Monday, July 14, 2014

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions that some care providers* have suggested asking any provider you are considering during your pregnancy and birth.
  1. How do you define “normal birth”?
  2. Can you give me an example how you typically manage a normal birth?
  3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  4. How long will you “allow me” to wait if I go overdue?
  5. What position(s) will you allow me to use when giving birth?
  6. How do you feel about IVs and continuous fetal monitoring?
  7. How do you feel about a woman eating and drinking in labor?
  8. What are your thoughts on pain relief in labor?
  9. How do you feel about cesareans?
Some childbirth educators would substitute different questions here and there from this list but it's a reasonable basic list to start with. Adapt as necessary for your own personal situation and concerns.

Also pay close attention to the provider's response to your questions. Of course, care providers have limited amounts of time to answer questions at most visits so it's important to be considerate and concise when you ask questions, but if they are impatient with your questions or dismissive of your concerns, that's a sign you might want to look elsewhere.

There are other additional questions you might want to ask if you are a woman of size, but more on that in future posts. If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Sample Answers to These Questions

So what are reasonable answers to the above questions? It really depends on the type of birth you are looking for and how interventive you want your care provider to be.

Some people want a totally natural birth, and some want all the interventions and machines that go PING that technology can give them. Neither approach is right or wrong; it's more a matter of what you prefer and the unique needs of your pregnancy.

However, it's far more difficult to find a provider truly supportive of natural birth than a provider that routinely uses lots of technology and interventions. So the slant of this post is going to lean more in the direction of finding someone supportive of natural birth, but readers should not infer any judgment of their own personal preferences. Again, adapt the questions to your own personal needs and preferences.

1. How do you define "normal birth"? 

To some care providers, "normal" birth means just about anything (including significant amounts of interventions), whereas to others it means an undisturbed, spontaneous labor resulting in a vaginal birth without any interventions. You can get some idea of a care provider's attitude towards birth and interventions by what they think of as "normal" in birth.

2. Can you give me an example how you typically manage a normal birth?

To some care providers, typical management includes inducing labor at 39 or 40 weeks, mandatory IV, epidural by 4 cm dilation, and active management of care (breaking the waters early in labor, aggressive management of contractions with oxytocin, etc.). To other care providers, induction is used only when medically indicated (concern over blood pressure, baby not growing well, etc.), IVs are not mandatory, epidurals are completely up to the mother's choice, and routine interventions in labor are not utilized unless medically indicated.

Again, neither is inherently right or wrong, just different ways of looking at and managing labor. By asking the question of how the care provider typically manages normal birth, they can begin to understand where the caregiver falls on the continuum of intervention.

3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?

This is an important question because it speaks to the caregiver's respect for patient autonomy and how they prefer to interact with patients. Some care providers never want their dictates questioned. Others give education on the pros and cons of procedures and make strong recommendations based on their training and knowledge, but respect the mother's right to choose for herself.

It's important to also point out that women vary greatly in their desire for informed decision-making. Some prefer to leave all the decision-making up to the care provider and don't want to be "burdened" with having to make those choices. Others want to be very involved in the decision-making. The question is designed to help you figure out which style of care you prefer, and whether that aligns with the care style of the provider you are interviewing.

4. How long will you "allow me" to wait if I go overdue?

There is a great deal of controversy about the safest time for women to go into labor. There is a small but significant risk for stillbirth as gestational age increases, but this risk has to be weighed against the significant risks of inducing labor earlier, which may increase the risk for harm from strong drugs or may increase the risk for cesarean. Current research varies quite a bit on whether a pregnancy should be induced to lower the risk for stillbirth or other poor outcomes. There is no "right" answer here, only an answer that reveals to you what your care provider routinely does.

Many care providers induce labor right at 39 or 40 weeks, some wait till 41 weeks, some wait till 42 weeks, some wait even longer as long as the baby's status is reassuring. Some prefer inducing earlier but will respect the mother's decision to wait if baby looks okay. The point is to know your care provider's preferences on this very important point and to explore how flexible they are about it.

5. What position(s) will you allow me to use when giving birth?

Most hospital births occur with the mother either flat on her back, propped up with her legs in stirrups, or with the mother pulling back on her knees ("supine" or "lithotomy" positions). This is our cultural expectation of birth, and nearly all media images of birth show this position.

In other cultures, however, many other birth positions are used, including kneeling, squatting, side-lying, hands-and-knees, and asymmetrical positions, and these labor positions have distinct advantages. Some providers are very comfortable allowing the mother to labor in positions like these, while other providers restrict the mother to only the typical hospital positions. The question is designed to help you find out how your provider feels about birth positions.

Be careful how you word the question, though. Many care providers tell you that they will "let" you labor in whatever position you want, but fail to reveal that when it comes time to actually push out the baby they want you in the usual positions. Many providers are extremely uncomfortable attending a birth in a position other than supine or lithotomy and will pressure you to change positions, even though there is quite a bit of evidence for the benefit of upright and other positions in birth.

Some women don't care about what position they give birth in or are uncomfortable experimenting with different positions. Others are adamant about having the freedom to move as their bodies dictate, especially as the baby emerges. The important thing is to find a provider that is comfortable with your preferences, so be sure to ask ahead of time about not only labor positions, but also what position they want you in for when the baby is actually coming out.

6. How do you feel about IVs and continuous fetal monitoring?

It is important to establish your provider's preferences about routine interventions like IVs and continuous fetal monitoring.

Some providers are fine with women laboring without an IV. Others mandate an IV for all their patients, while still others strike a middle course and only request that a heplock be placed so that emergency access would be faster if an IV became needed.

Although continuous fetal monitoring has not been shown to improve outcomes in low-risk women, it is still extremely common in nearly all hospitals. However, some providers are more flexible than others about when it starts, whether intermittent monitoring can be used instead, and whether mobile monitoring is allowed.

7. How do you feel about a woman eating and drinking in labor?

Some care providers and hospitals have strict rules about whether a woman is "allowed" to eat food or drink during labor, despite a lack of evidence showing harm from this practice. Many allow only ice chips to be used during labor. It is important to understand your caregiver's policies before labor.

8. What are your thoughts on pain relief in labor?

Women vary greatly in their wishes towards pain relief during labor. Some prefer to go natural, some want an epidural "in the parking lot," some would rather take a wait-and-see-if-it's-needed approach.

Some care providers are very respectful of a woman's wishes about pain management in labor. However, some practically mandate that all their patients receive an epidural, while others can be judgmental about any use of pain medications. Still others know many "tricks" to help women lower their need for pain relief in labor but are supportive of whatever the woman chooses at the time.

Respect for one's wishes regarding pain management during labor plays a strong role in women's satisfaction with their birth experience. It is vitally important to find a care provider who is aligned with your preferences and who will be supportive of your choices.

9. How do you feel about cesareans?

Some providers truly believe that vaginal birth is dangerous and that cesarean birth is to be preferred. Others believe that cesareans are to be avoided at virtually any cost. Most providers fall somewhere in between, but most tend to "lean" one way or the other. Obviously, every caregiver is supportive of cesareans when they are truly life-saving but their attitudes towards other cesareans (and the current cesarean rate in first-world countries) can be revealing about their underlying philosophies of birth and likelihood to use a cesarean.

Beware: Nice Is Not Enough

Don't let a care provider's bedside charm and personality supercede your own commonsense about interventions. A care provider can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get care from them that doesn't put you at risk for more complications. 

One midwife told the story of the following doctor on her blog:
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some care providers. They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.

The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, the midwife above summarized one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that. "Nice" is wonderful, but some care providers use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued or because it's more convenient for him/her. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance. Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.

What's his/her induction rate, cesarean rate, episiotomy rate? 

Also observe how the provider responds to questions about these things. That's as telling as the actual intervention rate.

For example, "I only do them when necessary" is not a helpful answer; for some docs, interventions like these are seen as "necessary" 60% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be quite low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."

Moral of the story: Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers. Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch out for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method" if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, or who subtly deride anyone who asks questions about cesarean or episiotomy rates. All providers should have a general idea of their cesarean and episiotomy rates. If they don't, that suggests that they don't think these rates are important or aren't concerned about their use.

Also ask when/why the provider would want to induce labor. If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 39, 40 or 41 weeks, and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications. You may want to find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.


You can have the "nicest" doctor or midwife in the world, and he or she can still coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough. You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

What questions were most helpful to you when you were interviewing providers? What questions do you wish you had asked? What advice do you have for other pregnant women looking for maternity care providers?

*July 2014 Update: These questions were originally shared in a much longer article ("In Search of Dr. Right: 11 Questions to Ask" by The Midwife Next Door) on another website, and I gave credit and linked to that article in my original post in 2010. Sadly, the original link has since been compromised and now goes to an extremely undesirable site, so I have stripped out all those links and am re-posting this article without them. The questions are helpful so I am keeping the post; but it's important to note that it originally arose from another's work.


Cassandra said...

I did research first and if I ever felt like I knew more than the provider, or simply questioned something said beyond needing further explanation, trust went out the window and I moved on. I can deal with someone who doesn't have a great demeanor as long as I believe they know what they're talking about. Even had to do this with a birth center midwife who overall shared the same views of birth as I did. I just couldn't trust her to know what to do, even if she actually did. Doubt was enough to make me see someone else.

Tami said...

I had a doctor exactly like the "Dr. Wonderful" the midwife described. Everyone loved him. Everyone thought he would never do something unnecessary, he only did things because he was saving the mother or the baby. He charmed many a woman into the OR unnecessarily. sigh... I also hate when women say "Well, you need to choose a doctor you can trust." Most of us DID trust our doctors! That's why we feel so betrayed! That's where the outrage comes from, when you realize the doctor you thought was helping you, making decisions in your best interest, the one who "went to medical school and thus knows more about you than you do", actually didn't have your best interest at heart, didn't care about your health, was more interested in getting home for dinner or out to a golf game (or wherever), or was trying to punish you for having an opinion.