A Guide to Client - Led Care

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Back to Basics

Upon finding out you are expecting a child, you will be faced with many decisions for your parenting journey. One of the first choices will be who you decide to seek prenatal care from. In the United States you can choose from the following care providers: obstetrician, family practice doctor, general medical doctor, certified nurse midwife, or direct entry midwife. No matter the care approach you choose, it is important to ensure you are well informed and prepared to self-educate on your pregnancy and parenting journey. 

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What is a midwife. 

There are several ways for midwives to practice in the United States. Primarily you see one of two credentials, the Certified Nurse Midwife or Certified Professional Midwife. CPM, or an LM; these midwives are not required to have a background in nursing prior to becoming a midwife. There are also traditional midwives who learn their trade experientially and have not attended a formal education program, nor do they hold any midwifery certifications. 

CPM: A Certified Professional Midwife is a knowledgeable, skilled, professional independent practitioner who has met the standards of NARM (North American Registry of Midwives) and is qualified to provide the midwives model of care. The CPM is the only model of care that requires experience in out of hospital settings. CPM’s practice through homebirth and freestanding birth centers. 

LM: A "licensed midwife” is an individual who has been issued a license to practice midwifery by the state they intend to practice within. The practice of midwifery authorizes the licensee to attend cases of normal pregnancy and childbirth, and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn; as outlined by their scope of practice for said state. Frequently this credential is paired with the CPM or CNM credential depending on state licensure. 

CNM: Certified Nurse-Midwives are trained in both nursing and midwifery. Their training is hospital-based, and the majority of CNMs practice in clinics and hospitals. Although their training occurs in medical settings, the CNM scope of practice allows them to provide care in any birth setting.

Midwives Model of Care

  • Monitor the physical, psychological, and social well-being of the client throughout the childbearing cycle.

  • Providing the client with individualized education, counselling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support. 

  • Minimizing technological interventions

  • Identifying and referring clients who require obstetric attention. 

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The application of this client-centered care has been proven to reduce the incidence of birth injury, trauma, and cesarean section. Midwifery care is evidence-based care, striving to empower clients and enable them to make informed decisions about their care and the care of their newborn(s).

What is an Obstetrician

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As defined by the Association of Obstetricians and Gynecologists (ACOG) - 

“Obstetrics and gynecology is a discipline dedicated to the broad, integrated medical and surgical care of women's health throughout their lifespan. The combined discipline of obstetrics and gynecology requires extensive study and understanding of reproductive physiology, including the physiologic, social, cultural, environmental and genetic factors that influence disease in women. This study and understanding of the reproductive physiology of women gives obstetricians and gynecologists a unique perspective in addressing gender-specific health care issues.

Preventive counseling and health education are essential and integral parts of the practice of obstetricians and gynecologists as they advance the individual and community-based health of women of all ages.

Obstetricians and gynecologists may choose a scope of practice ranging from primary ambulatory health care to concentration in a focused area of specialization.”


Transitioning to out of hospital care from conventional care. 

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As midwives, our transfer clients come into care at various stages of the childbearing process. It is always favorable for clients to begin care with the provider they intend to birth with; however, life is transient and we recognize the need for some clients to begin later in the process. 

Examples of transferred care are:

  • Shifting from conventional hospital based care with the onset of a new pregnancy

  • Mid-pregnancy transfer of care

  • Late transfer of care

Transferring care providers in the third trimester is considered a “late transfer”. When this occurs it is imperative for your new midwifery service provider to get to know you, only on a shorter timeline. When this happens there will often be more frequent prenatal visits so you can adequately voice your needs to your midwife, and for your midwife to learn more about you as their client. 

During a transfer of care the new care team will require the following: a copy of your medical records (especially the records of care for the current pregnancy), a detailed health history and review of obstetric history, lab work obtained during this pregnancy, ultrasound records for this pregnancy. This is not an exhaustive list and your provider may require more information as it pertains to your individual situation. Your midwifery team will have many questions for you to gain an understanding of who you are as a client, what experiences have brought you to this place, how you would like to move forward with this pregnancy, and any specific needs you may have. 

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Collaborative care - why it works so well for some, but not all. 

Collaborative medical care involves providers from multiple clinics/hospitals/disciplines working together for the support of their common patients. Collaborative care can achieve great results for client-centered care, but only when providers are able to cohesively share health information and openly discuss an individualized care plan. 

While co-care can work with extremely positive results, it is not always easy for providers to reach a place where the clients best interest is well supported. Some institutes, clinics, and hospitals have found a healthy balanced approach to co-care. While other groups clearly outline they are not willing to institute any form of collaborative care. 

This variance from medical group to medical group creates trickle down consequences for their clients. In an ideal medical system, all medical groups would open themselves up to working in a collaborative care model to ensure accessible care for all clients. 

Out of Hospital Care in a Nutshell

What are the Benefits of Out of Hospital Based Care

For low-risk patients there are plenty of good reasons to follow an out of hospital route of care.

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  1.  Autonomy is one of the primary benefits. With informed choice and client education at the forefront of midwifery care, clients can ensure a higher level of autonomy for themselves. Generally, you will have the opportunity to meet all team members and have them present for your birth (discounting special circumstances). 

  2. Client-led care allows clients to take charge of their health and the decisions that pertain to their care. 

  3. Decreased incidence of medical interventions (instrumental birth, cesarean section, etc.)

  4. Decreased severe perineal tearing

  5. Higher rates of successful long term breastfeeding relationships

  6. Decreased medical complications for newborns

  7. Six weeks of inclusive postpartum and newborn care 

Client responsibilities

In any medical system, both clients and providers have responsibilities within their relationship. The three primary responsibilities of clients within the out of hospital care system are:

  1. Honesty

  2. Self-Education

  3. Primary care choices must be made by the client

As well as, 

  1. Openness to midwifery suggestions for care

  2. Responsible and self reliant attitude towards prenatal care and labor

  3. Desire to become knowledgeable about labor, birth, and breastfeeding

  4. Commitment to open communication between self and provider(s)

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Provider responsibilities

The midwife has many responsibilities with regards to patient care, some of which are:

  1. Provide evidence-based care

  2. Work within an informed choice model of care

  3. Provide education throughout the prenatal, labor, birth, and postpartum period

  4. Ensure there is open, honest communication between client and provider(s)

  5. Clearly explain the scope of practice, limitations, and protocols to clients both at the onset of care and as need presents

  6. Commit clear boundaries with clients at the onset of care and as need presents

  7. Thoroughly communicate medical information to their client as well as midwifery management recommendations


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Shortcomings of convention hospital care for the low-risk pregnancy; and its importance for high-risk pregnancy.

For low risk clients, a conventional hospital based care system has many shortcomings. Hospital based care and its providers, namely obstetricians, play a crucial role in reproductive healthcare. They provide highly valued and often life saving treatment and procedures for millions of clients annually. Obstetrics fills a gap that out of hospital providers cannot fill. They bring with them the tools of surgery and medications that otherwise are unavailable to clients outside the hospital. The advancements of modern medicine are great, but with great power comes great responsibility. Understanding when to use this technology, and when to have restraint for the best care of clients is imperative.  

This level of care can be too much for clients in low-risk populations and subjecting them to interventions and procedures that are not fully appropriate for their course of care can lead to health consequences for clients and their children. When both high and low risk patients are grouped together within the same practice it becomes a challenge for providers to fully differentiate the specific needs of individual patients and in turn blanket protocols are formed. For the low-risk client,  these protocols (whether provider specific, or mandated by the medical institute itself) can prove detrimental to the outcome of their care and the care of their child. 



Resources



You've peed on a stick, now what?

9 steps after two pink lines appear.

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First and foremost congratulations and welcome to the journey of parenthood! This journey can stir up several emotions and questions. We have put together a lil list to provide a jumpstart on this wild ride.

Step 1 - Breathe

Breathe and allow yourself a moment to soak it all in. Whether this is your first or tenth, it is a big life change.

Step 2 - Acknowledge the pregnancy

When there is a faint line or uncertainty, acceptance can be difficult, but time is crucial throughout a pregnancy.Your at-home pregnancy tests are generally up to 97% accurate but only if directions are followed correctly. They are designed to detect a pregnancy hormone, human chorionic gonadotropin (hCG for short) in a woman’s urine, the test works best first thing in the morning.  Once you have acknowledged that you are indeed pregnant, how do you feel about that?

Step 3 - Take a moment to write

Write a list or outline of what is important to you for your birth. Where do you feel safe? Birth is a very intimate and loving experience, as well as overwhelming and intense. Those experiences are usually had in a private space where safety should be considered.

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Step 4 - Ask yourself, “Do I feel heard?”

As a woman, this pregnancy affects your body. Do you have a relationship with a care provider that listens? If you do not feel heard or taken care of, it will be difficult to build trust. This is the beginning of your long term sexual health. You are putting your life and your baby’s life in the provider’s hands. Trust is important.

This is your birth.
— Sara Badger, CPM

Step 5 - Choosing your care provider

Pregnancy is a long journey and your care provider will be walking alongside you for the duration. There are different types of providers, our hope is that you are able to choose the best one for your needs.

OBgyn practices do not typically offer a meet and greet appointment without an initial exam. There are several providers under one roof. Appointments do not often get rescheduled, they simply assign you to another provider for the scheduled prenatal.

Another option within a OBgyn practice is a CNM or Certified Nurse Midwife, their education path begins with nursing care then midwifery certification. They work under the license of the OBgyn.

If you’re looking for more individualized care, and an out-of-hospital birth is a consideration, a CPM midwife may be a route to consider.

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This is unknown territory, find time to ask questions, interview one or two providers in each type of practice. Bring a prepared list of questions with you.

Step 6 -Take a child birth class

Many people find themselves unsure as to how birth works. Gone are the days that birth was a family affair. We don’t always experience birth until it is happening to us. Then add in our partners, most often they do not know birth can take place out of the hospital, let alone that labor has phases. Knowing how labor works and becoming educated about your body, helps to alleviate the overall fear.

If you are in the Grand Rapids, Michigan area we highly recommend: https://www.grnaturalbirth.com

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Step 7 -

Stop Googling!

Step 8 - Read

Choose three books that will guide you to your desired birth. Throw away “what to expect when you’re expecting” and get “The Mama Natural week-by-week guide to pregnancy & childbirth” There are great new books out there, find them!!

Step 9 - PLAN YOUR POSTPARTUM!!