When I first made the decision to have a homebirth, when I became pregnant with J, my second child, I thought choosing a midwife would be easy. I had this idea that homebirth midwives would all be amazing and wonderful, and that it would be like night and day compared to the OB/GYN experiences that I’ve had before. I’ve come to realize that my assumptions were partially right, and partially wrong. Yes, most of the homebirth midwives that I know do practice in a way that is night and day from the OBs, but choosing a homebirth midwife that matches your personality can be surprisingly difficult, at least for me.

It’s important to mention that I’m incredibly lucky to live in a major metropolitan area. I have a lot of choice when it comes to midwives. Just thinking off the top of my head, I can think of 5 practices (solo or partnered) that are staffed with homebirth CNMs. There are also multiple choices for lay midwives, if I wanted to go that route. I also happy to be extremely lucky that I live in a state where the law actually makes insurance companies pay for homebirth. (My last homebirth, at a cost of $5,500, was entirely paid for by my insurance company). I’m guessing that if I lived in a different part of the country, where midwives are scarce, I might not have much choice at all. In that case, I might be forced to choose a midwife due to proximity or cost. But here in the New York Metro area, the choices are numerous.

When I chose the midwives for my last birth, I have to admit that I mostly chose them for 4 reasons – they were “nice”, they seemed competent, they seemed to have experience with my insurance plan and getting the insurance company to pay, and they were only a 45 min drive from my house. Now that I’m writing these things down, I’m seeing that cost and proximity were surprisingly important factors in the choice, even considering the good situation in the area that I live. When I talk about the fact that they were “nice”, I think I’m talking about bedside manner most of all. I had interviewed one other midwife before seeing the practice I used, and she seemed very stern and brusque, reminding me of way too many experiences with dehumanizing doctors. So when I met the practice I ended up using, their friendliness was a deciding factor.

I suppose if I were less picky, that would have been the end of the midwife difficulties. But here is the big problem that I think occurs fairly often with U.S. women who use homebirth midwives – as you go through your pregnancy and get to know your midwife, you sometimes change your mind. You see, most of the women I know don’t use their homebirth midwives for regular GYN care. This is due to the fact that none of the homebirth midwives in my area are listed as in-network care providers on any insurance plan. They are either paid out-of-pocket, or they are paid by insurance companies for prenatal & homebirth services due to NYS law. No one I know goes to them for regular GYN care because their insurance company won’t pay for it. So women that I know start getting to know their homebirth midwives only at the beginning of their pregnancies.

Anyone who has ever seen a therapist knows that it sometimes takes several long appointments before you can tell if your therapist is well-suited to your personality, and if the therapy is “going anywhere”. I’ve screened therapists before also, and it’s a real pain in the neck. You go through your whole life story, telling them all your innermost problems and being asked all sorts of questions, and then sometimes, a few weeks or months down the line, you realize that they suck and you need to go through the whole process again to find a new therapist. That “trying on” process is definitely not fun when you are stressed/depressed/psychotic/whatever.

The process of getting to know and screening a midwife is also not always fun when you are pregnant and hormonal/having morning sickness/feeling stressed/nesting/whatever. It’s hard to know, looking at the 40 week deadline (give or take), whether the relationship is working and making you feel confidant about the birth, or whether it is “going nowhere”. Trouble is, if you finally come to think you have the wrong midwife at 30 weeks along, it can be hard to motivate yourself to break off the relationship and start a whole new search.

During my last pregnancy, I was faced with just such a choice. For various reasons, I ended up having doubts about my “nice” midwives. The doubts didn’t start right away. They sort of crept up on me over several months, until I was suddenly left crying to Arp one day, at approximately 35 weeks. I felt less than trusting of them at the birth, but felt psychologically unable to summon up enough strength to find someone new. It was a tough situation. I kept second-guessing myself. I wondered if I was just being overly emotional, as this was the end of my pregnancy and I was definitely feeling very moody and not exactly stable. So what Arp and I ended up doing was talking about ways that he could play a part in protecting me and being a go-between so that I could feel comfortable with the end of my pregnancy and birth. Sounds like something you might experience in a hospital birth, where the doula ends up being a go-between, eh? Well, it can happen in homebirth situations, too.  And that is something that I had not expected.

If I could go back and change things, I would have changed midwives as soon and I knew that I had doubts. I would have summoned the energy and bravery to sever the relationship and look elsewhere. Even better than that, I would have paid more attention earlier on in the relationship, when some small issues arose, and did some more questioning and negotiation to make the relationship more healthy. I think that if I had paid a little more attention, I would have known a lot earlier that things were not working. And finally, I would have initially interviewed more than 3 midwives. I would have asked every homebirthing woman that I knew about the nitty gritty experiences she had with her midwife.

Here are some questions that I’ve come to realize are important to me when it comes to screening a homebirth midwife (and these are things that I never would have thought of initially):

• How medically oriented is the midwife? Some women like their midwife to be more medically oriented, and that makes them feel safe. Other women want a more “crunchy” midwife, someone who spends time on the emotional aspects of pregnancy and birth. While I started out thinking I wanted a more medical experience, I’ve come to realize that I’m a lot crunchier than I realized. It’s worth it to explore who you are, and then choose a midwife to match.
• What kind of presence does the midwife have during a birth? Some midwives are very hands-off, others more hands-on. Some midwives have a very obvious presence, while others disappear into the woodwork. It may be worthwhile to talk to other women about their birthing experiences with the midwife to get an idea of what they are really like at a birth. If you don’t like what you are hearing, you can consider whether to change midwives, or have some negotiations with the midwife about how you really want your birth to be. At my last birth, I ended up with midwives that sat around staring at me, from less than 3 feet away, for several hours. It was only later that I realized how disturbing this was for me. In the throws of hard labor, you may not have the strength to speak up about something like that, or the ability to tell what is bothering you. But these sorts of details can make a big difference in the birth.
• How close of a relationship do you want to have with your midwife? Some midwives are rather remote, while others are more like friends. My last midwife was extremely remote. I shared a ton of information with them about myself and my family, and yet I know almost nothing about her family. In contrast, my current midwife has been known to say that she “becomes goods friends with all her clients”. Some pregnant women are going to want a more professional relationship, and may find friendship with their midwife to be intrusive. Others may need to “bond” with their midwife in order to feel comfortable to let it all hang out during birth. It’s worthwhile to find out where you are in a spectrum, and find a midwife to match.
• Does the midwife’s talk match her actions? This is a question that you can really only answer by talking to other women that have used the midwife. At first glance, most of the midwives in my area have the same talk. They all have excellently low episiotomy and transfer rates, for instance. They all say good things about breastfeeding. But I’ve come to learn from the stories of other women that midwives may act in birth differently than their words would initially suggest. For instance, in my last birth, my breastfeeding relationship was delayed due to various procedures after the birth. Although they were verbally supportive of breastfeeding, and had breastfed their own children, their actions after birth really ran counter to that belief.  I never thought this would occur in a homebirth, and I wish that I had been more assertive about my need to nurse right away.

Now that I’ve worked through some of these issues over the course of my pregnancy, I’m definitely more prepared to work more closely with my midwife to plan this coming birth.  I’m determined to be more open about my wishes, and to more fully describe them.  I’m hoping this time that I’ll have the right midwife for our family.