Actually, I have 37 questions, but that doesn't really make for a catchy title.

How to Choose Your Pregnancy Care Provider and Place of Birth

Pregnancy and birth are such immensely vital times in a woman and a baby's life. Choosing a health professional who will care for you during pregnancy and birth is not a decision that should be taken lightly. The outcomes of your pregnancy and birth, including the health of you and your baby, can very well depend on who you choose to be your care provider.

In this article, I hope to help guide expectant women to choose a care provider who empowers women and has the best interests of women and babies at heart.

The Options

In South Africa, a lot of women aren't even aware that they have options. The norm in this country is to visit a doctor during pregnancy and give birth in a hospital.

I have to admit it. I was one of those people who had never heard the word "midwife" literally until I started studying to become one (well, it was part of the package of the B.Cur Nursing Sciences degree). I did not have a particular passion for midwifery during my student years, but I fell irrevocably into the deep end of midwifery during my second year of working as a professional nurse. Read more about that here: https://steemit.com/naturalmedicine/@vanessamidwife/my-midwifery-history.

My views regarding pregnancy, childbirth and parenting have evolved and transformed magnificently in the past 10 years. I feel that being open-minded and welcoming change, especially when it is ushered in by (possibly thousands of) hours of research, have helped me to become a midwife that empowers people to have the best pregnancy and parenting journey they could hope for. I am so grateful to God for leading me on this path and being there for me when I don't always have answers.

Here are the basic options for pregnant women in South Africa. I am sure it is similar in a lot of countries around the world.

• Doctor - In South Africa especially, women opt to go to private doctors for pregnancy care. They may see a general practitioner or an obstetrician. These women give birth at private hospitals (paid by medical aid or cash) where a doctor delivers the baby (either by vaginal birth or by C-section).

• Midwife - Midwives provide pregnancy care for women at government-funded clinics and private midwives also see their clients during pregnancy. Midwives help women to give birth in government-funded hospitals (excluding C-Sections) and midwife-led units. Private midwives may be allowed to attend to a woman's birth in some private hospitals if that is previously arranged. Private midwives may work at birthing units (Genesis Clinic is South Africa's most famous facility like this) or birthing homes (sometimes the midwife's own home equipped with a birthing room). Private midwives also do home births, where the midwife travels to the client's own home for the birth.

In summary, a woman typically can choose between:

• A doctor in a hospital
• A midwife in a hospital
• A midwife in a birthing unit
• A midwife's birthing home
• Home birth with a midwife
  (I am not going to address unassisted births, also known as freebirthing, where a woman intentionally gives birth without medical assistance.)

My specialty is home births.

Midwife-Led Care vs Doctor-Led Care in Research

The majority of women choose a doctor as their care provider in pregnancy and a hospital as their place of birth, because they are under the impression that those are the safest options. Many studies have shown that, for low-risk pregnancies, midwife-led care at a home birth is preferable. One study goes so far as to state that "...hospital birth for healthy pregnancies and elective cesarean surgery are commonly practiced, dangerous, out-of-date medical routines unsupported by research."

According to many large studies, low-risk women who choose to give birth with a midwife:

• Have a 95% chance of having a vaginal birth, while women who choose to birth in a hospital have a 70% (sometimes as low as 50%) chance of having a vaginal birth
• Have a lower risk for fetal dystocia (baby getting stuck during birth due to size or position)
• Have less medical interventions (induction, augmentation, analgesia, epidural, electronic fetal monitoring, episiotomy, assisted vaginal deliveries, manual removal of placenta, C-sections)
• Have fewer complications (intrapartum hemorrhage, ruptured uterus, perineal damage, post-partum hemorrhage, eclampsia, admission to ICU, blood transfusions, infections)
• Are less likely to have antenatal hospital admissions
• Have a higher rate of successfully initiated breastfeeding
• Have an overall higher level of satisfaction with their birth experience

Babies born at home have similar rates of perinatal morbidity and mortality as those born in a hospital, and have fewer rates of:

• Birth trauma
• Resuscitation after birth
• Meconium aspiration
• Hypoxic ischemic encephalopathy (brain damage that occurs when a baby's brain doesn't receive enough oxygen and blood)
• Intrauterine hypoxia (insufficient oxygen supply to the baby)
  Babies born at home have more diverse beneficial bacteria present in their gut, which has lifelong implications for the immune system and metabolism.

Here are links to some of the articles (there are many more) that substantiate the above claims.
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1996-6
https://www.ncbi.nlm.nih.gov/pubmed/20572620
https://www.ncbi.nlm.nih.gov/pubmed/19747264
https://www.ncbi.nlm.nih.gov/pubmed/19720688
https://www.bmj.com/content/346/bmj.f3263
https://www.ncbi.nlm.nih.gov/pubmed/18429515
https://www.ncbi.nlm.nih.gov/pubmed/21236528
https://www.ncbi.nlm.nih.gov/pubmed/18843666
https://www.ncbi.nlm.nih.gov/pubmed/18843666
https://www.ncbi.nlm.nih.gov/pubmed/29408739
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4399594/
https://www.nature.com/articles/s41598-018-33995-7

Evidence-Based Practice Is the Gold Standard

The problem with a lot of hospitals is that their policies interfere with evidence-based practice. It takes approximately 17 years before new research is implemented in everyday practice. Many hospitals are not up to date with which practices are best for a pregnant woman and a newborn baby. So when it comes to many of the points under the next topic of evidence-based practice, you most likely won't have a choice in the matter, because the hospital policies very often overrule the preference of the care provider. For example, when you discuss uninterrupted skin-to-skin with your baby for the first hour after birth, your doctor might say, "Yes, of course, that is the best and you can definitely do that." The problem is that the nurses in the hospital will take your baby away because they "have to" weigh, bath, vaccinate and incubate your baby immediately after birth. So your care provider's opinion won't necessarily influence the care you receive in a hospital.

I feel that it is extremely important to note that all midwives are not the same and not all doctors are the same. There are exceptionally great midwives and doctors, and there are midwives and doctors that honestly provide less than optimal care. The standard to hold everyone to is evidence-based practice. Is your care provider doing what is best for you and your baby according to the latest research?

I am going to write an article about evidence-based practice after I am done with this one. I might even need to address each point in separate articles. Here are the basic points that you should discuss with your care provider:

• Do I need an ultrasound, and if so, how often do you perform an ultrasound?
• Do you do pelvic assessments and does your interpretation of the pelvic assessment decide whether I can birth vaginally?
• How far pregnant will you let me get before requiring a medical induction of labour?
• Can I phone your personal number any time of the day if I need pregnancy- or parenting-specific help?
• How often do you do episiotomies?
• How often do your clients go for C-sections?
• What do you use to listen to the baby's heartbeat?
• Do you do intermittent or continuous fetal monitoring?
• Can I labour in whatever positions are most comfortable for me?
• Am I allowed to eat and drink during labour?
• Can I freely use the toilet during labour?
• Do you give routine intravenous fluid during labour?
• What pain relief do you recommend?
• Do you do routine rupture of membranes?
• Do you do routine vaginal examinations during labour?
• Can I give birth in whatever positions are most comfortable to me?
• Can I give birth in water?
• Will you allow me to make whatever noise I please while I am in labour and pushing?
• Who is allowed to be with me when I labour and give birth?
• Will you coach me to push, or let me follow my body's own signals?
• How long do you let the baby's cord stay attached to the placenta before you feel the need to cut it?
• How do you resuscitate a newborn, if the need arises?
• Will you leave my baby skin-to-skin with me, for at least an hour?
• How do you deal with perineal tears?
• How do you manage the third stage of labour (when the placenta comes out)?
• What do you do in the event of post-partum hemorrhage?
• If I end up with a C-section, will you allow delayed cord clamping, skin-to-skin and initiation of breastfeeding during the operation, and prevent unnecessary separation of me and my baby after the C-section?
• Do you require chloramphenicol eye ointment for my baby, even if I don't have gonorrhea or chlamydia?
• How do you help a woman who is having a hard time with breastfeeding?
• Do you routinely check a newborn's blood glucose?
• Do you require newborn babies to be kept in an incubator?
• Will you respect my choice as to what substances I consent to be administered to my baby?
• Do you require or recommend any additional fluids except colostrum and breastmilk to be given to a newborn baby?
• Do you routinely put a hat on the newborn's head immediately after delivery, during skin-to-skin time?
• When will my baby be bathed, and what products will be used?
• If in a hospital or birth center, will rooming-in be practiced or do babies get taken away from the mother at any time to a baby room/nursery?
• If in a hospital or birth center, how will you ensure my baby doesn't get swapped or stolen?

It is essential to know your care provider's opinion on each of these questions, and maybe even more. I will try to think of more questions that might need to be addressed when I write in-depth articles.

I was not sure how I should word these questions in this article, in reference to my over-use of the phrase "allowed to". I am not a supporter of disempowering a woman in labour. A woman shouldn't be "allowed to" assume a comfortable position for pushing. Saying that she is "allowed to" takes the power out of the woman's hands and puts it into the care providers hands. When a woman gives birth, she is still in charge of her body and can decide what she wants to do with it. So most of the questions would be phrased totally differently, if I wasn't wary of offending people. Here are some examples of how I would rather write the questions: Will you please just get over yourself if you are uncomfortable with me giving birth on the floor in a deep squat and catching my baby with my own hands? Will you please just get over yourself if you are uncomfortable with me bringing my mom, husband, grandmother, sister, cousin, best friend, photographer, doula and whoever else I would like to be with me when I am in labour? Would you mind if I prefer that you don't stick your fingers and get a bunch of your different students to stick their fingers in my vagina?

Many of these questions might sound ridiculous, and you might think it unnecessary to even raise the topic with your care provider. For example, take the question about making sounds during labour. When I worked in the hospital, I heard care providers say countlessly, "Stop making a noise!", "Shut your mouth!"

A woman needs to choose a care provider who will respect her as a person, respect her baby as a person, and do what is best for her and her baby according to research, not tradition, policy or convenience. If your care provider seems unwilling to change their usual ways of practice for you, to ensure that you and your baby get evidence-based care, or if the place where you plan to give birth is unfriendly towards mothers and babies, I highly recommend that you find a new caregiver and place of birth.

For women who choose a doctor as their care provider, something very important to note and discuss with the doctor, is that, very often, the doctor that a woman has been seeing and getting to know during her pregnancy might not be on call when she goes into labour, and the woman then gets a total stranger (the doctor on call) who comes to deliver the baby. This sudden change in care provider usually results in the woman's birth plan being turned on its head, because the new doctor has not agreed to all the evidence-based practice that the woman desires for her birth.

Many medical aids severely limit your choice of care providers and some even remove your right to choose a care provider, by saying that the care providers you are interested in are not part of their "network".

My last point is that, regardless of where and with which medical professional you are giving birth, a doula is an indispensable part of your birth team! Doulas improve birth outcomes in practically every given setting. A doula today should be as common as an episiotomy was in the 90's (that is, 100% of first-time birthers received one.)

If I am taking too long to address a specific topic that you may be interested in, please feel free to send me a message so that I can share the relevant research with you, if you need the answers urgently.