Choosing a Midwife - A Guide

If you're a birth nerd like me, you won't need advice around choosing a good midwife. You'll have read enough birth stories and birth articles to appreciate how influential the midwife can be in the whole pregnancy, birthing and new parenting thing, and you'll have a fair idea about what it is you're seeking in a midwife. This blog post is designed to assist the novices out there, and also those of you who didn't get what you wanted out of a previous midwife you had.

Writing a guide to help you find the right midwife for you requires some assumptions on my part about what you want from your pregnancy and birthing experience (something you may not have even considered at this stage). Read the following points and if they feel right for you, this blog may be particularly helpful in guiding your choice of midwife...

  • you view pregnancy and birth as normal, healthy experiences, not illnesses 
  • you want to be an active participant in decisions around your pregnancy and birth care and appreciate the importance of being well-informed
  • you are prepared to take responsibility for your health and wellbeing during your pregnancy, such as eating well, minimising alcohol intake, etc.

Whoever you end up choosing as your midwife, they need to be someone who you feel you will develop a good rapport with and whose philosophy and practice will support you to achieve an holistically positive and safe birth outcome (by 'holistically' I mean relating to the 'whole' of your being - not just physical aspects, but also mental, emotional and spiritual). Therefore, you will probably need to meet with and interview a number of midwives to determine who is the best fit for you. As a starting point, I suggest you get recommendations from friends who have had positive birth experiences, especially those who had minimal medical interventions. I know this will sound a bit biased of me but women who chose to birth at home and who felt well supported by their midwife to do just that, will probably be the best ones to get recommendations from. 

Even if you have no intention of birthing at home, midwives who predominantly care for home birthing women tend to have a stronger belief in the benefits of natural birth and their practice is more likely to reflect this. In other words, midwives who attend a lot of home births are, in my experience, less likely to interfere with a healthy birth process and are more likely to assist and support women to make fully informed decisions about their care. Of course I am generalising here and just as there are some excellent midwives who don't do many home births, there will also be home birth midwives who do not do their job well. So, how do you ascertain which midwife will be a good fit for you? You set up a time to meet and talk with them and you find out about important aspects of their practice. The following are some examples of the sorts of things that you may want to ask...

"Tell me about your philosophy around birth." This may seem a bit of a wishy-washy question to ask, but the answer will likely reveal a lot about the midwife's beliefs and practice. Does she talk about birth being natural and healthy? Does she talk about the partnership between herself and her clients, and of supporting women to make well informed decisions around their care? Does she acknowledge the importance of 'continuity of care' or 'following through' with a client's care right through her pregnancy, labour, birth and postnatally? The language she uses may be quite revealing... does she use the word 'client' or 'women' to refer to the women she cares for, or does she refer to her 'patients'? (pregnant women are not sick!) Does she talk about 'attending births' or 'delivering babies'? (remember here that it is the woman, not the midwife, who 'delivers' their baby). These are just a few examples of what might be revealed when you ask this question.

"What are your thoughts on home birth?" Regardless of whether you think you might want to birth at home or not, this is a good question to ask because you will be able to establish her true thoughts around 'natural birth'. Is she really positive about home birth, or does she have a lot of reservations? Has she had much experience with attending home births? If not, why not? It may be because few women in her area are seeking them out, but quite possibly it's because she isn't forthcoming with the information that home is an appropriate and positive birth option for most women during her antenatal care of them. This would ring alarm bells for me - if she does not trust the normal birth process then surely she is more likely to intervene with labours unnecessarily. Not good!

"How long have you been a midwife?" If she is a bit inexperienced, ask who mentors her and what involvement her mentor has in her practice. Or if she is no longer mentored, does she work with a supportive midwife partner/team of midwives who share a similar philosophy and practice to hers? Ensuring your midwife has good collegial support will help to reassure you if she is still a bit inexperienced. Plus, newer midwives often have a wonderful passion for their practice that makes you feel extra cared for and appreciated.

"What antenatal care will you provide?" Most midwives see their clients once a month from 12 - 28 weeks of pregnancy (sometimes starting earlier in the pregnancy), then fortnightly until 36 weeks, then weekly until birth. Some midwives expect you to come to their clinic whereas others are happy/prefer to come to your home (I liked the home visits because it kept birth feeling very 'normal' rather than feeling more like a doctors appointment). Some midwives will take 20 - 30 minutes to do an antenatal appointment (take your blood pressure, get you to pee on a stick, feel your tummy to see how baby's growing... and that's about it!). Others do those things PLUS sit and talk with you for up to an hour, sometimes more if needed. This talking is a VERY important aspect of your care. There are a lot of important matters that you will need to discuss with your midwife... about coping with pain in labour, about breastfeeding, about vitamin K, about your fears, about your hopes, etc etc etc.

"What labour care will you provide?" "What if I need to transfer to hospital?" (if planning a home birth) Your midwife should be willing to stay with you from when you feel you need her until a couple of hours after you have birthed your baby and placenta. If you have a particularly long labour your midwife may need to take a break and get someone else to take over for a while so that she can feel re-energised and safe to continue supporting you. This same care should apply regardless of where you plan to birth. If you are planning a home birth and end up needing to transfer to the hospital your midwife should continue to support you in the hospital setting, even if that is just in a 'support person'/advocacy type role (some home birth midwives don't have an 'access agreement' at the hospital so won't be permitted to carry out other parts of the midwife's role).

"If pregnancy becomes complicated or if I end up needing a c-section will you remain involved in my care?" Your midwife may refer you to a specialist for consultation if a complication arises. She should, however, continue to be your primary maternity care provider. It's my understanding that NZ midwives get paid a minimal birth fee if they choose to attend elective caesareans, and get paid the full birth fee for attending emergency caesareans. Therefore, it would be solely for the benefit of her clients if your LMC midwife chooses to attend elective c-sections. I know I certainly did when I practiced midwifery. If I had needed an elective caesarean section, I would certainly have liked for my midwife to be there to support me. 

"What postnatal care do you provide?" In my experience, this is a very 'telling' part of a midwife's philosophy and practice. NZ midwives are only required to do a minimum of 7 postnatal visits in the 4 - 6 week period following birth. Of course they can choose to do more but they will not be paid a higher postnatal fee for doing so. When I was a midwife I used to visit new mothers every day following birth until they felt comfortable to go a day or two without seeing me. I would then, in consultation with them and taking into account their personal needs, space the visits out more and more until the final visit at 6 weeks. By wholeheartedly supporting women during the postnatal period, midwives are much more able to provide the mother with the information and support needed to increase her confidence and help stave off potential issues like postnatal depression, breast infections, etc (or to give her additional assistance if those problems do arise). Some midwives (particularly those with large caseloads) only give the minimally required postnatal care to all women regardless of their individual needs. Ask what the average amount of care the midwife gives to first-time mothers is. It's a really important part of the care you receive but something you often don't really consider all that much until you need it (the birth is often the main focus for first-timers). Even if you live semi-rurally or remote-rurally, your midwife should still be coming to your home to carry out your full postnatal care (midwives can apply for a travel-costs fee if this is the case).

"What 'time off' do you have?" "What if you can't be at my birth?" "Who will be my back-up midwife? And will I get to meet her during my pregnancy?" You spend your pregnancy developing a trusting relationship with your midwife so it's reassuring to know that she is likely to be the one who will care for you when it comes to your labour and birth. Some midwives take more holidays/time-off than others (they have their own families to find time for and will need some time to themselves to prevent burn-out), but whatever their individual time-off schedule, make sure it is one that you feel comfortable with. If she is unavailable at the time of your birth then it is important that you have had the opportunity to get to know the back-up midwife prior to birth to make sure you feel comfortable with her. Most midwives work with another midwife(s) who shares a similar philosophy and practice to their own, but it will pay to ask whether this is the case for each midwife you interview. Note also that if a midwife is going to be on holiday shortly after you are 'due' then there is a high possibility that she will a) be unable to provide your postnatal care (so another midwife will provide that part of your care), and b) miss your birth (lots of babies choose to come well after their 'due date').

"How many women do you book each month?" Another really important question! The more women a midwife cares for, the less time she has for each of her individual clients, and the higher the likelihood that she will be attending someone else's birth when you give birth. The midwives who have high caseloads are, from what women have told me, useless at providing care that extends beyond the mere basics. They are the ones who do 20 minute antenatal appointments in their clinics; they are the ones who rush women's labours eg. prefer to unnecessarily (and inappropriately!) rupture her membranes; and they are the ones who provide the minimal postnatal care that is required of them. The NZ College of Midwives recommends that midwives book no more than 4 - 6 women per month (though I, personally, would be dubious of a midwife who attends an average of 6 births per month).

"Can you tell me some of your basic practice statistics?" Such as...

 

What % of the births you attend take place a) in hospital, b) in a birth centre, and c) at home? I would feel more trusting of a midwife's practice and philosophy if she was very experienced with attending births outside of the hospital. Midwives who support and encourage home and birth centre births are more likely to believe that birth is a normal, healthy process that, for most women, is most suited to taking place outside of the hospital environment (hospitals are for sick people and those in need of medical intervention). Hospital birth should be the exception rather than the rule for healthy women.

 

Of the planned home births, what % of your clients end up transferring to hospital? The number here should be very low if the midwife trusts the normal birth process, if she is patient and if she is knowledgeable about the normal variations associated with birth (ie. transfer is only necessary if complications occur that necessitate obstetric intervention, not simply because a woman is taking a long time to give birth, for instance).

What % of your clients have a caesarean? The World Health Organisation recommends that the caesarean section rate should be lower than 15% (around 1 in 4 women give birth via caesarean in NZ, and the rate keeps climbing). I would be looking for a midwife whose caesarean rate was lower than 15% (preferably less than 10% on average) because I don't honestly believe that more than 10% of women are incapable of birthing their babies without the need for a caesarean.

What % of your clients have an Induction of Labour? One of the reasons the c section rate is so high is because nationally we have such a high rate of induction (one medical intervention often leads to another, such as the drugs used to stimulate labour causing distress in the baby). I can't find the stats but I am all too aware that we have a very high rate of medical induction for 'post dates' pregnancies. If your pregnancy happens to last longer than 42 weeks (which something I recently read said that up to 10% of pregnancies do), you may be advised to undergo an induction of labour and, most likely, will be scared by the medical establishment into doing so. But more and more research is countering the argument that going beyond 42 weeks of pregnancy is risky. Your midwife should be forthcoming in providing you with all the relevant research you need, and supporting you, to make the informed decision that is right for you. She should also prepare you for the sorts of things the obstetrician is likely to advise if you decide to have a specialist consultation. Knowledge is power! Make sure you exercise your right to informed decision making and consent. That said, I would be very wary of a midwife who has a significant induction of labour rate. A midwife I talked to today said that she sometimes goes for years without any of her clients having an induction, and that when they do it is extremely rare that it is for 'post dates'.

What % of your clients are exclusively breastfeeding at 6 weeks postpartum? The same midwife mentioned in the paragraph above said that 97% of her clients are exclusively breastfeeding their babies at the 6 week mark. "But," she said, "I put my all into supporting women to successfully breastfeed." It is important that you have a midwife who is 100% committed to supporting you to breastfeed your baby. The establishment of breastfeeding can be an incredibly challenging experience for some women, and the midwife needs to do her bit to ensure the woman is given the best chance of success. I had an horrendous time for the first few weeks trying to breastfeed my first child. We lived rurally and my devoted midwife would travel in every day (sometimes more than once!) to help me with my breastfeeding. I am so grateful for the support I received and went on to breastfeed my daughter for 3 years!

What phone support do you offer during my pregnancy, birth and postnatally? Your midwife (or her back-up) should be available for phone support 24 hours a day, 7 days a week throughout the entirety of your care. If you have any concerns at any time you should feel totally comfortable to call your midwife so that you can access information or treatment and/or allay your fears.

And, of course, ask any other questions that are important for you. For example, if you are particularly keen on alternative therapies you could ask whether she incorporates any alternative therapies into her practice (some midwives regularly use homeopathy and/or herbs, for instance). 

You will probably get a reasonable feel for who seems the right fit for you after interviewing a few midwives. If, during the course of your midwifery care, you become unhappy with your choice of midwife you are entitled to change your LMC at any time. Don't stick with a midwife because you feel obligated to... birth is too much of an important and precious occasion in your life to settle for a midwife who is not right for you. Also, be wary of settling for a midwife because she seems 'nice'. Sure, you want a midwife who you get on well with, but don't put nice-ness over and above other more important qualities such as knowledgeable, caring, wise, capable etc, etc. Nice midwives are sometimes not the best advocates because they fear stepping on someone else's toes (I know I was one of those 'nice' midwives - I was wonderful at looking after the emotional needs of my clients but sometimes I was a bit pathetic at advocating for women when it really mattered). 

Finally, here are a couple of links that may be useful for you to read before you search out a midwife. This one is the NZ College of Midwives list of things you can expect from your LMC, and this one is a list of your rights during pregnancy and birth.

 

“Some midwives pull women up the hill and say I will get you through this. Other midwives walk behind quietly and gently say, ‘I believe in you.’” -Patricia M. Couch
This is seconds after I'd birthed my first baby into my mothers hands and she'd passed her to me between my legs. See my wonderful midwife quietly watching on from the side.

This is seconds after I'd birthed my first baby into my mothers hands and she'd passed her to me between my legs. See my wonderful midwife quietly watching on from the side.