Finding a Lead Maternity Carer

Pregnant? The next thing to do is find a lead maternity carer who will look after you and your baby from woah to go, write Sue Pullon and Cheryl Benn in an extract from The New Zealand Pregnancy Book. 

You need to decide who will be your lead maternity carer (LMC) as early as is practicable - within the first three to four months of your pregnancy. Your LMC will provide your care during pregnancy, labour and birth, and after the baby is born (for up to four to six weeks). Currently, about 80% of lead maternity care is provided by midwives. A small number of GPs (known as GP obstetricians) and specialist obstetricians are also registered as LMCs.

However, before you choose and register with your LMC, you can get early antenatal care from your own GP, another GP, a registered midwife, a family planning doctor or a specialist obstetrician. This is known as "non-LMC first trimester care". As long as this care starts within the first 12 weeks, it can extend up to 14 weeks, or later under urgent circumstances. It is funded by the government to ensure all pregnant women have access to initial pregnancy care, free of charge and regardless of their circumstances.

There is a shortage of LMCs in some areas, so it is advisable to seek one early. If possible, interview a few people to ensure you find the LMC who best meets your needs.

After your pregnancy has been confirmed, you should not be charged for your antenatal care (unless you see a specialist obstetrician for private, not primary, maternity care). The LMC you register with will be paid by the Ministry of Health for the care they provide. Your pregnancy care will continue to be fully funded by the government, even if you have to transfer later to a specialist because of some problem that needs further attention. If your care becomes unexpectedly complicated and needs to be managed by a specialist obstetrician in a fully equipped maternity hospital, the hospital team then becomes your LMC, at no charge to you.

While your LMC has overall responsibility for your care, they will work with other health professionals to provide all the services you need. For example, if your LMC is a GP or specialist obstetrician, they will always work with a midwife around the time of your labour and birth, and often during your pregnancy as well. If your LMC is an independent midwife, she may share your care with another midwife during your pregnancy, labour and birth. Other health professionals, such as anaesthetists, paediatricians and lactation consultants, can also be called in if necessary.

Midwife as your LMC
Midwives are fully educated and trained in all aspects of normal pregnancy care, labour, delivery and postnatal care. Many handle both home and hospital births. They are also educated to detect problems and complications and to seek help when dealing with such cases. Some midwives work as hospital employees on a shift basis, while others are employees who manage case loads of women - they provide all their antenatal, labour, birth and postnatal care as part of a team of midwives. Other midwives choose to be self-employed and provide all maternity care to a case load of women, working with other health professionals as required.

For specific pregnancy problems, your midwife will usually refer you directly to a specialist obstetrician. In certain circumstances, especially in rural areas, she may work with a GP obstetrician. For other medical problems, particularly those unrelated to pregnancy (such as a chest infection), you will need to see a GP. But because apparently unrelated conditions may in fact affect pregnancy, and pregnancy may affect a medical condition you already have, you should seek your midwife's advice if you are in any doubt. For example, a woman with asthma would normally see her GP about the condition but, because pregnancy may make the asthma change, both her doctor and midwife need to know about any problems or changes in medication.

GP obstetrician as your LMC
GP obstetricians are fully qualified general practitioners who have extra education and training in all aspects of obstetric care. They work with a midwife to provide care during pregnancy, labour and birth, and after the baby is born. Some may assist at home births. Although the number of GPs in New Zealand is stable (and many are able to provide early antenatal, or first trimester, care), the number of GPs who are also practising GP obstetricians has rapidly decreased in the last 10 years.

GP obstetricians are trained to cope with most of the common situations that arise in pregnancy. But with more complicated problems, your GP obstetrician will arrange (with your consent) for you to be seen by a specialist. This specialist care is free of charge if arranged through the local hospital's obstetric service, but you may have to pay if it is arranged with a private obstetrician.

All doctors registered to practise in New Zealand are listed on the medical register, with details of their "vocational scope" (the particular area of work in which they specialise). Fully qualified general practitioners are registered under the vocational scope "General Practice", and specialist obstetricians are registered under the vocational scope "Obstetrics and Gynaecology". Doctors who do not have a vocational scope listed beside their name are usually still undergoing postgraduate training to become fully qualified in their field (such as general practice, obstetrics and gynaecology or paediatrics). All these details can be viewed in the "Find a registered doctor" section of the Medical Council of New Zealand's website.

Specialist obstetrician as LMC
Specialist obstetricians are fully qualified to deal with all complications arising in pregnancy and birth, including Caesarean sections. They work in maternity hospitals and many also have private practices offering pregnancy care. They do not, except in very exceptional circumstances, assist at home births, since their expertise is in dealing with abnormal pregnancies and complicated deliveries that are best dealt with in hospital.

A specialist obstetrician acting as your LMC will work with a midwife or midwives to provide all your pregnancy care. The obstetrician will arrange for a colleague to look after you if they themselves are ill, or away. They will initially see you in their private rooms or surgery. In most places, you can have your baby in the local hospital, with your specialist in charge of your care. In a few areas, private hospital care is an option.

Specialist obstetricians working in a private capacity are able to apply a part charge that you will need to pay. Charges vary widely, so check this out before deciding on this type of care.

How to decide
First and foremost, it is important to find a midwife and/or doctor you get on well with, and can talk to openly and easily. So it pays to check out whether their philosophy on pregnancy and childbirth is compatible with yours.
Questions you could ask when  choosing your LMC:

• What is your philosophy on pregnancy care, childbirth and post-natal care?
• Will you provide all my care or will others be involved?
• How can I contact you if I need help or advice?
• Who will provide back-up care if you can't be there?
• What birthing options do you offer?
• Where will my antenatal visits be? In my home? At a clinic?
• Do you offer home birth and what happens if I need hospital care?
• How many antenatal visits can I expect to have?
• What happens if I need specialist care during my pregnancy or labour?
• Who would you consult first if any problems arose during pregnancy and/or birth?
• Will you visit me in hospital? What will your role be?
• Are you likely to be away when I'm due?
• How many postnatal visits can I expect, both in hospital and at home?
• How will you communicate with my primary care provider?

Your LMC should also be someone whose professional expertise you respect. That doesn't necessarily mean you will agree with everything they suggest, but there may be times during your pregnancy, labour or birth when you need to have faith in advice or recommendations from your LMC. Ultimately, the decisions made at such times need to be negotiated between you, your LMC and often those closest to you. Ask about your LMC's training and experience if you are unsure.

If, like the majority of women, you anticipate a fairly normal pregnancy and delivery, the LMC midwife and/or GP obstetrician service works very well. However, if you run into complications, your LMC may have to work in consultation with an obstetrician or hand your care over to a specialist at the hospital.

A small number of women feel happier seeing a specialist obstetrician privately for their pregnancy care. Whether or not problems are anticipated, you may feel you want to see the same highly qualified person throughout your pregnancy and delivery, without having to worry about being transferred to someone else's care if complications arise. Specialist obstetricians in private practice often work closely with two or three midwives and you will have the opportunity to get to know them well over the course of your pregnancy. In some areas, this care will continue through labour, birth and afterwards; in other places, you may be cared for during labour by several midwives in the hospital, some of whom you may not have met before. However, all midwives, whether they know you well or not, will do their very best to give you the care and attention you need. Remember that using a specialist obstetrician may be a costly option, because this type of private care is only minimally subsidised by the government.

Where to have your baby
In choosing your LMC, you may have already considered where you will give birth. If you haven't, you should start thinking about the options now and discuss them with your LMC. There are three main possibilities:

• Birth at home (planned home birth)
• Birth in a small primary maternity hospital or independent birthing unit
• Birth in a larger hospital with full facilities (these hospitals can provide "secondary" and/or "tertiary" care)

The choices available to you will depend, at least in part, on where you live. Home birth may not be an option in your area if there is no home birth midwife available. Giving birth in a small, intimate country hospital will not be possible if you live in a big city that has no such facility nearby. And an epidural will only be available in a larger hospital.