Who leads your prenatal care in the US: OB, family doctor or midwife

The choice is yours, which is the hard part

Unlike systems where a midwife is assigned by default, the United States asks you to pick your own prenatal care provider. The federal Office on Women's Health frames the decision practically: you will see this provider many times before you have your baby, so make sure the person has a good reputation and listens to and respects you.

It then adds the constraint that decides most choices. You will want to find out if the doctor or midwife can deliver your baby in the place you want to give birth, and your provider should be willing and able to give you the information and support you need to make an informed choice about breastfeeding or bottle-feeding.

Obstetricians

Obstetricians are medical doctors who specialise in the care of pregnant women and in delivering babies. They also have special training in surgery, so they are able to perform a cesarean delivery. Federal guidance is direct about who should see one: women who have health problems or are at risk of pregnancy complications should see an obstetrician.

Maternal-fetal medicine

Women with the highest-risk pregnancies might need special care from a maternal-fetal medicine specialist, a medical doctor who cares for high-risk pregnancies. If your pregnancy is considered high risk, federal guidance suggests sharing your concerns with your doctor and asking them to explain your actual risks and the chance of a real problem, rather than carrying an unquantified worry for six months.

Family practice doctors

Family practice doctors provide care for the whole family through all stages of life, including during pregnancy and delivery and after birth. The limitation to know is that most family practice doctors cannot perform cesarean deliveries, so if one becomes necessary another physician takes over.

The advantage is continuity of a different kind: the same doctor who cared for you before pregnancy can care for your baby afterwards.

Midwives, and why the letters matter

A certified nurse-midwife and a certified professional midwife are both trained to provide pregnancy and postpartum care, and midwives can be a good option for healthy women at low risk of problems during pregnancy, labor or delivery. The difference is training and usual workplace.

A certified nurse-midwife is educated in both nursing and midwifery, and most CNMs practise in hospitals and birth centers. A certified professional midwife is required to have experience delivering babies in home settings, because most CPMs practise in homes and birthing centers.

Federal guidance sets one non-negotiable: all midwives should have a back-up plan with an obstetrician in case of a problem or emergency. Ask what that plan is and which physician and hospital it names.

The visit schedule

Regular checkups matter, and the typical federal schedule is specific. Routine checkups occur once each month for weeks 4 through 28, then more often as you get closer to your due date. At the first visit your provider performs a full physical exam, takes blood for lab tests and calculates your due date, and may do a breast exam, a pelvic exam and a cervical exam including a Pap test.

After that, most prenatal visits include checking your blood pressure and weight, checking the baby's heart rate and measuring your abdomen to check the baby's growth. Screenings for gestational diabetes, Down syndrome and HIV are suggested for all women; other tests may be offered based on your age, personal or family health history, and ethnic background.

The question behind the question

In the US, choosing a provider and choosing a payer are the same decision. Your plan's network determines which obstetricians, midwives and hospitals you can use without a bill you did not expect, so verify network status for the provider and the delivery facility before your second appointment.

If cost is the obstacle, federal guidance is clear that women in every state can get help paying for medical care during pregnancy, and that every state has a programme. Marketplace and Medicaid plans cover pregnancy and childbirth, because maternity and newborn care is an essential health benefit. What differs is who qualifies and for what.

What varies by state, and we will not average it

Midwifery licensure, which credentials may attend a birth in which setting, and Medicaid eligibility thresholds are all set state by state. There is no single national answer and we are not going to generalise from one state. Your state health department and your insurer's member services line are the two calls that give you your real answer.

Before you commit

Ask where they deliver. Ask who covers when they are off. Ask what proportion of their patients have cesareans and under what circumstances. Ask, if you are seeing a midwife, for the name of the back-up obstetrician. And ask your primary care doctor, friends and family for recommendations, which federal guidance explicitly suggests.

Paying for prenatal care

If the cost of care is the obstacle, the federal position is more encouraging than most people expect. Women in every state can get help to pay for medical care during their pregnancies, and every state in the United States has a programme that gives medical care, information, advice and other services important for a healthy pregnancy.

Federal guidance also suggests asking a social worker at a local hospital or social service agency, who will be able to tell you where to go for help.

Choosing well, not just quickly

When making your choice, federal guidance suggests weighing reputation, personality and bedside manner alongside the practical constraints. You will see this person many times, often at moments when you are frightened, and a provider who listens is not a luxury.

Ask what happens when they are unavailable, because in most US practices someone else will attend if your provider is off call. Ask who that is, and whether you will meet them.