Choosing your provider

[sillygoosegirl]

Anyone else struggle/struggling to choose a provider?

I have two main choices I am considering.

A. A larger practice of OBs and midwives associated with one of the most highly rated hospital near my home. So far I've had 2 appointments with 2 midwives, and have a 3rd appointment next week with a 3rd. (So many so early because I got sick, and because I'm scheduled for a sequential screen.) So far, I've liked both midwives a lot, but I'm not sure the likelihood that in such a big practice I will like the one who actually attends my birth, or even really get to know any of them. I'm also concerned because their c-section rate is over 30%, which is ridiculous (but also consistent with all the area hospitals except Kaiser). I very much want to avoid a c-section, and especially avoid any early interventions that can cause a c-section to become necessary. I'd like to have an unmediated birth, possibly a water birth (because that's supposed to help a lot with the pain), but while the first midwife said they are supportive of unmediated births, she didn't go into any detail about what they actually do to support that. She says they don't do water births. She says she has personally attended water births in the past, and thinks they are fine, but this hospital is not set up for them, so they can't do them. I feel like they have a little bit more of an attitude of, "we know what you need and you don't need to know anything," than I would like. Especially working in healthcare myself, I know how slow big institutions can be to adopt the newest best practices, so I'm not really feeling the trust there that I want to have. I feel like my questions about labor and delivery have been met with a little bit of an attitude of, "it's not time for you to worry about that yet," which I don't agree with in a big way.

B. The other option is a water birth center near my job, which is all midwives. My insurance will only cover (and even then as out of network) if I see a CNM, which is definitely my preference anyway. But only one of their midwives is a CNM, although they have another starting in June. They partner with other CNMs elsewhere in the city, so if my CNM is attending another birth, they will have someone else qualified to attend my birth, but someone I wouldn't know super well if at all. I've been really impressed by the water birth center itself, and I really appreciate how open they have been on their labor and delivery options, and what to expect. But I didn't really click with the CNM I had my first appointment with. I didn't dislike her, but she didn't make me feel super at ease either. Maybe I will warm up to her, and maybe I'll like the other CNM they are adding in June. Their appointments are on the long side, and you spend the whole appointment with the midwife rather than a few minutes with the provider and a lot with the MA, so it's definitely feeling better from the perspective of getting the chance to ask my questions. They transfer 12% of their patients to local area hospitals during labor, but the midwife stays with you if you have to go to the hospital and is your advocate there too. Their overall c-section rate is about 5%. Their safety record is excellent, though their number of births per year is low, so it's not really statistically significant. I feel like they are being a little more, "whatever you want" about some of the prenatal care than I want them to be. I want to be in control of my own health, but I also want to know what they think is best and also why. I think some of my trust may have also been eroded by reading up on the bios and learning that like half of their midwives (though I think not mine) and the owner are Mormon. Which made me feel uncomfortable with saying that I want genetic testing (scheduled that at the other clinic). I don't want to be the person who pre-judges based on religion, but it's hard not to worry that they will pre-judge me for being a godless pagan who might have an abortion if she got bad news. Then again, at the informational session they did explicitly say they welcome all kinds of families. And at the first visit they did offer a referral to a lab they work with that does genetic testing.

I've spoken with folks at a couple other clinics that sounded promising, but they don't accept patients with my insurance. And I don't want to go anywhere far from home/work.

Right now, I'm on a normal prenatal schedule with both, which at 11 weeks isn't a ton of visits, but I'm going to have to choose soon, and I'm not sure how I'm going to do it.

My one friend who has had a baby in this city in the last 10 years was all about the epidural and interventions. Which is fine, but not what I'm after so I'm not going to go to her for recommendations.

Anyone else struggling with this decision? How are you handling it?

[melsamoony]

My gut says option A....although I would rather an option with a smaller practice. I go to a 2 doctor practice. As long as I deliver during the week, my doctor will deliver my baby, otherwise I may get someone else. The priority for me is the prenatal care itself as I want someone I am comfortable talking with and asking questions to provide me care for 9 months. I am going to a very good hospital for delivery so I know I will be in good hands no matter who actually delivers the baby.

I am also hoping to go epidural free (I have had problems with them in the past) and my practice is very supportive of that. Is there another option for you with a smaller practice?

[smock]

So option A is in-network for your insurance and option B is out-of-network? Can you figure out roughly the cost difference between the two? That might sway me towards option A even if it means you can't do a water birth.

[sillygoosegirl]

Apr 24, 2014 14:43:44 GMT -5 smock said:

So option A is in-network for your insurance and option B is out-of-network? Can you figure out roughly the cost difference between the two? That might sway me towards option A even if it means you can't do a water birth.

Yes, but it's only a $2500 out-of-pocket maximum (though the birth center estimates we will only pay $2000, and I haven't been able to get an estimate on the hospital, though it's a $200 copay + 20% coinsurance no deductible, so it could be cheaper, but any complications and I think I'm basically hitting the out-of-pocket maximum either way). The bigger issue is them only having the one CNM until June. I thought about asking the self-pay cost, but I do want my birth attended by a CNM.

[Saudade]

Just a quick note:

That 30% c/s rate also includes all RCS, emergency, high risk, etc. So while it looks high compared to the 5% of the birth center, it doesn't mean it's for first time moms.

[sillygoosegirl]

Apr 24, 2014 15:34:38 GMT -5 Saudade said:

Just a quick note:

That 30% c/s rate also includes all RCS, emergency, high risk, etc. So while it looks high compared to the 5% of the birth center, it doesn't mean it's for first time moms.

It's true, but c/s rates have more than doubled in most of the nation in the last 2 decades, and it has not improved overall health outcomes for mothers or babies, nor has there been any major change in the overall health of pregnant women that can explain it. I wish the hospital had a breakdown of how many of those c/s were for what reasons, and how many of those women were still considered low risk when they went into labor, but they don't. I haven't been able to find such information for any of the local hospitals.

[Saudade]

Apr 24, 2014 16:13:33 GMT -5 sillygoosegirl said:

Apr 24, 2014 15:34:38 GMT -5 Saudade said:

Just a quick note:

That 30% c/s rate also includes all RCS, emergency, high risk, etc. So while it looks high compared to the 5% of the birth center, it doesn't mean it's for first time moms.

It's true, but c/s rates have more than doubled in most of the nation in the last 2 decades, and it has not improved overall health outcomes for mothers or babies, nor has there been any major change in the overall health of pregnant women that can explain it. I wish the hospital had a breakdown of how many of those c/s were for what reasons, and how many of those women were still considered low risk when they went into labor, but they don't. I haven't been able to find such information for any of the local hospitals.

Totally agree. 

My hospital as around a 30% c/s rate because they can't do vbacs. So any pt that wants to deliver with the provider in town, has to have a RCS. It sucks. Most women don't go for a vbac here because it requires a 60 minute drive to the hospital that does vbacs.  So then you go have a vbac with someone you haven't been going to for prenatal care and haven't been forming that relationship. I mean, you could do your prenatal care there, but it's a lot of driving over 9 months.

If you google your state + c/s rate, is there anything that breaks it down? I found on for MN (where I live) but it only breaks it down by c/s nothing extra. 

[Saudade]

oops.

[mannah]

Your preferences sound exactly like mine, and I would strongly lean to option B. It's definitely complicated with the CNM requirement but it sounds like that practice is much more in tune with your overall vibe and theory of the kind of patient driven experience you want. Feel free to private message me if you want to get into details-I'm also (planning to!) delivering at a birth center.

[curbsideprophet]

Are there any other combo OB/midwife practices you can consider? Is the 30% c-section rate for the hospital or specific to your provider? That could make a big difference. You providers number may be lower than the hospitals. Do they have bathtubs in the labor rooms at the hospital? Will they allow you to labor in the bathtub or shower? While not the same as having a birth pool and delivering in the water, it could be enough to help you get through labor without medication.

I had a pain med free hospital birth that was attended by a CNM midwife. My practice does allow you to attempt water birth under ideal conditions, but you do have to supply/set up/take down everything for it. If you have specific questions let me know and I can try and help. The closest birth center was over an hour away so I did not really consider it an option.

It sounds like the birth center lines up more with what you want, but the insurance situation would concern me. I would want to get more info from the OB/midwife group before ruling them out.

[purrbox]

I agree with curbsideprophet about looking into OB/midwife practices.

For me, the fact that there is only one CNM would absolutely turn me away from that birth center. I've heard horror stories from people who gave birth under a non-certified midwives, and quite frankly, I question any place that would allow them to oversee the birth.

[sillygoosegirl]

Apr 24, 2014 17:50:53 GMT -5 jjwritergirl said:

My options were basically the same as you, and my concerns were also similar. I ended up choosing the midwife/hospital practice for a few key reasons. One of the biggest was a greater understanding of insurance, and the costs that could be accrued in the case of an emergency transfer. Is the hospital they refer to in an emergency within your network? That is really important.

Here is the thread on MMM that helped influence my decision. I learned a lot. pandce.proboards.com/thread/277192/choosing-out-network-doctor

Very interesting.  I'll do some more reading on the insurance aspect.  They say that with most transfers, there is no reason you can't go to the hospital of your choice, and the hospital I'd choose (on my insurance) is only 11 minutes away from the birthing center in light traffic (15-20 during rush hour).  The birthing center is also 15 minutes away from two other good hospitals on my insurance.  In comparison, the two closest hospitals to the birthing center, where they normally transfer when the patient doesn't have a preference, are 6 and 9 minutes away in light traffic.  

I will see if I can get more information about the other hospitals.  The ones my insurance covers are better hospitals, and the same company runs the hospitals and the insurance, so I don't think it's necessarily a case of the other hospitals being out-of-network for having ridiculously high prices (though I can see how that would be the case sometimes).  On the other hand, sticker prices for any health care services are ridiculous compared with negotiated rates, just kind of in general.  Definitely something for me to get more information about... 

[sillygoosegirl]

Apr 24, 2014 19:01:51 GMT -5 purrbox said:

I agree with curbsideprophet about looking into OB/midwife practices.

For me, the fact that there is only one CNM would absolutely turn me away from that birth center. I've heard horror stories from people who gave birth under a non-certified midwives, and quite frankly, I question any place that would allow them to oversee the birth.

All their midwives are certified, but most of them are CPMs rather than CNMs.

[purrbox]

Apr 24, 2014 19:06:58 GMT -5 sillygoosegirl said:

Apr 24, 2014 19:01:51 GMT -5 purrbox said:

I agree with curbsideprophet about looking into OB/midwife practices.

For me, the fact that there is only one CNM would absolutely turn me away from that birth center. I've heard horror stories from people who gave birth under a non-certified midwives, and quite frankly, I question any place that would allow them to oversee the birth.

All their midwives are certified, but most of them are CPMs rather than CNMs.

I don't know much about midwifery, but from what I understand there are actually lay midwives that have no certification. Either way, I personally would only go with a midwife that was also a nurse. And the fact that there's only one of those at that birth center would make me uneasy.

Then again, I'm also risk averse and absolutely don't mind the idea of an OB cutting me open if they think that it could prevent even a slight chance of something bad happening to the baby.

Edit: I don't mean for that to sound snarky, lol. I'm just saying that I don't factor in issues like c-section rates when I'm hunting around for an OB. If I cared more about those statistics then I might lean more to the birthing center. However, I have different mindset so my first choice would be the OB practice with a midwife.

[Deleted]

I would pick A for insurance covering purposes.

I don't even know my hospitals c-section rate.

Our office has 7+ drs and you usually see the same one your whole pregnancy but the each only deliver one day a week so it's only a 1/7 chance they'll deliver you. Tbh, I barely saw the dr during my last labor/delivery. He walked in as I started pushing and left after she was born. I think he did check me once too but the nurses do so much more during labor and if your hospital is highly rated then I'm sure they're good