Home or Hospital?

I got the chance to be a part of a truly beautiful, peaceful, powerful, well supported, safe, mother-and-baby centered home birth attended by two incredible midwives yesterday. This little one came almost exactly 9 years after I attended my first birth (also at home) and felt like a wonderful full circle.

If you are exploring your options for safe, patient-centered, evidence-based care in pregnancy, birth, and postpartum, I’d like you to strongly consider at least interviewing some home birth midwives in your area and doing some research around why home birth is a reasonable option for most pregnant folks. I’ve included some videos and links here and look out for my upcoming longer article on midwifery care here on the blog.

For those who are concerned about the out of pocket cost:

Pregnancy Challenge Week #1 -- Choosing a care provider

I’m starting a series of challenges to expectant parents to encourage them to take small steps toward better care, more informed decision making, and a smoother transition into parenthood.

Over the next few weeks, I’ll be posting on action item in this vein, with some information for why and some resources for how. I imagine the challenges will be steeper for some families than others. I also imagine that it will vary person-to-person which action items are more difficult than the others. Some families, too, I imagine won’t face a ton of barriers, but just needed some guidance on the fact that these things are available.

So let’s start with the challenge for Week 1:

I challenge any pregnant person, at any stage in their pregnancy, to go out and interview 4 primary care providers in their area.

While this might seem most beneficial for families earlier on in their pregnancy journey, if you are not feeling 100% supported, informed, and comfortable in your care, it is not too late to look around. Truly, most of my birth clients wind up hiring a doula in their late second or third trimesters because they thought they were going to get more education and support in pregnancy at some point from their providers and realize fairly far along that they need to outsource.

It doesn’t have to be that way. Don’t accept sub-par care for ANY REASON.

If you are not digging the approach your primary care provider is offering, or you know that the person you are seeing for primary care in pregnancy will not be the one working with you in birth to make decisions, why would you expect them to suddenly jive with you come your day of birth?

how to choose a care provider in pregnancy

Do you want to be pressured into decisions you don’t agree with when you are having a baby? Do you want to have to come in expecting to fight off things you don’t agree with? Do you want to continue care when you are skeptical of where advice is coming from? Do you want to feel like you are paying a TON of money to still feel lost after months of working with someone through your pregnancy? Do you already feel like you’re having to give up a lot of your parenting desires to appease your provider’s thoughts around your care? Do you think your visits are long enough? Do you feel exhausted from having to outsource a lot of your education to get the support you need?

The communication you are getting through pregnancy is a dress rehearsal for the big day with that provider/practice/place of birth. You don’t need to wade through care that feels inadequate and hope for the best. A doula can only do so much to help you in this circumstance, too. It really matters who is guiding you in the clinical components of pregnancy and who will be there to help make major medical decisions with you in birth.

So here’s is what I propose -- Spend 1-2 hours a week for two weeks in interview with 4 additional providers and/or go on a birth center or hospital tour or open house or to a meet the midwife event.  

I read an article recently that said that on average, we watch about 550 hours of Netflix per year. We spend an average of 53 minutes on Instagram per day and 2.5 hours scrolling on our phones total through each day on average. I’m challenging you to spend 2 full hours A WEEK for two weeks face to face with the provider who is going to be your primary point person for one of the most intense and important experiences of your life.

Except we do…that ACOJ study makes it really clear. Doc’s make decisions based on “opinion” not science.

Except we do…that ACOJ study makes it really clear. Doc’s make decisions based on “opinion” not science.

I want to encourage you to pick 4 providers who offer something different than the care you are currently receiving -- a midwife with hospital privileges, a family practice doctor with hospital privileges within your network who can transition into your baby’s primary pediatric care provider, an independent homebirth midwife team or two, or going to a free standing birth center’s open house tour.

I promise you that this won’t be a waste of time, even if you feel these providers or locations feel like a stretch for you for whatever reason. You are not bothering them, this is part of your job. If you switch providers, they won’t be hurt or care, it’s part of their job to work with new people all the time. They are there to answer your questions and address common concerns/dispel myths about their care. You will feel fairly certain in these hours that you have seen what other care looks like and if you choose not to switch, you can feel confident you made the right choice for your family. If you have been questioning your care, you have started a foundation toward understanding that something different exists and how to access it. There is a very clear and palpable difference in the styles and types of care each different type of provider can offer. It’s worth the investigation.

The Harvard School of Public Medicine did a large survey a few years back and discovered that most families choose the place they’re going to give birth (the hospital where they’ll give birth for 99% of American women) because it was the closest one to them. This is not necessarily the best fit for most families. They also found in the same research project that it was clear that the setting and provider made the most difference in whether or not a birth ended in a cesarean surgery, not risk status or how the labor progressed. This is due in large part to litigation-based care and not evidence based care, doctor opinion, and the lack of continuity of care with shift-based primary and birth care, and lack of continuous labor support in hospital settings. With that in mind, isn’t it worth spending 4-8 hours investigating your options?

Here are some questions to take to these interviews :

  • What is your training and background?

  • How many years have you been practicing?

  • What is your philosophy on pregnancy and birth support?

  • How do you approach clinical testing and exam options? Do you perform those all yourself?

  • If I hire you, how likely will it be that you will attend my birth?

  • Where are you able to support me in birth (home, birth center, hospital)?

  • What is your personal cesarean rate/rate of the place you attend births/transfer rate (for out of hospital midwife practices)?

  • How often do you attend unmedicated vaginal births?*

  • How long do your prenatal sessions typically last? What topics do they cover?

  • Do you offer centering programs or childbirth prep classes in your practice?

  • Do you encourage working with doulas?

  • How much communication can I have directly with you in pregnancy and labor via phone/text/email?

  • How many pregnant persons do you support in a month?

  • What does your follow up care look like?

  • Are you available around my due date?

  • What is your rate and do you accept insurance/sliding scale?

You should be looking for more than just a pleasant bedside manner. Many families say to me that they stuck with their provider because they felt unsure of how to switch and anyway, their provider was “nice.” Since an ACOJ paper pointed out that ⅔ of standard OBGYN practices were based in low-tier or opinion based evidence, I’d say it’s a good idea to look beyond proximity to your home and how nicely your provider might be telling you inaccurate information.

And I don’t mean to pick on doctors alone -- You might find your dream clinician by switching to a new practice or different hospital. Not all midwives are identical and it might take interviewing a few to find a fit you feel comfortable working with. Home birth might be off the table for you in your mind, but you hadn’t thought to check out the free standing** birth center in your area.

Hiring a doula earlier on in your pregnancy journey can help a lot with this. Doulas are interacting with primary providers and individual birth centers and hospitals often and can give you a pretty broad starting point for some providers who might prove to be a good fit. They can also help affirm your decisions, ease your anxieties about switching, and help you sort out some of the ins and outs of the insurance issues.

This is also a big part of my pregnancy consultations services and I can do in person or virtual consults on this topic exclusively if you’re needing further resources for how to choose a provider that’s right for you. In ten years of this work in many different states, a few other countries, in hospitals and out, I can tell you that who you have by your side in pregnancy, birth, and postpartum makes an ENORMOUS impact on your safety and satisfaction with the experience, completely independent of the outcome. You need a provider in line with your wishes in birth and parenting. I’m here to help you find them.

If you’ve accepted this challenge and want to share your story, please feel free to comment below, send me an email, or touch base with me on Instagram @Rosewoodrepro. Happy hunting!

*If that is something you are hoping for it is important to ask this that specifically. Many doctors are trained to use “natural” birth to mean “vaginal” birth, regardless of medical management leading up to that outcome. You might want to also ask for more specific information on how many inductions they oversee a month/year, how often they use vacuums or forceps in births, how often they support parents not wanting medical pain management, if they “labor sit” or spend non-management time during birth in the on call room, their thoughts on “post-dates” inductions, what they consider to be a “high risk” pregnancy, if they treat pregnancies in persons over 35 years old as “high risk,” etc.

**A note on the language around “birth centers,” many hospitals are now calling their maternity floors “birth centers” and maybe having a nurse midwife or two on staff, but this is very very different than a free standing birth center with independent, case-load midwives, something many families don’t realize till they do the hospital tour late in the third trimester and realize it’s not a separate unit from the standard hospital birth care and are disappointed.

"Big BABY"

This is me as a 9lb 12oz newborn, just two days old and just home from the hospital where my tiny mama pushed me out unmedicated in 12 hours.


Recent conversations with some past and current clients about “big babies” got me worked up a little. The fever pitch of the obsession over fetal and infant weight is alive and well, friends. One of my current clients, despite not having any hospital-based care and seeing midwives who are so chill and supportive and not sounding any alarms about her baby’s size is still stressing HARD about having a big baby. It’s making her think about how each day she’s still pregnant = more oz. In talking this over with her, and talking her out of feeling kinda embarrassed about it, I mentioned how even though she hasn’t gotten any negative messaging about the fear around having a “big baby” from her care providers, it’s so prevalent in our culture it’s nearly impossible to avoid. Likely she’s had more than one friend and family member have a cesarean birth because of having a “big baby.”

People gasp and guffaw at trading newborn weights, but unless there is a pregnancy pathology that might make baby grow disproportionately, there’s an incredibly low change of growing a baby that your body can’t push out vaginally. In cases where that happens, there is often fetal overlap of the baby’s head over the pregnant person’s pubic bone, which can be felt easily in palpations during regular prenatal exams in the third trimester. But that only happens when care providers offer palpation, which most hospital-based providers do not. Pregnant folks who have had major injuries to the pelvic bones because of an accident or the like can sometimes have obstructed pelvic brims that could potentially make it hard to vaginally birth any size baby, which might only be discovered in labor. Same goes for those who were severely malnourished before puberty and have had bouts of rickets, which can alter the shape of the pelvis. Those things are admittedly rare.

Otherwise, when care providers tell a laboring person that there pelvis is “too small” or their baby “too big,” it’s often a matter of faulty ultrasound readings (they can be 1-2lbs off on average), a lack of patience, a mal-positioned baby in labor (for any number of reasons) and perhaps to a degree a lack of willingness of staff to support a laboring person to attempt to position baby into a better spot in the pelvis naturally, or just used as an afterthought to justify an unnecessary surgery. There are certain hospitals and certain providers who tell nearly all of their clients this after they have performed cesareans. I hear this kind of talk in the hallways of every hospital I’ve ever worked in.

When I volunteered at a hospital in Tacoma that touted itself as the “most natural in the Seattle-Tacoma area,” there were nights where I sat around not doing anything because one particular doctor told every patient their baby was too big, induced them, and scheduled all of their cesareans before 10pm and would sleep in the on call room most of the night. I like to remind my client that those stories of practicing such unsafe and non-evidence based medicine with such blatant abandon are rare. Instead, most likely the ways they pressure you into a medical birth for suspected big baby are much more subtle and span the entirety of the prenatal care. There are some care providers who just do not feel entirely comfortable having labor start and progress on it’s own and are very likely to use unsubstantiated information on fetal size, maternal age, and so forth to coerce parents into letting them manage pregnancy and birth more medically. It may be that if you went into labor spontaneously, even after 40 weeks, your baby would have been in a better position in the pelvis and “fit” just fine. Or that if you were at the hospital down the street with a different provider and different policies, your baby would not be seen as having been “big".” Or if you were being attended by a midwife and giving birth in a birth center or having a homebirth, no mention of “big baby” would have graced your ears and you’d push out a baby weighing over 8lbs in any given amount of time.

If left to your own wiles, you will grow the baby to the size you need in order to give birth the way that makes most physiological sense. Some babies weight more because they are quite long and born to tall parents. Some babes are short and chunky, but have totally typical sized heads that can move through a pelvis with ease. Some babes have larger heads, but are born to a parent with a roomy pelvis. Some tall people have small and skinny babies. Some small people have small and skinny babies. There is some thought around small people making fatter babies to withstand colder climates and food scarcity, as can be common with folks with ancestral ties to more northern or mountainous regions.

Most babies born outside of the hospital system here in the U.S. are born at around 8lbs. The reason the average nationally is lower is because of the number of preterm babies born here, both spontaneously and through our 44% induction rate. When I look for protocol papers on suspected “big baby” from other countries, I don’t find “suspected large fetal weight” or any such thing to be a determining factor in the decision to induce or for elective cesarean in any. Considering the fact that we are the only nation with a rising maternal morbidity and mortality rate in the world, it seems reasonable to question these practices around fetal size and other opinion-based reasons for induction and surgery.

Birth should not be treated as a set of medical procedures, but as a physiological act, an important family and cultural event, and a unique time between mother and child.

— “Strategic measures to reduce the caesarean section rate in Brazil",”

The Lancet, October 2018

Currently, there are two studies going around stating that there is “no evidence supporting letting pregnancy go beyond 39 weeks” for fetal safety and again stresses the fear care providers have around suspected large babies. However, the papers also state that there may be a number of reasons why expectant parents would choose to keep babies in till spontaneous labor, which is also very safe and in some ways safer, and can help babes increase fat stores, which help with early thermoregulation and other indicators of “thriving,” which is more important than the number on the scale. The papers note that there was a slight decrease in cesarean births amongst those induced at 39 weeks versus those who went into spontaneous labor at term. However, these studies have a somewhat small sample size of pregnant women who don’t fit the demographic of much of my clientele, or even the national average. For more information and a major breakdown of this study, check out Henci Goer’s article on Science and Sensibility. It’s also worth noting that the much larger and more comprehensive series of Lancet articles about the harmful rate of global cesarean births just published mention that amongst healthy women in developed countries, not inducing until 42 weeks might actually help lower cesarean rates and decrease infant and maternal mortality and morbidity in these countries.

Besides, really the bulk of the work of labor is to make room for the fetal head, which molds and shapes to fit the pelvis it’s in and has nothing to do with a fat or skinny babe, or a big or tiny laboring person.

Shoulder dystocia is a major risk in birth, but fetal weight is not the only factor, and the one dystocia I ever saw was with a 7lb 2 oz baby born two days after it’s supposed guess date (to a woman who’s instincts were to keep turning onto her hands and knees, but was repeatedly instructed to flip over, but whom I believe implicitly knew what that baby needed to get out safely, if she was just given the chance.)

If we’re ditching scale culture for adults, can we please start with ditching obsessing over weight before the person is even born!?

Quick Link Share - Reading Scientific Papers

Hi there,

I wanted to share this awesome article on reading and understanding scientific papers. This is so important for a number of reasons, primarily considering that 2/3 of standard obstetrics procedures are based on doctor opinion and not sound medical evidence. This forces parents in pregnancy and birth to be confronted with major medical decisions they may not fully understand. It’s worth taking a look at this article as you start to formulate your decisions on testing, procedures, care providers, and place of delivery even very early on in your fertility and pregnancy journeys. This is also really crucial for anyone making primary health decisions, since the issues around obstetric practices in the U.S. are a symptom of a wider lack of time spent with patients in making informed and collaborated decisions.

How to Read and Understand Scientific Papers by the Patient Empowerment Network