“I want a natural birth. I need a midwife!”
“I want every drug in the book. Give me an obstetrician!”
These statements demonstrate two common misconceptions about the labour experience, but they don’t even come close to painting the whole picture. Choosing a primary care provider for nine-plus months of pregnancy, labour and delivery and postpartum adjustment is extremely personal, and the right answer will be different for every individual. Whether you pick a midwife, a family doctor or an obstetrician (or end up with some combination of the three) will depend on a wide variety of factors. Here’s what you need to consider.
First, what is a midwife? What is an obstetrician?
You’ve probably had a family doctor throughout your life, but you may not be as familiar with obstetricians and midwives. Obstetricians, or obstetrician-gynaecologists (OB/GYNs), are medical doctors who specialize in pregnancy and childbirth, especially in the management of high-risk pregnancies and pregnancy complications. Midwives undergo a four-year bachelor of health sciences degree in midwifery and are experts in healthy pregnancies. Family physicians, obstetricians and midwives are skilled medical professionals who have hospital privileges, offer lab tests and ultrasounds, and maintain a standard schedule for prenatal visits.
Midwife or OB: What is the safest option?
In Canada, whether you choose a registered midwife, a family physician or an obstetrician, you can feel comfortable knowing that their practice is well regulated, with national guidelines and protocols governed by each province and territory. “We’ve come a long way to achieve a safe system of care in Canada,” says Jennifer Blake, chief executive officer of The Society of Obstetricians and Gynaecologists of Canada (SOGC). “Wherever women enter the system, it’s designed to look after their safety and well-being.”
Now, you may be wondering how you’re supposed to make a choice if midwives, family doctors and obstetricians are educated, well regulated and safe. It’s time for you to answer these questions.
Do you have a typical, healthy pregnancy?
If the answer is yes, then you can take your pick of practitioners. However, if you have a high-risk pregnancy (you are having twins or triplets, have had previous abdominal surgeries or have diabetes, asthma or other health issues), you may be best served by an obstetrician with experience in unique, potentially complex prenatal care and delivery.
If your pregnancy is healthy, you may feel most comfortable with your family physician, provided that they are among the 40 percent of family physicians in Canada who offer prenatal care (though only about 10 percent actually deliver babies). In some areas, like Vancouver, there are even family practices that focus exclusively on prenatal, intrapartum and postpartum care. Alternatively, you may choose a midwife (all of whom are experts in healthy pregnancies) and able to devote plenty of time to your care.
Statistics vary greatly by source and province. However, according to the Provincial Health Services Authority, obstetricians attended 50.7 percent of births in British Columbia from 2015 to 2016, family physicians attended 32.1 percent, and midwives attended 15 percent. In Ontario, based on numbers from BORN, Ontario’s pregnancy, birth and childhood registry, the bulk of births from 2016 to 2017 were attended by obstetricians (76.3 percent), followed by midwives (10.7 percent), although the Canadian Association of Midwives puts the percentage a little higher (16 percent) from 2016 to 2018.
Where do you want to deliver?
If you have a low-risk pregnancy and dream of delivering at home or in a birthing centre, choose a midwife because, in most cases, family doctors and obstetricians only practice in hospital settings. However, if you know you want to deliver in a hospital, you can choose any type of provider, including a midwife. In Ontario, between April 2017 and March 2018, 83 percent of births attended by midwives were in hospital, 14 percent took place at home and three percent were at birthing centres.
How much one-on-one care is important to you?
Midwives are typically able to offer the most one-on-one care, including before, during and after delivery. Their prenatal appointments are about 30 to 45 minutes long, they’re able to provide undivided attention during labour and delivery, and they often provide home visits in the early days after childbirth. Family doctors and obstetricians are often pulled in multiple directions, which means that their prenatal and postpartum appointments tend to be shorter and they rely heavily on the support of nursing staff during the labour process.
Is continuity of care important to you?
It’s impossible to guarantee that the same provider that follows you throughout your pregnancy will also deliver your child, but certain practitioners work harder than others to promote continuity of care. Some obstetricians and family physicians remain on-call for their patients or provide small call groups (meaning that you’ll probably be attended by one of a small number of doctors). Midwives also make continuity of care a central tenet of their practice. “Usually, you’ll meet a small team of midwives and they are very likely to attend your birth,” says Elizabeth Brandeis, president of the Association of Ontario Midwives. If it’s important for you to have a familiar face in the delivery room, ask about your care provider’s policy early on in your pregnancy.
What are your feelings on pain management and medical interventions?
“We live in an era where medical interventions have become quite routine in pregnancy and childbirth,” says Brandeis. “The midwifery model believes that, though those medical interventions are sometimes necessary, they certainly don’t need to be routine.” If you choose a midwife, you will first be offered natural methods of pain management, such as water immersion, position changes and counter-pressure massage. (You can also get drug-free pain management, such as water immersion, with obstetricians.) “But midwives are not against epidurals and see them as a useful tool when necessary,” says Brandeis. However, note that epidurals are only available in a hospital setting.
Of course, you can also have a completely unmedicated, vaginal delivery in a hospital with a physician if there are no complications. “The rate of caesarean sections is the same whether you have an obstetrician, a family doctor or a midwife,” says Blake. “It’s not a question of who is providing the care but whether or not a caesarean is the safer mode of delivery.” In Canada, about 28 percent of hospital deliveries were performed by C-section from 2016 to 2017. The number of midwifery patients who delivered by C-section in Ontario in the same year was much lower (17 percent), but the majority of those patients had low-risk pregnancies to begin with. In British Columbia, the number of midwifery patients who had C-sections was at 20.6 percent from 2015 to 2016.
What happens if you choose a midwife or family doctor but have complications?
Regardless of the type of provider you choose, a good practitioner will understand their scope of practice and stay within it, says B. Anthony Armson, president of the SOGC, which means that they will ask for help from other experts in their network if they need it. If you are delivering at home or in a birthing centre and have complications, you may need to transfer to a hospital, where your midwife will continue to work with you or transfer your care to an obstetrician, depending on the circumstance and region. If you’re already in a hospital, your midwife or family doctor can consult directly with an obstetrician, who may consult a maternal-fetal medicine specialist. “The best model for safe care is one that looks at the whole team,” says Blake. “You never know which members of the team you’re going to require.”
Before making your final decision, there are a few other things to consider.
Access to family physicians and obstetricians is covered by provincial and territorial healthcare. “Fortunately, we’re almost at the point where we can say that there’s also regulated, funded midwifery in every jurisdiction across Canada,” says Brandeis. The only regions that don’t have provincially or territorially funded midwifery care are Prince Edward Island and the Yukon. “However, Prince Edward Island announced its intention to roll out funded midwifery regulation in 2020, and the Yukon is at the final stages of working out its policy framework as well,” says Brandeis.
If you live in a rural area, you may not be able to access the services of an obstetrician without travelling and may be limited to a family physician. “Rural family physicians are far more likely to provide obstetrical care than their urban counterparts,” according to The Vanier Institute of the Family. If you’re hoping for an obstetrician, you will probably have to venture to an urban centre. In northern communities, many women with low-risk pregnancies deliver at birthing centres with midwives. However, in many other areas—including cities—the demand for midwives still exceeds the supply. If you wish to go the midwife route, start contacting midwives or midwifery practices as early in your pregnancy as possible.
Ultimately, a big part of your decision will come down to finding a provider whose personality and philosophy mesh with your own—and, in the end, that’s usually more important than the type of provider you choose. Keep an open mind, get recommendations from family and friends and meet a few experts in person if possible.