The Nitty Gritty of Midwife Selection

I’ve spent a lot of time over the last two years interviewing midwives—first in Georgia, for Story’s birth, and now in Seattle, for the birth of my seond child. And so I’ve given a lot of thought to how to find one I really like.

There are plenty of places on the web where you can find lists of questions to ask potential midwives. The trouble with a lot of these lists—aside from the fact that they’re as long as your arm—is that I feel they fail to really get at anything beyond the basics.

When your midwife tells you that she almost never performs episiotomies, that she always attends births with an assistant, that she’s certified in neonatal resuscitation, and that she’ll induce when you’re approaching 42 weeks of pregnancy—well, all you’ve really learned is that she’s a professional working within the accepted standards of her field. Good to know, but you haven’t really learned anything special about her, anything that would make her you say, “This woman is the one I want to hold my baby’s life in her hands.”

So I’ve tried to compose a small list of questions that, for me anyway, have been helpful at digging a little deeper.

1. How often do you perform episiotomies?

Ok, wasn’t this one of the questions that I just said was sort of basic and not that revelatory? Well, yes, it is. Any midwife worth her salt will tell you that she never, or almost never, performs episiotomies, possibly with a faintly appalled look on her face.

The reason I include this question is because I find that it is almost invariably followed up with a story about the one time she had to, or almost had to, perform one. Stories like this are invaluable. If there was just one piece of advice I could give you when you’re looking for a midwife, it would be this: get them to tell you some stories!

You learn so much from their stories: how much do they respect and care for their patients? How confident are they? Are they cautious, bold, quick-thinking, direct? How exactly do they approach this whole midwifery thing?

And the great thing about their episiotomy story is that it will be a story about a difficult birth. You’ll learn about how they operate under pressure. These are the three stories told by the midwives I interviewed when I was looking in Atlanta:

• Story #1: “I did one once. This was a case where the baby was tangled up in the cord, which was a little bit short to begin with. And because of this, the placenta tore off the uterine wall. The birth canal was filling up with blood, so I did the episiotomy, got the baby out.” I liked this story a lot. I liked even more the cool, matter-of-fact confidence with which it was delivered. This was a woman who knew her stuff, and didn’t doubt it.
• Story #2: “I have only had to do two episiotomies, in, maybe, a thousand births? And, in hindsight, I probably should have done them sooner. But, you know, that’s just not where my mind goes at all.” I liked this story a heck of a lot less. I definitely didn’t want someone who was going to be quick with the scissors .. but I did want someone who, when things got dicey, would have the presence of mind to consider all the options available to her.
• Story #3: “In twenty years, I’ve done one. The mom had been pushing for a long time, and wasn’t making much progress. And the baby’s heart rate was dropping. It wasn’t coming back up between contractions the way it should have. And so I made the decision to go ahead and do the episiotomy and get him out. And later, I remember crying about it to my sister, because I just felt like it’s such an awful thing to do to a woman.” I loved this story. This was what I wanted: if someone had to cut me up, I wanted her to wind up crying.

You can always cut to the chase and say, “Tell me about a difficult birth you attended.” But I’ve found some people find this question nonplussing. And anyway, you only get one story that way. By going the episiotomy route, you can follow up with several other similar questions to elicit more and more stories that will help you understand your midwife’s standard of care. Some others include: “What are the reasons you might transfer me to a hospital?” “What happens if the baby needs help breathing?” or “Do you deliver breech?”

2. What resources do you have that might be helpful to me?

Your ideal midwife should have a network of professional contacts who can help you with all aspects of pregnancy, and beyond. My midwife in Atlanta had a list of doctors all over the metro area who would be willing to serve as a backup doctor in the event that I needed to transfer to a hospital (not a lot of doctors are willing, in Georgia). We had some insurance issues at the time, and she was able to hook us up with a nursing school that would provide detailed, lengthy ultrasounds at the low, low price of $25 a pop.

She also knew a number of pediatricians who wouldn’t flip out when I brought my homebirthed baby in for her first exam. By and large, I think these pediatricians were more accepting of the less-medical parenting style favored by many women who choose homebirth; certainly the one we went to was totally copacetic with our plans for a delayed immunization schedule.

The value of this question is going to depend a lot on where you live. Now that we live in oh-so-crunchy-Washington, I’ve discovered that it hardly matters. Midwifery and natural parenting are much more widely accepted here, and most, if not all, midwives have such a network of contacts.

But in Georgia? It mattered.

3. What do you think is the most important thing I can do for a healthy pregnancy and delivery?

As with Question #1, you’re not really listening for the initial answer here. You don’t want the advice, per se, what you want to know is: what will her practice do to help you achieve this goal?

If she talks about eating healthy, does she want to go over your entire diet with you? If she talks about forming a robust placenta, does she add that she’d like to routinely test your iron levels to make sure you’re able to do so? Maybe she strongly recommends a Bradley class, and she knows a great instructor. If she wants you to do Kegels… well, she can’t help you there. You’re on your own.

But whatever she says, her response to this question will give you some idea of what it’s going to be like to be treated by her. It’ll also give you an idea of how simpatica the two of you are. If she wants to overhaul your diet and you’re really not interested, maybe you’re just not a good fit for one another.

On Trust

Trust is a hugely important in the delivery room, whether it’s in a hospital or your own home. Maybe more so at home, because you have more agency there, more ability to act and affect what is happening.

And so you really need a midwife who you can place your whole faith in. When she tells you to push, or to stop pushing, or to get in the car so she can drive you to the hospital, you need to know that she knows what she’s talking about. You need to be able to let yourself be guided by her.

And that only comes with an extreme level of trust. That’s why it’s so essential to find a good midwife, and I hope these questions help somewhat.