Dear Doulas and Team: I am currently  24 weeks pregnant and am wanting to change care providers.  I am curious about exploring the option of an out-of-hospital birth in the Asheville area but I don’t know enough about it.  I’d like to find a care provider with an uplifting presence who supports me in following my instincts and intuition before, during and after my birth and is also versed in evidence-based care and skilled with interventions and medical technologies. What are your recommendations?

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Thank you for making the decision to find the right care provider for you!  It can be scary to “change it up” midway through a pregnancy, and it can sometimes be challenging to speak up and ask for what you need.  However, we believe that being honest with your needs and asking for exactly what’s right for you is always worth the effort!

Trust in your team

Feeling a sense of trust and ease with the person and team that will help you birth your baby is an essential aspect of a positive birth experience. Getting along with your care providers is important! Even if they are the top-rated clinician in your area, personality match matters too. Along with your primary care provider (midwife or doctor), a birth doula is another great addition to the support network. One unique quality of doula care is that their role is to support you not only physically and emotionally, but also with solid evidence-based information, while always deferring to your primary care provider and to your instincts and intuition to make decisions. If something comes up with your primary care provider that you feel confused or conflicted about, a doula can help you by giving you evidence-based resources to explain what your care provider is offering.  Doulas then allow spaciousness for you to make your own choices about how to proceed.

Out-of-hospital options

There are several different options for out-of-hospital births with credentialed professionals in our area, each with their own qualities, characteristics, benefits and risk factors:

• Birth Center birth
• Home birth with a Certified Nurse Midwife (CNM)
• Home birth with a Certified Professional Midwife (CPM)
• Home birth with an OB/GYN or Physician

Whew!  That’s a lot to choose from. Finding the best care for you and your family is a very personal choice.  We’ll share some information here about each birthing scenario to help support you as you make your decision.

Birth Centers are independent facilities that are usually stand-alone, but sometimes are part of a hospital. Here in Asheville, our birth center is not directly connected with Mission Hospital, but is very close by (1). Midwives are most often the care providers on staff at birth centers, and this is the case here in Asheville. In North Carolina, Certified Nurse Midwives (CNMs) attend birth center births. In many other states Certified Professional Midwives (CPMs) staff birth centers. Birth centers tend to be “homey” feeling, with normal beds instead of hospital beds, and lots of options for moving around and making yourself comfortable. They typically have some medical technologies available, such as IV fluids and oxygen, but don’t offer interventions like epidurals or cesarean birth. “In birth centers, midwives and staff hold to the “wellness” model of birth, which means that they provide continuous, supportive care and interventions are used only when medically necessary” (2).

Birth centers are an option for “low risk” pregnancies, and each has their own set of guidelines to determine eligibility. Maternal age, blood pressure, blood sugar, baby’s position at term, and pregnancy with a single baby vs. multiples are common criteria. Our birth center here in Asheville has a great FAQ section that lists their guidelines (3). Evidence shows that both maternal and fetal outcomes are very good at birth centers, and that cesarean birth and other intervention rates are much lower than at hospitals, even compared to other low-risk moms (2). Many birth centers accept Medicaid and other insurance plans.

Home births obviously take place at a family’s residence, and can be attended by a variety of care providers, including doctors or midwives. The term “midwife” can mean different things in different contexts and cultures, but can generally be broken down into two categories of credentialed professionals:

• Certified Nurse Midwives (CNMs) are Registered Nurses (RNs) who have completed accredited graduate studies, including clinical experience, and passed a certification exam. They are licensed in all 50 states. CNMs are not required to have clinical experience in out-of-hospital settings in order to obtain their license. Continuing education is required to maintain the credential (4). At the time of writing, there is only one CNM in Asheville attending home births. CM is a credential that can be held by someone without their RN, but who has completed the graduate studies and other steps required to obtain a CNM credential (4).

• Certified Professional Midwives (CPMs) have completed a course of training, education, supervised clinical experience, and a written exam. CPMs are accredited by the same organization that accredits CNMs, and are the only accredited professionals that are required to have out-of-hospital birth experience. Continuing education is required to maintain the credential. At the time of writing, CPMs were licensed in 31 states. North Carolina is not one of these states…yet (5). At the time of writing there are just a few CPMs attending home births in Asheville (at their own risk).

Some physicians or OB/GYNs attend home births as well. In these cases, their training and licensure is the same as their counterparts who attend only hospital or birth center births. In many cases, these doctors have hospital privileges, which means that they could continue caring for a patient if she needed to transport to a hospital setting. Some doctors who attend home births are not able to do this. At the time of writing there is one doctor who attends home births in Asheville, who does not have hospital privileges. CNMs may also be able to transport with their patients if the need arises, but not in all cases.  It’s good to ask an out of hospital care provider what care looks like in a transport situation.

Home births, like birth center births, are most appropriate for “low risk” pregnancies. Each care provider has their own criteria for determining eligibility. While home birth is still much less common than hospital or even birth center births, “between 2004 and 2010, the number of home births in the United States rose by 41%” (6). Current evidence-based information is somewhat mixed in terms of the safety of home births for mothers and babies. Upon examination of research, this can probably be attributed to the fact that skill and experience level of care provider, and maternal risk factors are not always considered in research outcomes (7).  “Low-risk women in [one 16,924-woman] sample experienced high rates of normal physiologic birth and very low rates of operative birth and interventions, with no concomitant increase in adverse events” (6).  Without further research it is not fair to say that home birth is fundamentally more or less risky than hospital or birth center birth.

The choice of where and how to give birth remains in the hands of each family.  We hope that this information is helpful as you find your way to the most ideal birthing environment and support team for you.

Resources

1. WNC Birth Center
2. Evidence Confirms Birth Centers Provide Top-Notch Care, Rebecca Dekker, PhD, RN, APRN, for the American Center of Birth Centers, January 31, 2013.
3. WNC Birth Center, FAQ
4. The American College of Nurse Midwives: The Credentials CNM and CM
5. North American Registry of Midwives
6. Home births in the United States, 1990 – 2009. Marian F. MacDorman, PhD.; T.J. Mathews, M.S.; and Eugen Declercq, PhD.
7. Planned Out-of-Hospital Birth and Birth Outcomes. Johnathan M. Snowden, PhD., Ellen L. Tilden, Ph.D., CNM, Janice Snyder, RN, Brian Quigley, B.S., Aaron B. Caughy, MD, Ph.D., and Yvonne W. Cheng, MD, Ph.D.