By Chris Parker
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By Judy Keen
In rare instances--Nancy Nelson says it's less than one percent of all patients--a midwife will offer a patient a contract. That means she sees the woman for every prenatal visit, promises to be there for the delivery and visits her postpartum. Usually contracts are only offered to close friends or family members.
Frantzich, who has had five contract patients since she began practicing in 1996, says continuity from prenatal through postpartum care allows the development of "a relationship that is really rich and deep. I get to know all the intricacies of that woman and I can follow her along physically, emotionally, and spiritually. It's what I believe is true midwifery."
Many midwives admit that in an ideal world, all pregnant patients would have this type of continuous care. However, contract patients are strongly discouraged or disallowed at all of the local midwife clinics. For one thing, the midwife who has a contract patient is on call twenty-four hours a day for two to four weeks around the patient's due date. Second, if for any reason the contracted midwife can't be there for the delivery, the patient may be quite upset, not having mentally prepared for the possibility of working with another midwife. Third, the midwife may be called in for the delivery during a time when she is expected in the clinic, and then clinic coverage has to be hastily arranged. And lastly, patients who do not receive contracts may perceive favoritism if others do.
Effect on outcomes
While almost every woman who has given birth and every caregiver who has delivered a baby has an opinion on the subject, little research has been done on whether continuity of provider during pregnancy affects medical outcomes.
In a 1993 study of pregnant adolescents in Portugal, the control group had routine prenatal care from different obstetricians at each visit, while the study group saw the same obstetrician for twice as many prenatal visits. The infants of the mothers in the study group had higher birthweights and fewer of them needed care in the high-risk pediatric unit.
Discontinuity of provider during prenatal care has also been shown to have a negative effect on patient satisfaction. And it is certainly possible that women's satisfaction with their care may affect pregnancy outcomes. A patient who sees several prenatal providers may feel like she has to start all over again with each one, and may feel more like a number than a woman embarked on the most transformative experience of her life.
Several studies have shown that the presence of a doula, who is not medically trained but who provides continuous comfort to the laboring woman, can shorten the length of labor, reduce the rate of Caesarean and forceps deliveries, and decrease the need for pain-relieving drugs and labor stimulants like pitocin. It would stand to reason that the continuous presence of a medical professional during labor may have the same effects, if he or she provided the emotional support that doulas provide in addition to medical care.
Dr. Yeh thinks that for experienced physicians and midwives, there is no medical advantage to tracking a woman for the length of her labor. But some midwives, including Frantzich and Nelson, believe that watching a woman labor results in less intervention. "Because nurse midwives tend to spend more time with a woman in labor, they are more apt to discern when things are going normally and should be left alone, and when intervention might make for a more optimal outcome," Nelson says.
"If I have been there at the bedside for hours," Frantzich says, "the woman is more willing to listen if I suggest natural things to stimulate labor or relieve pain like changing position or getting in the tub. But if the woman is exhausted and she doesn't know me from anyone else, she may just say, 'I'm not going anywhere. Give me drugs.'"
Hangsleben feels that watching a woman labor can help to predict and manage the delivery. "If labor is slow and tedious and painful, you may have a longer pushing phase. It sometimes predicts that you've got a bigger kid or the baby is posterior," she says. Other observations that can be useful, she says, include how the woman responds to pain, how physically strong she is, how tired she is, and what kind of relationship she has with her support people.
The obstetrician for Kirsten Allen's first labor "poked his head in twice for about a minute" but didn't stay with her until the last fifteen minutes of pushing. "He had me lie flat on my back and was wondering why my contractions were slowing down. It took the doula to say, 'Excuse me, if you put a pillow under her right hip, she'll have the baby. That's how her labor has progressed the fastest this whole time.' So the nurse listened to that and put something under my right hip and I had the baby," Allen says.
Common sense would suggest that the longer a caregiver has known a woman, the more sensitive he or she can be to that woman's desires, needs and capabilities relative to childbirth. I was fortunate enough to have been offered a contract by a midwife/friend when I became pregnant last year. Carrie Frantzich saw me for each prenatal visit, allowing time for the formation of a communicative, trusting relationship. As it turned out, my labor was very long (thirty-three hours) and difficult, but Carrie stuck with me and delivered my baby vaginally and without unnecessary drugs or interventions, as I had requested. I wonder if the outcome would have been as favorable with providers I barely knew--or if they would have taken the more expedient route of a vacuum or Caesarean delivery. I also wonder if my husband and I would have maintained the fortitude to keep laboring so long without Carrie's expert management and continuous, warm support.