So you’ve checked out all the available options for birth choices in your local area - free, paid, and support systems to run alongside them. Whilst money is one factor to consider when choosing a pregnancy, birth and postpartum care provider (and a vital one), there are many other questions you may like to ask your provider (but first yourself) before you commit to employing someone to look after you. Free or otherwise, the care provider is employed by you and should adhere to your family and cultural values no matter what. Here are some (but not all!) questions that can be considered before hiring someone (including free providers) to care for you during your baby journey. Most women will only give birth a couple of times in their life, so make it the best time you can have. Putting aside time to really think about what you want for your birth and introduction to becoming a mother will never be time wasted.

Here’s some suggestions for questions to ask…

What are your opinions around birth being a physiological process?

This answer to this question will give you an idea of how medicalised the obstetrician or midwife believes birth should be. This is key in finding out whether or not your values and your providers’ values match up. Trust your instincts with this question - last minute recommendations during labour will be based on how they truly feel deep down about physiological birth.

Do you think the decisions surrounding labour and childbirth rest primarily with the birthing mother?

The answer you receive to this question will tell you how involved you will be “allowed” to be. To be honest, if the word “allowed” comes into this conversation, then run a mile. Your human rights dictate that the sole decision maker in the birthing space is you and only you. If a Dr or Midwife does not practise with a consent based model then they will generally fare badly when it comes to birth outcomes - therefore again, run a mile.

What are your ultrasound/scan policies? Can I decline if I choose?

Usually Obstetricians have ultrasound machines in their offices and can offer a scan at each visit. This is on top of the regularly offered scans at 12 and 20 weeks. While scans can help reassure a mother, there is no concrete evidence that multiple scans are beneficial to outcomes, and women who have more scans open their pregnancy up to more scrutiny, even though ultrasounds are often misleading. Something to think about…

What are your policies on various prenatal testing, including Gestational Diabetes, routine urine testing and GBS swabs? Can I decline and expect the same level of care?

Most providers prefer certain tests to be done throughout pregnancy, but it is always within your rights to decline. After researching the risks and benefits of each individual test, remember before making a decision - once a test is done, you forever have those results posted on your “file”. Your provider can then choose to allocate you to a certain risk group - this doesn't have to be based on clinical guidelines or hospital policies but can be on their own risk assessment. Many of the things tested for throughout pregnancy have other symptoms that a provider should pick up with regular contact and relationship with their women. These tests can “risk you out” of many programmes, or even flag you for induction pressure - proceed with caution if a provider has a list of tests that are non-negotiable.

How long can I expect my visits to be with you? Do you have any holidays planned around my guess date?

Many obstetricians and hospital midwives can only spare 15-20 minutes per woman to go through any checks or questions you may have. Navigate towards a provider that can give you more quality time, and definitely doesn’t have any holidays booked around your due month.

Can I expect to have you present through my pregnancy, birth and postpartum periods?

This is called continuity of care, or continuity of relationship and is really important to a lot of women. Imagine having to get to know new carers continuously through your pregnancy, labour and then postpartum. It can be exhausting fostering a new relationship, and if you have to defend some decisions you make 100 times over - well let’s just say there are better ways to spend your mama energy, it can really wear you down. Try and find someone who can support you throughout your journey to motherhood. While you can get a level of continuity of care from an OB, if you are truly wanting continuity of care you may need to look at group or private midwifery care. If there is no one in your area that offers this care, then you could consider a doula to take this place of continuous support alongside your medical carer. There are mountains of research now showing that women who have continuity of care have a more positive birth experience.

Can I have a doula and partner present at both antenatal appointments and birth?

The pandemic has complicated this question, the fact remains that you have rights to have support people at your birth - whether that is family or someone employed by you. The World Health Organisation states in their Safe Childbirth Checklist that all providers should encourage a woman to have a birth companion. This is because women have better outcomes with birth companions and doulas present: Doula-assisted mothers are less likely to have a low birth weight baby, experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding.

What are your views on a pregnancy exceeding estimated due dates?

Although the WHO advises “There is insufficient evidence to recommend induction of labour for women with uncomplicated pregnancies before 41 weeks of pregnancy”, it is the norm for mums to feel “overdue” after 40 weeks. It is important for you to know how your provider is going to feel about going over 40 weeks so that you can prepare for the late stages of pregnancy.

In addition to this, EDD’s can be inaccurately calculated anyway, as the timing of ovulation of every woman is unique and each person’s gestation can be varied also. Women can birth perfectly healthy babies at 37 weeks while others birth perfectly healthy babies at 43 weeks. There is no normal when it comes to gestation and spontaneous labour.

What are your induction rates and what are your reasons for suggesting induction? If I do not consent to induction, can I expect to have the same level of care? If I do consent to an induction, can you support me to have an active birth?

A staggering 43% of first time mums are induced in Australia. Say what??? Obviously, there are some cases where an induction can be evidence based - but if being faced with the big baby or ageing placenta discussion then it’s highly likely that the obstetrician does not make recommendations based on evidence. Evidence shows that a placenta does not “age” after a specific date, nor can you tell a baby’s weight accurately until it is actually born. Another reason for induction can be to “schedule” your baby to fit a timeline of the doctor, partner or family visits. When looking into the benefits and risks of induction it is interesting to note that induction of labour for non-medical reasons is associated with higher birth interventions and more adverse outcomes. It can be quite a long, complex process and not as easy as “just getting induced”. In saying that, induction can still be a positive experience - depending on the support you have around all the other decisions that come during your induction.

Do you (or the hospital you admit to) have time limits after admission, or after waters break (Membrane Rupture), or after a certain dilation is reached?

Putting a time limit on labour is a dangerous business, as no woman has the exact labour as another. There’s a lot of research that shows with proper care, waiting for up to 48-72 hours after the water breaks does not increase the risk of infection or death to babies who are born to mothers who meet certain criteria. While Australia says that 4cm dilation is established labour, other countries agree 6cm is the same - so while cervical dilation can be encouraging for some mothers, it's not the be all and end all of labour progression. Providers who put time limits on labour can be hard to work with during labour, as they want to either rush you along or put pressure on you if you aren’t adhering to the linear graph of a mystical labour. (PS this mystical linear labour doesn’t exist)

Do you have a policy on vaginal/cervical exams, and if I decline can I expect the same level of care?

Did you know some providers prefer to check your cervix every week from 37 weeks? Many women don’t know this, and also don’t know that there is no evidence to support any benefit to this practice. Although prenatal cervical exams may satisfy the curiosity of a provider or even yourself, a prenatal cervical exam can lead to a premature rupture of membrane (PROM). And as we have just discussed, PROM (which is an induction of labour) can lead to increased intervention and decreased outcomes.

When it comes to cervical exams in labour - the cervix can be extremely shy. There are many reports of a cervix recoiling during an exam and then dilating in a very short amount of time following this. Perhaps we just aren't supposed to have fingers up there? Either way, they can be disheartening or encouraging and they should be your choice and you should be able to expect the same level of care regardless of whether your cervix is measured or not. I can reassure you I have welcomed 4 babies into this world without a single cervical exam - so cervical dilation really shouldn't bear any worth when it comes to your birth progress.

What are your Caesarean birth rates and what are your reasons for suggesting a caesarean birth? Have you conducted a maternal led or gentle caesarean birth? If not, are you open to this if a CS is what I choose?

It’s interesting to note that the World Health Organisation estimate that the percentage of births that should require caesarean (for medical reasons and the health of mother or baby), lies between 5-15%, with a special note that any caesarean rates above 15% often result in more harm to mother and child than benefit. The CS rate in Australia is 37% and climbing. Sit with that for a minute, and decide if you would like to avoid this. If so - what can you do to avoid this? Your birth is in your hands, and every decision you make can have a positive effect on your birth outcome.

Of course, medically necessary belly births are available to those who require one due to things like placenta previa (placenta covering the cervix), birth defects or chronic health conditions. Just because you have to have a belly birth doesn’t mean that you have to forgo things like skin to skin or being involved in the birth process. In a Maternal Assisted Caesarean (MAC) mothers are actively involved in lifting their baby out of the womb and having skin to skin bonding straight away which may help breastfeeding establish and mums mental health flourish. It also can allow for delayed cord clamping, which can be vital to a baby’s first few weeks - see the blog I wrote on this.

What are your instrumental birth rates? Can you conduct an instrumental birth without an episiotomy?

Are they vacuum happy when it comes to getting the baby out? Is this based on a time schedule that they have for the baby to be out or usually a legitimate medical concern? Not only that, but did you know a skilled OB should be able to conduct an instrumental birth without an episiotomy? It’s worth asking the question to know what could pop up.

What are your episiotomy rates and opinion on episiotomies?

While routine episiotomy is a thing of the past (well I darn well hope it is!) - This is a great question to ask your OB or Midwife. An episiotomy could effect your ongoing recovery and future sexual experiences, so it’s super important to know that your provider would know where to snip if they had to. An episiotomy wound can be more painful and heals less well than a spontaneous tear, and there are other ways to encourage a baby out (i.e. changing the position to open up the pelvis) rather than widening the vaginal opening.

Do you have a policy on the 3rd stage (delivery of placenta) being actively managed in all births?

After you have birthed your baby, you will need to birth the amazing organ that you guys made together - the placenta. It detaches from your uterine wall - more easily if you have had delayed cord clamping and baby nuzzling the boob - and is delivered the same way as your baby. There are minor contractions that come with it, this closes off the blood vessels and gives the placenta a good shove out. Because it has no bones, one woman describes the birth of her placenta like birthing a squid! It’s the easier part of labour, and finishes the whole process so that you can enjoy your baby uninterrupted. Some providers or hospitals prefer to recommend “active management” - which usually involves an injection into the leg of synthetic labour hormone to hurry the placenta out. It can also mean premature cutting of the umbilical cord (before all the blood has reached your baby), and cord traction (lightly pulling the cord - which has the risk of having the cord snap). The majority of physiological births will not require an active 3rd stage management as when you breastfeed or move around after birth the placenta will make its way out on its own. In fact it is the safest option for mums who have had a physiological birth to then have a physiological third stage.

What are your policies or regular practices around optimal cord clamping?

Optimal cord clamping is waiting until the umbilical cord runs white to cut. There has never been any evidence to support the practice of cutting the cord as soon as baby is born, and the research shows that when the cord is left unclamped until it runs white (i.e. all the blood has gone from the placenta to the baby), the baby is less likely to experience anaemia, blood transfusions and other conditions. The baby will benefit from months of iron stores due to this valuable supply of blood, which contains precious cord blood and stem cells. Clinical guidelines now show that “waiting for white” should be implemented by every maternal health provider.

What is your view of skin-to-skin?

Skin to skin may seem just a lovely thing to do once your baby is born - but it actually has some really important health benefits for both you and your baby, whether you give birth vaginally or via the belly. Skin to skin involves placing a sweet little nude newborn on the mum's bare chest and covering the babe with blankets to keep it warm. Ideally, this happens immediately after birth (however that happens) and babe stays there at least until after they have nuzzled their way to the boob (possibly a couple of hours). As long as your baby is doing alright, paediatricians can even do checks while bub is snuggled in on your chest. Benefits to baby include: the heart rate, breathing, and oxygen levels were more likely to remain stable, there is a beneficial increase in blood sugar, not to mention more easily established and longer breastfeeding.

Some researchers found that skin-to-skin care provides benefits to breastfeeding after Caesarean birth as well. The mothers who had received skin-to-skin care were 22% more likely to still be breastfeeding one and four months after the birth. It’s all wins for skin to skin, and definitely something to advocate for with your health provider.

Now, here are some questions that may be unique to your situation:

What are your recommendations when it comes to:

Vaginal twin birth

Vaginal Birth After Caesarean (VBAC)

Vaginal breech birth (frank or footling)

Many OB’s are intimidated by a vaginal birth with one of the above “complexities” as it is not something that is routinely taught to them. Keep in mind that OB’s are professionals at complicated birth and birth surgery, whilst most midwives are professionals in physiological birth. A doula can help you navigate either way you would like to turn, either medical or physiological and advocate for you no matter who your provider is.

These are just questions that cover the most common things that come up during pregnancy and birth, but a doula or private midwife can help you navigate the individual questions that come up during your care also…

When you are chatting to a prospective provider, it’s likely that the reaction you receive from them will be a guide to whether you will match as a team - trust your instincts and the feels you get. It is never too late to change providers (I did it at 32 weeks!) or to bring on another team member to advocate for your birth choices - you don’t want to go into birth stressed or worried that you will have to fight to be heard, or worried that you will be coerced while you are vulnerable. The beginning of your birth story starts when forming your team during pregnancy, and I really encourage you to trust your gut when it comes to making these decisions.

It’s important to always remember that with your great decision making comes great responsibility. Making no decision and “going with the flow” is still a decision and still passes the responsibility to you. This is your body and your baby - and you will be amazing mama! Go forth and interview!