetal medicine specialists in order to optimize care for both the mother and her fetus.

Issues to consider. Maternal-fetal medicine specialists concentrate solely on the problems that occur with pregnancy. Most women don't need their services because most pregnancies are fairly routine. In addition, these specialists tend to be less directly involved with their patients than are family physicians, ob-gyns and midwives. However, this isn't true for all maternal-fetal medicine specialists. Don't let it stop you from seeking one out if you need the type of care he or she can provide.

A maternal-fetal medicine specialist rarely serves as the primary health care provider for a pregnant woman. This specialist is brought in at the request of another health care provider, such as an ob-gyn or a certified nurse-midwife.

You might choose a maternal-fetal medicine specialist if:

• You have a severe medical condition complicating your pregnancy, such as an infectious disease, heart disease, kidney disease or cancer.

• You've previously had severe pregnancy complications or had recurrent pregnancy losses.

• You plan on having prenatal diagnostic or therapeutic procedures, such as comprehensive ultrasound, chorionic villus sampling, amniocentesis, or fetal surgery or treatment.

• You're a known carrier of a severe genetic condition that may be passed on to your baby.

• Your baby has been diagnosed before birth with a medical condition, such as spina bifida.

Midwives

Midwives provide preconception, maternity and postpartum care for women at low risk of complications during pregnancy. Throughout much of the world, midwives are the traditional care providers for women during pregnancy. In the United States, the use of midwives is steadily increasing.

In general, midwives follow a philosophy that builds on the view that women have been having babies for millennia, and that they don't always need all of the technologic intervention that's available.

Training for midwives

Midwives don't have a medical degree. But most receive formal training in midwifery and in well-woman care. Midwives are often classified according to the training they've received:

• Certified nurse-midwives are registered nurses who have completed advanced training in obstetrics and gynecology and have graduated from an accredited nurse-midwifery program. They are certified by the American College of Nurse-Midwives (ACNM), for which they must pass several exams. Certified nurse-midwives are licensed in all 50 states and the District of Columbia. Some can prescribe medications. Most can recommend diet, exercise and lifestyle changes.

• Direct-entry midwives don't have a nursing degree but may be trained in other areas of health care. They may have training through self-study, apprenticeship, a midwifery school or a college- or university-based program separate from nursing. They may be licensed, certified or neither. Different states have different licensing requirements. Some states have very strict standards. Others don't regulate midwives at all.

• Certified midwives are direct-entry midwives who have been certified by the American College of Nurse-Midwives and have met the same standards required by the college as certified nurse-midwives. This is a fairly new certification and is currently licensed only in the state of New York. However, other states and midwifery organizations may use the same designation for individuals whom they have licensed. Although this may sound confusing, most certified midwives are happy to explain to you where they got their certification.

• Certified professional midwives are direct-entry midwives who have been certified by the North American Registry of Midwives, an international certification agency created by the Midwives Alliance of North America.

• Lay midwives are uncertified or unlicensed midwives who generally have had more-informal training.

Most midwives in the United States today are certified nurse-midwives or certified midwives.

Practice. Midwives may work in a hospital setting, in a birthing center or in your home. They may practice solo but often are part of a group practice, such as a team of obstetric care providers. Most midwives are associated with an ob-gyn in case problems occur. The majority of certified nurse-midwives attend births in a hospital or birthing center, although some may attend a birth in a home. Direct-entry midwives are more likely to deliver at home.

Advantages. Midwifery care may offer a more natural, less regimented approach to pregnancy and childbirth than does standard care. If you give birth attended by a midwife in a hospital, you'll still have access to pain relief medications.

In many cases, a midwife is able to provide greater individual attention during pregnancy and is more likely to be present during labor and delivery than is a doctor. Various studies have found no significant differences in outcome between having a midwife attendant who's integrated with an existing health care system and having a doctor attendant for women with low-risk pregnancies.

Issues to consider. When considering a midwife for your primary obstetrical care, check to see that she or he has a backup arrangement with a hospital so that you can have access to obstetrical skills and equipment in case of pregnancy or birthing problems.

If you're not giving birth in a hospital, create an emergency plan with your midwife. Include details such as the name and number of your midwife's backup doctor, the hospital you'll be taken to, how you'll get there, the name and number of the persons who need to be alerted and contingency plans for your other children, if you have any. This can reduce stress later if you need to be transferred during labor. Birthing centers often do this as a matter of policy.

If you're thinking of working with a midwife but aren't sure about his or her credentials, ask him or her about training and certification and licensure in your state. The American College of Nurse-Midwives suggests asking the following questions:

• Did you graduate from a nationally accredited midwifery program?

• Did your midwifery education require preparation in core sciences such as biology, chemistry, anatomy and physiology, and others?

• Have you passed a national certification examination?

• Are you licensed to practice?

• How will you determine if I am an appropriate candidate for midwifery care? What will happen if I need the care of a doctor?

• Are you prepared to provide well-woman and gynecological care, including screening for common health problems and writing prescriptions?

• Are you certified by the American College of Nurse-Midwives Certification Council?

You might choose a midwife if:

• You're free of health problems and you expect to have a low-risk pregnancy.

• You want someone who can spend a significant amount of time discussing your pregnancy with you.

• You prefer a more personalized approach to the birthing process.

• You desire a less regimented birthing process.

• You desire fewer interventions.

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