Continuity of Care: Are You Getting It? Part II - CNM's in the Hospital
Updated: Sep 4, 2019
All mamas want continuity of care. This is hard-wired as an expectation in women. Once you have chosen a medical care provider, it’s totally normal not to want to switch. However, in order to receive the best of care and to provide not only the safest experience, but also the one that is most likely to honor the psychological needs of the mother and infant, choosing a provider who truly provides continuity of care definitely provides an advantage. Most situations in the U.S. do not provide true continuity of care – being aware of this reality is important, too, so that you can make other choices to make up for some of that and not go in blindly trusting that all will be taken care. Many new families are completely taken off guard by the realities of labor and birth in the U.S. vs. what they thought would await them as part of their care. It’s an understandable naiveté
I started this conversation with this blog post. So, continuing our focus on continuity of care, let’s take a look at certified nurse midwives (CNM's) in the hospital. How this works in your area will partially depend on the midwifery program in the hospital you choose. The programs I am familiar with locally have a group practice. During the prenatal period, pregnant mothers with a group midwifery practice generally see a different midwife for each prenatal – could be that you see a certain midwife more than once. Since you do not know which midwife will be on call on the day of your birth, this rotation system gives you a chance to have a little familiarity with your potential midwife on the big Birth Day. Continuity of care during the prenatal period: No, you don’t have the same midwife for each visit. There is some continuity within the group as a whole.
How about during labor and delivery? CNM's are generally on call for 12 - 24 hour shifts. You do not know who will be on call, but if you time your entrance into the hospital right (not completely controllable, but can be doable), you could have the same midwife while you labor and for your delivery. The advantage to this is that even though you did not have continuity of care prenatally, you do have a midwife on the floor while you are laboring. She is directly involved with your care and able to observe you in real time and not have information translated (and potentially missed or misinterpreted) via phone calls from a nurse. There is no substitute for being there. Certified nurse midwives are autonomous medical care providers who specialize in normal labor and delivery. They are not below doctors. Midwives simply specialize in normality, while OB’s specialize in the complications of pregnancy.
If you are in the labor during a shift change, you may get another midwife, but the good news is that you may have met her before (unlike with a nurse shift change at the hospital – here you are confronted with another complete stranger. This is another thing to consider with OB care.) Continuity of care during labor and delivery: Not completely. The 12 - 24 hour shift with the midwife there on the floor the whole time is an advantage from a physical safety and psychological viewpoint over OB care and you do have continuity during that shift period. It’s a bit of a compromise with the shift system, but you don’t know who you are really going to get with the vast majority of OB group care either and you certainly don’t have an inkling who your nurse is going to be if you are with an OB. So, it’s definitely a step up.
During the postpartum period, most hospital-based midwifery programs are similar to OB care here. The baby’s care goes to the pediatric care provider. Mothers have a six-week check-up with the midwife group. Usually there is no follow up in the days and early weeks following the birth. If you know of a hospital-based midwifery program that checks-in with the new family in the first days and weeks after release from the hospital, let me know. I would love to learn more about this program and how it works. Sharing is caring. Continuity of care postpartum: Similar situation to OB's - lack of continuity of care; room for improvement.
So, for the postpartum period – you’ve got to get your own ducks in row. A midwifery program is usually more pro-active during the prenatal period in directing new mothers about classes and actions they can take to support themselves during pregnancy, labor and birth, and the postpartum period. If you put your own support systems in place, midwifery care in the hospital can be a good compromise to getting the labor and birth experience you want, especially if you are considering natural childbirth.
Summing up continuity of care for hospital-based CNM’s: This is not continuity of care in the complete sense of having the same provider for the prenatal period, labor and delivery, and the postpartum period. It is a compromise and it is more honest than OB care as no one is pretending like it is complete continuity of care. The upside is having a provider who may have more experience with natural birth and also the longer shift period when a midwife is actually on the hospital floor. Having the primary care provider on the floor while you are laboring is really important for a number of reasons (we’ll get to that in another post.) Additionally, the midwife who greets you when you come to the maternity care unit could very well be the one who is with you at the birth. And you won’t be waiting for her to arrive in order for you to push your baby out, as she is already there.
Because this is a hospital birth situation and is not continuity of care I do recommend taking the following steps to ensure the best experience and to make for a smoother transition to family life:
Become aware of the steps you need to take to keep you and your baby in the healthy and normal continuum (also know as “low-risk”)
Once you know these steps, practice daily with love and intention (leave perfection behind – it’s not helpful to you and your baby to try to do everything “perfectly.”)
Find community and a support network: set yourself up with classes and connections with birth and breastfeeding professionals who can help you find your way so you can set yourself up for a good transition to family life
A thorough and practical childbirth education course is a must. This is not jut for first time parents. If your first birth was not positive or did not go the way you wanted, education can make a huge difference the next time around.
If you have friends and/or family knowledgeable about physiological birth, breastfeeding and baby care, enlist their help and support.
If you do not have friends or family members with these skill sets, a doula can be a source of support and knowledge. She can be a personal guide and help you find your navigation skills in a new territory.
If you are not planning on having a doula (and even if you are!), I recommend a Bradley Method childbirth education course whether you plan a natural birth or not. A Bradley Method course delves deep into a lot of choices you have as parents and makes you aware of what you need to prepare for throughout your pregnancy for the labor and birth as well as when baby comes home.
Remember, while you don’t need to worry about doing everything perfectly, you do need to take steps to prepare for your labor, birth, and postpartum. Learning to advocate for yourself and take action is the number one most important step you and your partner can take to help you both create a great start to your new family life. This starts with your choice of provider and understanding the strengths and weaknesses of each provider and the situation as a whole. There is a lot you can do to support yourself and I encourage you to take a honest look at your provider and what this person(s) can and cannot do for you. There is no right and no wrong. Just what is. When you honestly look at that and understand it, you can make choices that will serve you.