The Delivery Debate

We both still vividly remember the moment we found out we were having our first babies. It was incredibly joyful—and also very scary. We knew that decisions we made during pregnancy would have a lifelong impact on our children's health. Like most mothers-to-be we were bombarded with sometimes unwanted and often conflicting advice from relatives, friends, and colleagues. No topic seemed immune to dispute. Apricot nectar or ginger ale for morning sickness? Asparagus or grapefruit for swollen ankles? But those debates paled before the most critical question: who would we trust to bring our children into the world?

Because we were young and healthy, we were considered low-risk for problems during pregnancy or delivery, and we had some choices. Barbara selected a hospital-based midwifery practice. Pat decided on an obstetrician. Both of us were grateful to the people we picked, especially when we unexpectedly ran into trouble. Early blood tests indicated that Barbara's son might have serious birth defects, and the midwives immediately referred her to a neonatologist who helped her and her husband understand the issues they might face. It was an anxious pregnancy, and the midwives were an important source of support. Fortunately, her son was born healthy. Pat had what seemed to be a perfect pregnancy until her water broke at 23 weeks. Her husband rushed her to the hospital, where her first son was born weighing little more than a pound. The staff of the neonatal intensive care nursery used every resource they had to keep him alive and minimize damage and, thanks to their heroic efforts, her miracle baby survived and prospered.

Two decades later our sons are grown. But the issues surrounding the choice of a childbirth provider seem even more fraught, primarily because the number of women giving birth via cesarean section has increased 50 percent in the last 10 years, according to the National Center for Health Statistics. Cesareans now account for nearly a third of all U.S. births—a record high. Though they can be life-saving to both mother and baby in an emergency, and are also vital when a mother is suffering from a potentially fatal condition like preeclampsia, there are concerns that too many may be elective—a matter of choice, not medical necessity. It's not clear precisely what accounts for the overall increase in cesareans. Various reports have blamed greedy hospitals or doctors, who make more money from surgery, working mothers who schedule births in between business meetings, and the rising rate of health problems like obesity and diabetes that can lead to complications during delivery. Whatever the reason, the statistic alarms many women and has prompted many childbirth providers to wonder if mothers-to-be are getting enough information on all their delivery options.

The need to avoid unnecessary cesareans is one of the main messages of "The Business of Being Born," a new documentary by former talk show host Ricki Lake that explores various methods of childbirth. It is also fueling a national campaign, led by The Big Push for Midwives 2008, to license more midwives to preside over births at home in an effort to lower the chances of unneeded surgery. But the home-birth method, which now represents only about 1 percent of all U.S. births, has its own critics. The American College of Obstetricians and Gynecologists (ACOG) recently reiterated what it describes as its "long-standing opposition" to the practice—a statement that angered home-birth advocates, who accused ACOG of trying to limit women's choices. Between the controversy over elective cesarean sections and the debate about home births, it can be especially confusing these days for women trying to decide how and where to have their babies—and who will help them deliver. Here's a rundown of the options.

Obstetricians: With more than 50,000 members, ACOG is the major professional organization representing obstetricians. In this country, doctors preside over about 90 percent of all births, with virtually all doctor-assisted births taking place in hospitals. Dr. David Redfern, an obstetrician for 19 years who is Missouri section chair for ACOG, said the organization believes that choosing a provider with a standardized medical education—whether doctors or certified nurse-midwives—is the surest route to a safe delivery. "We are concerned about the complications that quite often arise without warning," he says. "The home-birth advocates want you to believe that they can recognize these major catastrophic things and hit the hold button while they transport the patient to the hospital and everything will be OK. That hasn't been our experience."

If you choose a doctor and hospital setting but are still concerned about the possibility of an unnecessary cesarean, ask lots of questions. Maureen Corry, executive director of Childbirth Connection, a nonprofit group, advises women to interview potential doctors and hospitals about their C-section rates. "If a doctor wouldn't talk to me about it, I would have concerns," she says. If you've already had a first child through a cesarean, you can still ask if the doctor will help you try for a vaginal delivery this time. The main concern for women who have had previous cesareans is uterine rupture, so discuss the risks and benefits with your provider.

Certified Nurse-Midwives: Midwives with this credential from the American College of Nurse-Midwives ( the certification process is administered by the American Midwifery Certification Board) are licensed in all 50 states. The vast majority (about 98 percent) deliver babies in hospitals, where many studies show they have good outcomes. The ACNM says that of the small percentage of their patients who deliver at home or in free-standing birth centers, only about 9.1 percent were transferred to the hospital during labor or just after delivery. In 2005 certified nurse-midwives attended more than 306,377 births in the United States, which represented 7.4 percent of all births and 11.2 percent of vaginal births, according to the National Center for Health Statistics. That number has been rising steadily since 1975. CNMs generally have traditional nurses' training along with special training in midwifery; more than two-thirds also have a master's degree, the ACNM says. (In a press release issued earlier this month, ACOG says it doesn't support the provision of care by midwives who are not certified by the American College of Nurse Midwives or the American Midwifery Certification Board.)

Lorrie Kaplan, ACNM's executive director, advises consumers to be just as careful in selecting a midwife as they would any other health-care provider. Some questions: can the midwife prescribe medications if needed? What type of degree does she have? Is she certified? By whom? If the birth is at home, what's the backup hospital? Does the midwife have privileges at that hospital or will she have to leave you at the door? Who is the backup doctor? Also, Kaplan advises asking for client references.

A good candidate for this kind of midwifery care would be a healthy woman having a normal pregnancy, says Mairi Breen Rothman, a certified nurse-midwife in Maryland. A woman with a more complicated medical history would probably choose a doctor's practice. Rothman says CNMs often work with physicians. "We understand that we are a team," she says. "It's important for all of us to work together."

Certified Professional Midwives: About 1,300 midwives have received this credential from the North American Registry of Midwives. They specialize in out-of-hospital deliveries, either at home or in a birth center, and their training emphasizes experience—especially in out-of-hospital settings—over a traditional hospital-based medical education. They have three to five years of clinical training under another CPM and must also pass a written exam. For more details of their qualifications, check out the registry's Web site. CPMs are licensed and regulated in 24 states, says Katie Prown, campaign manager of The Big Push for Midwives 2008, which aims to extend that licensing to the entire country. Prown rejects ACOG's claims that CPMs are less qualified than CNMs. "If those accusations were true, then we would see a different trend than what we are looking at right now," she says. "In the last five years Utah, Wisconsin, Virginia and Minnesota have licensed certified professional midwives … These states are seeing good results. If they were seeing bad results, states would be outlawing CPMs." Prown says that trying to make CPMs illegal could potentially create a more dangerous situation. "When CPMs are forced to go underground," she says, "they get shut out of the health-care system, and that doesn't serve babies or mothers well at all." Prown also says it is a myth that when women are transferred to the hospital it is an emergency. "Often," she says, " we see women who want to go to the hospital for pain relief or because they are exhausted."

CPMs are a primary resource for women who want to deliver at home, since the majority of CNMs practice in hospitals. If you choose this option, you would want to understand the midwife's qualifications as well as the laws in your state governing this kind of practice. You should also check whether your insurance covers out-of-hospital care. Finally, it is important to find out what would happen in case of emergency. Again, as Kaplan advises, you want to know what connection the midwife has to doctors and hospitals so that the transfer can be seamless. If there is a backup doctor, you could ask to meet that person.

We think it's important that women understand the risks and benefits of all health-care decisions, including the choice of a childbirth provider. Your conclusion should be based on the best scientific evidence as well as your own personal preferences and beliefs. "As a woman and a mom and an obstetrician, I feel strongly that patients should have choices," says Dr. Anne Foster-Rosales, former chair of ACOG's international committee. "But I think making it as safe as possible is very important." Foster-Rosales has worked with mothers around the world, including in countries where most women give birth at home with untrained attendants. Because of what she has seen, she feels that it is important that home-birth providers not feel ostracized so that they can come to the hospital if necessary. Emergencies may be rare, but the course of an individual pregnancy is unpredictable no matter where you choose to give birth. Protect yourself and your baby by learning as much as you can.