When Bridget Malisow realized she was pregnant last spring, she called an Edina obstetrician recommended by a friend. Bridget liked the idea of seeing this highly regarded surgeon for her first pregnancy. "I felt comfortable that if something went wrong during the delivery, she would be right there and could handle everything," Bridget says.
At Bridget's first prenatal visit, though, her new doctor said she could not guarantee her own presence for the delivery and explained that another doctor may be present instead. As it turned out, when Bridget went into labor, her doctor was not on call and did not attend the birth.
But by that time, Bridget didn't much care if her doctor was there or not. "Out of about twelve prenatal visits, I saw my doctor for maybe four of them," she says. "Sometimes she was at the hospital delivering a baby. Other times her schedule was too full and I couldn't get in with her. Other times she was out for health reasons." Over the course of her pregnancy, Bridget saw three different physicians and one nurse practitioner.
The doctor-roulette continued when she arrived at Fairview Southdale Hospital to deliver. Three physicians "popped in and out" during her sixteen-hour labor, none of whom she had met before. The third doctor was in the room for about forty-five minutes before Bridget's daughter was born.
Certainly, this scenario bears no resemblance to the cherished image of the concerned, kindly doctor assisting a woman through pregnancy, childbirth, and postnatal care. Many first-time mothers who expect to form a trusting relationship with a medical professional who will share their childbirth experience are disappointed to find that, in many Twin Cities clinics, continuity of care is a thing of the past.
While mother-newborn bonding is a hot topic, little is heard these days about mother-caregiver bonding. How important to pregnant women is continuity of health-care provider during prenatal care? Does a mother care whether she knows the person who delivers her baby? Are medical outcomes affected when strangers deliver strangers?
Continuity of prenatal care
The first pregnancy can be overwhelming for many women. Full of doubts and questions about her own and her baby's health, a mother-to-be needs consistent answers and a good deal of reassurance. One 1995 study found that pregnant women find continuity of provider, clear explanations, and accessibility of care important in prenatal care, with the provider relationship having the greatest influence on their satisfaction.
Nationally, most childbirths are handled by physicians; about five percent are supervised by certified nurse midwives (CNMs). Physician and nurse-midwife groups in the Twin Cities have distinct styles and policies regarding continuity of prenatal and maternity care.
Many local physicians try to adhere to the traditional model of seeing a woman consistently for all nine to fourteen of her prenatal visits. The nine OB-GYNs who practice at HealthEast's clinics in Shoreview and Woodbury, for example, make every effort to see their own patients. At the HealthPartners clinics, a pregnant woman can expect to see her chosen doctor alternating with a nurse midwife, who will perform the more educational aspects of prenatal care. At Hennepin County Medical Center's (HCMC) resident continuity clinics, a pregnant patient is scheduled to be seen by the same resident for each visit.
At other metro-area clinics, seeing the same doctor prenatally is possible but the patient has to bend her schedule to fit her doctor's. When Bridget was in her seventh month of pregnancy, her clinic suggested that she schedule her prenatal visits far in advance to help in getting appointments with her own doctor. "I wish I had known that earlier," Bridget says.
In a recent study conducted at the University of Exeter in the United Kingdom, virtually all of the 116 women surveyed wanted to be cared for throughout their pregnancy by one practitioner whom they knew well. But some women have priorities other than continuity of care, like getting an appointment at a particular time or scheduling their visits when an interpreter will be present, says Virginia Lupo, M.D., director of maternal-fetal medicine at HCMC. "The overriding concern is what is most convenient for the patient at the time," she says. "With a second pregnancy, for example, you're living with a toddler and there's just no time to think about being pregnant. You get in there for those prenatal visits and get out. You're not going to let a doctor's schedule run your life."
The stranger in the delivery room
While some physicians promise continuity during prenatal care, rare is the doctor who assures a woman that he will attend her delivery. Virtually every Twin Cities hospital has a call group of ten to thirty obstetricians, and whoever happens to be on call when a woman shows up in labor will attend the birth. The reason, of course, is that if physicians promised to attend all their patients' births, they would be on call twenty-four hours a day, 365 days a year. And the smaller the call group, the more time each doctor spends on call.
"There are a lot fewer physicians in this world [than before] who are willing to make their time totally available to their patients many nights a week," Dr. Lupo says. "It's an unlivable lifestyle. You can't have a carte blanche on your life every other night when you have a family and kids. More and more women and men in medicine are finding their voice and saying, 'No, I'm not going to work ninety hours a week after residency.'"
It bothers some women more than others that their labor physician is based on luck-of-the-draw. For her second pregnancy, Paulette Mattson saw one obstetrician prenatally but didn't know who would be on call for her delivery at Fairview-University Medical Center in Minneapolis. "Here I had spent all this time, prenatally, with one physician, and he wasn't even going to be there to see the end result," she says. "But when the time came, I really didn't care. I just wanted somebody who had a medical background to get the baby out!"
For Paulette, having a prior relationship with the doctor who delivers her child isn't as important as his or her bedside manner. With Paulette's first pregnancy, the obstetrician she saw prenatally was also there for the delivery, but only "for the last half-hour, the last hurrah," she says. Moreover, he was "kind of a cold person. I know doctors are busy, but right after Sarah was born he rushed off to do another operation. Sure, it was nice to know that he was going to be there, but what counts is whether he is compassionate," she says.
Nancy Nelson, R.N., supervisor of operations at Park Nicollet Meadowbrook Clinic in St. Louis Park, feels it would be to the patient's advantage to see the same person from prenatal care through delivery. "You form a stronger relationship. The trust aspect is increased." But, she adds, many women who elect to see a physician (as opposed to a nurse midwife) for maternity care "come with the idea, 'Just get me through the pregnancy and I don't care who does the delivery.' The women rely more on themselves to get through the labor process."
Bridget is a good example of that philosophy. "Before I went into labor, it bothered me that I didn't know what physician would be there," she says. "But during labor--maybe because of the drugs--I didn't care as long as my husband was there. That gave me the most comfort. The doctors were just in and out. It was my labor, and I felt I wanted to handle it myself," she says.
Because of the discontinuity in physician seen for prenatal care and for labor/delivery, some clinics ask women to rotate through the physician group and see them all prenatally. This way, the woman will have at least met the physician who is on call for her delivery. However, she may meet a physician during prenatal care whom she really dislikes, and feel anxious about encountering that physician during labor.
Johanna Bomster had her first baby in April at Abbott Northwestern Hospital in Minneapolis. She had been encouraged to see all five physicians practicing at Women's Health Consultants in Minneapolis during her prenatal care. There were two doctors in the group that she hoped not to see in the hospital birthing room. "One was very brisk and abrupt, and another I just didn't connect with," Johanna says. Although it was not possible to request that these doctors not attend her delivery, "I was really fortunate," she says. "I had seen the physician who delivered my baby for five of my prenatal visits, including the last two. And I liked her. In my childbirth preparation classes, all the woman were saying, 'I hope I get so-and-so for the birth.' But we all knew it would be whoever was on call."
At some clinics, a patient can ask that a certain doctor not attend her birth. "A woman may have encountered a physician before in an emergency situation and she will tell us that under no circumstances will she allow that physician to touch her. Or she may have had an undesirable circumstance with a first pregnancy and she can request not to see that physician again. We always have a back-up physician on call for situations like that," says Nancy Nelson of Park Nicollet.
Women who are really uncomfortable with the idea of seeing a strange doctor in the delivery room can better their odds at some clinics. The HealthEast obstetricians try to deliver their own patients during the daytime, whereas at night usually the person on call does deliveries. "It's at least a fifty-percent chance that a woman will be delivered by her own doctor," says HealthEast's Laura France, M.D. "And I tend to try to deliver my own patients at night as well, because I am the only female in this group and my patients often come to me for that reason. Or if I have a particular patient that I know wouldn't do well with another person, I will cover for that as well."
HealthPartners is aiming to be able to assure patients that one of the providers they see prenatally also does the delivery, "but we don't have that just yet," says John Yeh, M.D., head of OB-GYN. "There are circumstances in which a physician will come in for a particular patient's delivery. There may be a special medical problem or a special understanding," he says. But, in general, a HealthPartners patient has about a one in ten chance of seeing her doctor at the delivery.
Some women who want a continuous advisor throughout pregnancy and childbirth hire a doula, or supportive layperson. Minneapolis doula Lisa Perez says she acts as a "resource and friend" for the pregnant woman, meeting regularly with her prenatally, attending the entire labor and birth and visiting her postpartum. During the labor, when the woman may not know the medical personnel in the room, "I provide encouragement, support, compassion, and a belief in the work of the body, that the body can do this," Lisa says. "I can provide relief, whether physical or comic, and a positive, continual presence." Allina Health System has begun integrating doulas into its delivery rooms, including at Abbott Northwestern Hospital.
Certified nurse midwives
Like the physician clinics, none of the nurse midwife groups in the Twin Cities promise that a woman will have a particular caregiver for her delivery. CNMs also vary in how they provide prenatal care.
At some clinics, such as Park Nicollet Meadowbrook, HealthEast OB-GYN, and Fairview-Riverside Women's Clinic in Minneapolis, pregnant women are asked to rotate through the midwife group during prenatal care. "With our group of seven nurse midwives, that gets to be a bit of a challenge. But most of the time patients do meet most of us," says Karin Hangsleben, CNM, Fairview's director of nurse midwifery. At the HCMC clinics, prenatal patients rotate through only two or three nurse midwives. Patients at the HealthPartners clinics can expect to see the same nurse midwife for each visit. (The Allina clinics do not employ nurse midwives.)
Most midwife clinics that normally encourage prenatal visit rotation will honor a patient's request to see certain providers. Often it is up to the patient to make this happen. When Kirsten Allen went to Community Nurse Midwives at Riverside in Minneapolis for her second pregnancy, she met each of the CNMs once and then scheduled the rest of her prenatal appointments with the ones she liked. "I knew who I wanted the relationship with," she says. "The ones I didn't like, I just avoided."
Carrie Frantzich, a CNM with HealthEast, advises women to find a midwife they are comfortable with at the beginning of pregnancy, see her a few times, and then in the middle of pregnancy rotate through and meet a few more of the clinic's midwives. At the end of pregnancy, when visits become weekly, Frantzich thinks it's a good idea to try and see the midwife who was seen in the beginning. "If you go past your due date, it's really helpful to be talking about that to the midwife who originally determined your date of conception," she says. "Also, if a woman is at risk of preterm labor and we are deciding between bed rest or medications or hospitalization, having the same midwife check her cervix at each visit helps in finding subtleties of change. This can help to avoid an intervention, like hospitalization."
Bonding in labor
Because of the call-group system for deliveries, a woman may not know the midwife who attends her birth. However, unlike most physicians, nurse midwives usually spend several hours with a laboring woman prior to the delivery. "Midwife means 'with woman,'" says Claire Nelson, codirector of nurse-midwife services at HCMC. "It's part of our nature to be with someone when they are in labor and watch the process unfold."
Hangsleben says that "when the patient comes in to the hospital, the midwife spends the time needed to get a sense of who she is and what she wants from the birth experience. Maybe it's not as personalized as if you saw her for nine months, but it's pretty good."
In Frantzich's experience, "[midwives and patients] bond very quickly in labor. You are at the woman's side laboring with her for hours, and it's very intense and emotional and real. You just cut to the chase and bond." Claire Nelson of HCMC agrees that "the real intimate support midwives give in labor means that the woman isn't losing a lot if she hasn't met the midwife before." Lisa Perez says she has also seen laboring women bond with physicians they hadn't met before.
Many midwives will ask their patients to write out a birth plan that states their preferences for labor and delivery, including use or avoidance of medications and other interventions. "All of this will be down on paper so if the woman has a midwife she hasn't met for labor, she won't feel like the midwife doesn't know her desires," Claire Nelson says. Birth plans are rarely encouraged with physician-attended deliveries.
Women who really want to have a particular midwife for their delivery can try to "time" their labor to coincide with that midwife's call schedule. Nancy Nelson says a woman near her due date can try various natural methods to stimulate uterine contractions and begin labor, including drinking raspberry leaf tea, having intercourse, and stimulating the nipples. Carrie Frantzich says if she and a prenatal patient connect well in the clinic, she will tell the patient when she will be on hospital call. "It's amazing how many women will actually go into labor then! There's a real strong mind-body connection," she says. Kirsten Allen got the call schedule for the month she was due and says she "willed" herself to have her baby when her favorite midwife was on duty.
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.
Making choices for care
Personalized pregnancy and childbirth experiences are a relic from the days when medical practices had only a few providers who shared call. Small practices can still be found in rural areas, but most Twin Cities clinics have become very large, both to meet the demands of the population and to survive in the HMO-dominated marketplace. Besides the difficulty with call coverage that small practices entail, they are not as attractive to payers like HMOs and insurance companies. "Across the country there are numerous groups of three or four midwives," says Hangsleben. "And we've heard of some of them being dropped by insurance companies because they don't bring in enough business. So there is a marketplace issue that we have to be sensitive to. . . . By the same token, the HMOs in Minnesota are very good to us. Around the country, HMOs often mean the nurse midwives are cut out of the market. Here, nurse midwives are part of the care-provider system. It's an interesting balance."
Despite all the constraints on the system, every pregnant woman should know that she has some control over how her prenatal care and delivery will go. It often takes persistence, though, to get what you want. Most clinics will honor a prenatal patient's request to see only certain providers, but she may have to adjust her schedule accordingly to make that happen. It is more difficult to control who will be present for the delivery, but a woman who feels strongly about a certain provider, either negatively or positively, should at least make her desires known. All the clinics in the Twin Cities want return and word-of-mouth business, and they will do what they can to keep their customers happy.
Diana Kenney is a Minneapolis writer specializing in health and medicine. When she became pregnant last spring, she was working as editor of Minnesota Physician newspaper. This is her first contribution to Minnesota Parent. A bibliography for this article is available: send your request and SASE to Minnesota Parent, 401 N. Third Street, Suite 550, Minneapolis, MN, 55401.
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