Will my insurance or Medicaid pay for midwifery care and out-of-hospital birth?
Many insurance companies will pay for out-of-hospital midwifery care. Some states have passed laws requiring private insurance companies to pay for any and all licensed providers in that state. Montana does not have such a law, so insurance is not required to pay for midwifery car. I recommend clients with private insurance verify coverage with their carriers. Medicaid pays for home birth and birth in many states but not in Montana.
I am committed to having an out of hospital birth, but I don’t have insurance or Medicaid, and I don’t know if I can afford to pay for midwifery care out-of-pocket.
No one should be denied midwifery care for financial reasons. I will consider alternate payment plans for low-income, cash-paying clients who are committed to having an out-of hospital birth.
What are the differences between licensed midwives (LMs), certified professional midwives (CPMs), and nurse-midwives (CNMs)?
Licensed midwives (LMs) are autonomous health care providers who provide primary maternity care to healthy women with normal pregnancies. LMs usually work in an out-of-hospital settings, attending births at home and in birth centers. LMs are regulated at the state level and are responsible to state midwifery laws and regulations. The title CPM, or Certified Professional Midwife, is a national credential for direct-entry midwives (non-nurse midwives). The majority of out-of-hospital midwives are CPMs, and some may also be LMs in states where midwifery is regulated (For example, ID, WA, OR). Nurse-midwives are certified to provide primary maternity care to women in all settings, and practice in accordance with the American College of Nurse-Midwives Standards of Practice. The majority of nurse-midwives are employed by hospitals or physicians although some practice independently and a smaller handful attend births in birth centers or at home.
Are there any differences between prenatal care with a Licensed Midwife and prenatal care with an OB/GYN, or nurse-midwife in the hospital?
Yes, there are many significant differences. Prenatal visits with homebirth midwives generally last about an hour. The clinical portion of a prenatal visit (measuring mama’s belly, listening to heart tones, feeling baby’s position, etc.,) takes about 7 minutes. The rest of the time we devote to getting to know our clients — their needs, desires, hopes, fears. Longer prenatal visits give us the time to grow comfortable with each other, to build trust, and to allow our relationship to evolve. Additionally, homebirth midwives do not generally have a one-size-fits-all approach to prenatal care; We do not insist every woman have the same standard screening tests and procedures. Midwives who have trained outside a medical setting are also more likely to spend time engaging client’s emotional and psychological needs and concerns than providers trained within the medical model. I welcome and encourage you to discuss any and all questions and concerns during your prenatal visits!
Is it safe to give birth at home? What if something goes wrong?
Scientific research conducted over the last four decades on maternal and neonatal outcomes clearly demonstrates that planned homebirth and birth center birth with midwives is at least as safe as hospital birth attended by obstetricians, if not safer. No study has ever demonstrated that hospital care is safer for low-risk women. There are no studies demonstrating that births attended by obstetricians are safer than births attended by midwives for normal pregnancy and birth. In many other developed nations, midwife-attended homebirth is quite common and is recognized and promoted as excellent care (Eg., Canada, UK, Australia, New Zealand, most Scandinavian countries, the Netherlands, and Japan). In fact, the UK national health care system is working to get low-risk women out of the hospital and into homes and birth centers to have their babies; the obstetricians are recognized as specialists in high-risk pregnancies and the midwives are recognized as experts in normal childbearing. More than half of all babies in the Netherlands are born at home with midwives. Their infant mortality rate is significantly lower than the United States.
Do I need to see a doctor before starting care with a midwife or having a home birth?
No. Midwives are primary care providers and provide complete maternity care to women having healthy pregnancies. Midwives are trained to identify potential complications and deviations from normal. In these cases, midwives consult with, or refer care to more specialized providers (obstetricians, perinatologists, pediatricians, etc.). Below are some of the more common conditions and occurrences that may necessitate transfer of care to a physician or hospital.
Preexisting high blood pressure not controlled by diet, exercise and medication
Pre-existing diabetes (this is different from “gestational diabetes”)
Heart, kidney or lung disease
Alcoholism or drug abuse or addiction
Preterm birth (before 37 weeks)
The baby’s umbilical cord prolapses when the water breaks
Baby has a non-reassuring heart rate or pattern during labor
Mother is unable or unwilling to take responsibility for her prenatal care and well-being
Do you work with any obstetricians or pediatricians?
Licensed Midwives and Certified Professional Midwives are autonomous providers and are not required to practice under physician authority. I do enjoy collaborating with physicians when needed and have had the great fortune (and pleasure) of working with some fantastic homebirth-friendly physicians over the years. There are times when moms and babies need or benefit from a more specialized level of care, and I am grateful for the availability of this care.
What if I want an ultrasound, or other specialized test?
Referrals are offered for all specialized obstetrical tests as desired, including ultrasound, and amniocentesis. I make every attempt to refer you to a homebirth-friendly provider.
I have been planning to have my baby in the hospital, but now I’m having second thoughts…. I am already so far along in my pregnancy — isn’t it too late to change plans?
It is never too late to do what feels best for you. It is actually quite common for women to transfer to a midwife and plan a homebirth after many months of prenatal care with a physician or CNM. Many women hope for a minimally interventive or drug-free hospital birth, and after taking the hospital tour in their third trimester realize that most of their needs and desires will likely be bypassed in favor of provider protocols and convenience. Each woman possesses the autonomy and wisdom to know which birthing environment feels best for her, even if it’s late in the game. It is your body, your birth, your baby.
I am over 35. Aren’t I too “high-risk” to have a homebirth?
No. The age of 35 was designated as the beginning of the “high-risk” age bracket NOT because of any significantly increased risk during pregnancy or birth but because of the nature of amniocentesis. At age 35, all mothers were assumed to want an amniocentesis, and at age 35 the chance of having a baby with Down’s syndrome is the same as the chance of having a miscarriage as the result of an amniocentesis. Any pregnant women receiving obstetric care who is over 35 is labeled “advanced maternal age,” and is treated as if she is a high-risk patient. This regrettable practice only serves to undermine women’s trust in their bodies and in normal birth.
I had a complication in a previous pregnancy or birth, and I am not sure if I am high-risk this time around?
This depends on the specific condition and the circumstances that led up to it. Many “complications” experienced in previous pregnancies or births result from interventions initiated by the birth attendant. Other complications are seemingly more random. In general, complications in pregnancy and birth do not repeat themselves, and are often prevented in future pregnancies and birth by maternal efforts, chance, or more woman-centered care on the part of the provider. During the consult or initial visit we discuss your reproductive and birth history in detail. We discuss at length the risk of the previous condition and any measures we can take to prevent it this time around. If we determine that the circumstances of your pregnancy are beyond my comfort level or experience, or that the hospital would be the safest place for you to give birth, I will help you find another midwife or an appropriate higher level care provider.
What if there is a complication during my labor or birth?
Most complications during labor and birth are not true emergencies. They are more like road bumps, and are easily are recognized in advance by a skilled provider. Thorough and attentive prenatal care also greatly diminishes the chances of complications in labor (hemorrhage, twins, preeclampsia, etc.). Most of the more common ‘road bump’ complications can be safely resolved at home with a skilled midwife, though occasionally the more specialized procedures and treatments available in the hospital can be quite helpful.
In rare instances, urgent complications do occur and this is why midwives are trained to quickly recognize and respond to any deviations from normal. This is, of course, why most women hire birth attendants — to recognize and assist conditions and complications that warrant quick intervention. Midwives are trained and prepared to manage and stabilize emergent situations. This is one of the reasons why we have such an excellent safety record.
If transfer to the hospital is necessary, I always accompany mothers and families to the hospital and facilitate their transfer to either a nurse-midwife or physician. Every attempt is made to transfer to our consulting obstetricians or other homebirth-friendly OBs or CNMs. (All clients are assisted in making a hospital transport plan toward the end of pregnancy to help ease the transition if it becomes necessary). At the hospital I am no longer the primary care provider but I do attempt to provide collaborative care with the physician or nurse-midwife when appropriate. I continue to advocate for your safe and humane treatment, and discuss with you the risks and benefits of any proposed procedures and treatments. I will stay with mothers and families through the birth and first hours postpartum.
It is important to recognize that complications arise in the hospital as well. In normal, low-risk pregnancies, these complications are often the direct result of some intervention, medication, or protocol used during the labor or birth. So we must look at the whole picture. There are risks inherent in childbirth no matter where a woman gives birth. There are risks at home and there are risks at the hospital. Each place possess a different set of risks. For example, when a woman gives birth at home she faces the very rare possibility that an emergent complication may arise. When a woman gives birth in the hospital she faces many risks for trauma and morbidity including a 1 in 3 chance of having a cesarean section which carries a higher mortality and complication rate than vaginal birth. Ideally every pregnant woman must consciously assess these risks for herself. Our job as healthcare providers is to inform women of the real set of risks she will encounter both in the hospital and at home.
Are you opposed to obstetricians or hospital birth?
Neither! As a surgical specialty, the field of obstetrics has contributed some life-saving specialized procedures to maternity care — namely cesarean section. These procedures and surgeries can save lives and improve outcomes for a small subset of birthing women. I am grateful for the specialized care OB/GYNs have to offer — they are a vital and necessary part of the maternity care system. I am also grateful for the availability of hospital birth for women who make the informed, conscious choice to birth there, and for the women and babies for need to birth there for the safest possible outcomes. In my twelve years of attending births I have witnessed many beautiful hospital births, most of them occurring at the University of New Mexico Health Sciences Center. I am fortunate to have had supportive relationships with physicians in the past and I hope to continue to develop new relationships with physicians and CNMs in the future. What I am opposed to is sacrificing normal, healthy birth and women’s autonomy in favor of institutional/physician protocol and convenience. These two forces are the primary contributors to the cascade of interventions that befall most birthing women, jacking up the rate of unnecessary cesareans, and often leaving women feeling traumatized and victimized postpartum.
I want to have a homebirth, but I am not sure my partner will be on board. How would you handle this?
Emotional health and well-being is so important in pregnancy. We should try to bring as much joy and harmony into our lives and bodies as we can. It is so important for partners to support your desires and needs surrounding your labor, birth, and the way you choose to welcome your child into the world. I encourage women and partners to come in together for a first consult visit to interview the midwife. I find that when partners are able to ask questions and investigate us out for themselves, they do begin to open up to midwifery care and recognize the wonderful benefits of gentle birth at home.
I don’t know anyone who has had a baby at home or in a birth center. Who does this?
Everyone! Woman and families choosing out-of-hospital birth come from all walks of life, all cultures, races, ages, faiths and incomes. My clients have ranged from 17 to 43 years old, and have been Christian, Atheist, Muslim, Pagan, Lesbian, Korean, British, Phillipino, single, divorced, and everything in between. Once discovered, you will find that homebirth communities are diverse and welcoming, and there are many classes, groups, and activities to be involved in!
Why don’t more women in the United States have their babies at home or in a birth center?
In the United States there are many obstacles to having a midwife-attended birth outside the hospital: political, social, economic, psychological, and so on. Many people are not aware that they have a choice in care beyond OBs and nurse-midwives. Midwifery is not legally recognized at the federal level — individual states maintain laws regulating or prohibiting the practice of midwifery. That’s right, midwifery is still illegal in some states on account of antiquated anti-midwife laws. In these states homebirth midwifery exists largely underground and is difficult to access. Woman living in these places are often unaware of any alternative to hospital birth, and the midwives practice in fear of felony criminal charges and imprisonment. Many communities do not have any out-of-hospital midwives. Most states do not require Medicaid or private insurance to pay for care, and many families cannot afford to pay out-of-pocket for maternity care. Midwifery is truly a calling for many midwives and their compensation often barely covers their time and expenses. Midwives struggle financially too and it is often difficult for them to keep practicing. They do not have the overhead to match the types of advertising hospital-based providers have. As a profession we lack the capital and political power that the obstetrics industry has; we have been marginalized for many decades and we have far fewer numbers. Finally, as a whole, the field of obstetrics continues to promote the myths that hospitals are the safest places to birth babies and that physicians are the safest providers for all women. This myth has been integrated into our society all the way up to the Capital steps and our legislators have a hand in perpetuating it to boot. Someday soon the maternity care crisis will force the US healthcare system to catch up to the rest of the world, and recognize the wisdom and safety of giving birth at home with a midwife.