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  • Writer's pictureSusan Martin

Continuity of Care: Are You Getting It? Part III - Midwives at Home or Birth Center

Updated: May 3, 2021

What helps a mama to feel at ease during her pregnancy, during labor and birth, and after her baby is born? Yep, it is continuity of care. In two prior blog posts I explored what is really being delivered (pun intended!) by obstetricians and certified nurse midwives in the hospital setting focusing on the issue of continuity of care and whether this important factor (that all mothers want) is met or not. The desire for this experience is the major mostly unconscious emotional factor that keeps women with their chosen health care provider, even if that provider’s skill set and philosophy does not line up with the pregnant mother’s visions for her birth experience. So, what I am saying is, expectant mothers want to feel safe with their provider and from their perspective they feel safest with the one they “know.” This is normal. This is natural.

There are good reasons to be completely aware of the circumstances under which your health care provider operates because this will really influence how your labor and birth go and your experience as a new parent. Understanding that what you expect as a mother is continuity of care, and then taking a close look under the covers to see what you are really getting can help you make choices that will be supportive for you and your baby.

So, let’s take a look at continuity of care from the lens of working with a midwife either in the home setting or at a free-standing birth center (meaning not at a hospital.) Midwives who attend births at home and/or run independent birth centers may be certified nurse midwives (CNM’s) or direct entry midwives such as a licensed midwife (LM) or a certified professional midwife (CPM.) Midwives are autonomous health care providers who provide clinical care for women during pregnancy, labor and birth, and the postpartum period. Midwives specialize in working with normal, healthy pregnancies. When a mother or baby pair moves outside the realm of normal and healthy, they are referred to the care of an OB (physicians whose specialty is the pathology of pregnancy and birth.) Just as an fyi, midwives can also provide regular well women care like annual exams for female reproductive health (you know, the Pap smear and all that jazz!)

Typically, during pregnancy the expectant mother sees the same midwife she hired (or midwife pair) at each of her visits. She will likely meet her midwife’s back-up person during one of these visits. Clinical visits with a home-birth/birth center midwife usually last around 45 minutes to an hour. A lot of this time is spent talking and getting to know each other. This gives the opportunity for the midwife to really understand what is going on with a mom and to help her stay healthy on multiple levels. This amount of time helps the expectant mother to feel truly at ease with her provider and creates a strong relationship. So, how does the CNM or LPM working in the home or birth center setting stack up on continuity of care during pregnancy? Sounds pretty awesome, right? That’s because it is the real deal with continuity of care. Check off “yea” for pregnancy continuity of care.

How about labor and delivery? Since most midwives work independently, and some in pairs or small teams, you are extremely likely to have your midwife on the day your baby decides to arrive. Your midwife will know exactly what has been going on during your pregnancy and she brings this deep knowledge of you and your baby to the labor and birth. She is communicating with you during early labor. She is with you during active labor – directly observing and watching over you. There is no nurse sharing updates over the phone or other means of distance communication, which creates the opportunity for misunderstanding or missed clinical information simply because of the fractured care. It is always safest to have your provider there during the labor and the birth. That is continuity of care – to BE THERE This provides both physical safety and emotional safety. Midwives stay until several hours after the birth to make sure mother and baby are both stable and doing well before leaving. Continuity of care during labor and delivery for midwifes at home or birth center? Yes, ma’am – continuity of care.

The beauty of it all this is that continuity of care continues on through the postpartum period. Midwives visit the new mother the day after delivery and several days postpartum to check-in on the health of the mother and her infant as well as to make sure breastfeeding is going well. Each individual practice will have a different number of days that they check-in after the birth during the initial weeks of postpartum - some have a minimum one-day check up, others have several days. Mind you, these visits are made in the mother’s abode. In the initial days after the birth, the midwife checks-in not only on the mother’s health, but also on the baby’s. Baby is checked over by the midwife and weighed. Nursing is assessed. Referrals are made if necessary. The mother goes to the midwife’s office for her six-week check-up. Continuity of care? – you bet! This is actually the best through-line for continuity of care of all the options currently in the U.S.

Working with a midwife at home or at an independent birthing center provides continuity of care in the true sense of the concept. There is a complete through-line of care that helps new parents have a smoother transition to new family life. The quality of care a mother receives from a midwife in these settings exceeds the care experienced in the offices of the majority of hospital based OB’s and CNM’s. The advantage is the quality of the relationship; the extra time allotted during the clinical sessions provides the opportunity for presence and authentic connection. The time spent makes it less likely that some important clinical situation will slip through the cracks. Midwives are constantly monitoring to make sure a mother takes actions to stay in the healthy and low-risk category.

Ironically, even though working with a midwife provides a high quality of continuity of care, the idea of birthing at home or in a birthing center may be an unfamiliar choice for many. This may lead to such a setting feeling “unsafe” for some parents. This is understandable considering cultural norms, and certainly it is not the right choice for everyone. Birthing at home or in a free-standing birth center is a legitimate choice for women who have healthy, normal pregnancies to consider, though, and it does have its own advantages. In the end. no one situation is exactly perfect and no one situation can guarantee an outcome. Only you know what situation feels best for you and your baby.

So now you know what continuity of care is and the providers that provide it and those who do not. This allows you to really consider your circumstances and what your needs are. The home birth setting sets the standard for continuity of care. In other countries you could get this level of care even in the hospital setting. This is what I would like to see – an expansion of true continuity of care. It leads to the best outcomes for mothers and babies.

For you, right now, the system is what the system is. If you are delivering at home or in the birth center, you are extremely likely to get continuity of care. If you are planning to deliver in the hospital, you are not getting continuity of care, but this is what your million-year old nervous system wants. So, knowledge is power. If you need and choose to deliver your baby in a system that is lacking, be pro-active about creating a bridge that will see you through (I’ve listed some ideas at the end of this post.) Taking responsibility and personal action will increase your likelihood of having a healthy pregnancy, a good birth, and a smoother transition to new parenthood. You deserve all of these!

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