Obstetrician or midwife: how & why to choose

Why do some people choose a midwife and others opt for an obstetrician? Pippa Henderson discusses the maternity care available in New Zealand, and how you might choose your LMC.

For those new to motherhood, or New Zealand, the acronym LMC can spark a guessing game. In social media it means Let Me Check, Lost My Connection or Like My Comment. In the Urban Dictionary it means Last-Minute Charlie – that person always running to catch the bus. In the US, it’s the League of Minnesota Cities. In the UK, it’s London Musicians Collective.

Here in Aotearoa, LMC simply stands for Lead Maternity Carer – the professional contracted through the Ministry of Health to provide or organise maternity care for pregnant women and their families.

Women have three options for an LMC: a midwife, an obstetrician or a general practitioner (GP) with a diploma in obstetrics.  Over the last 20 years, however, almost all GPs have withdrawn from maternity and labour care (with only a couple of GPs in Auckland still providing maternity care, and no more than 20 active GP LMCs across the country) so we’ll be focussing on the first two options here.

Independent midwives
Independent midwives are qualified to care for women with normal pregnancies. They work collaboratively with other health professionals so can refer you to an obstetrician if complications occur. The New Zealand College of Midwives website is a good source of information on their services, but the following is a summary of what you can expect from your midwife.

In the first trimester you’ll receive a comprehensive pregnancy assessment and a care plan to be updated throughout your pregnancy. You’ll also receive information on the role of your LMC, standards of care, screening tests, paid parental leave, and pregnancy and parenting education courses. Your midwife will also cover arrangements for backup cover and options for referral for additional care, should you need it.

During your second and third trimester, your midwife will monitor your progress, including early detection and management of any problems. They will update your care plan and provide one-to-one education on pregnancy, birth and parenting preparation.

Your midwife will arrange the booking of a maternity facility or birthing unit and provide specific education on labour and birth, including the role of your support people and pain management. They’ll also arrange for you to meet any other maternity carers who may be involved.

Your midwife will be responsible for your primary care during labour, including an initial assessment and regular monitoring. She’ll also provide all your primary care immediately after the birth, including the initial examination of baby, breastfeeding, suturing if required, and notifying the Registrar of Births.

There’ll be a daily postnatal visit if you are in hospital, and a total of 5-10 home visits, more if clinically needed. Your midwife will provide assistance and advice, and assess for the risk of postnatal depression and family violence. They will also provide information on immunisations, screening programmes and contraception.

The services of a midwife are free for New Zealand residents and New Zealand citizens. If complications arise and you’re referred to a hospital obstetrician, this is also free. Staying in a public hospital or a birthing centre is free too, however some birthing centres will charge for a private room. Charges may be incurred for ultrasounds, tests at private laboratories, and some antenatal classes.

Private obstetricians
Access to private obstetric care varies across the country with several group practices and obstetricians working in solo private practices based in Auckland, and a much smaller number in Wellington, Christchurch and Dunedin.

In central Auckland about 20-25% of women choose a private obstetrician as their LMC. In other parts of the country, this percentage will be less.

According to Dr Martin Sowter of Auckland Obstetric Centre (AOC), women booking with a private obstetrician tend to be older or have some significant past pregnancy or medical history that means that they are likely to need obstetric or medical care as well as midwifery care during their pregnancy and birth. However, Dr Sowter observes that a significant number of women seem to feel more comfortable with a more medical model of doctor-led care. "With about a third of first-time mothers delivering by Caesarean section or an instrumental vaginal delivery, some women want to know that, at some point antenatally, they will have met the doctor who will be performing their C-section or instrumental delivery. A small number of women will have had a bad experience during an earlier pregnancy (usually a labour ending in an emergency delivery) and prefer to book with an obstetrician, feeling that they will be more likely to have a choice about how they give birth in their next pregnancy" explains Dr Sowter.

Within the public hospital system there can be challenges in providing continuity of medical care, convenient appointments and easy access to advice out of hours, which again makes private obstetric care a preferred option for some women.

Dr Sowter states most obstetricians and obstetric groups charge between $5000 and $5500 in Auckland, with slightly lower charges in some centres. “This usually covers all visits, being available 24 hours a day every day of the year for advice, emergencies, and care during labour. Being delivered by C-section, having a multiple pregnancy or significant medical problems doesn’t incur any extra cost. Some unfunded screening tests, and some scans may be an additional cost.”

Women receiving midwifery-only care can and should be referred for an obstetric review, and potentially ongoing obstetrician care, if concerns arise during their pregnancy. “Most obstetricians who provide private care also provide acute and on-call obstetric care as part of the public hospital medical on-call roster” explains Dr Sowter.
He also confirms that this referred obstetric care is free at every New Zealand hospital, but notes the potential difference with this obstetric care is consistency. Women may potentially see a range of doctors (including trainees) throughout their care and may even have a doctor they've not met before for the actual delivery. "This is less likely to be the case if they choose a private obstetrician as their LMC” says Dr Sowter.

Private obstetricians arrange home visits by a post-natal midwife, and women will see their obstetrician for a six-week baby check. Well Child providers will usually have seen their baby at some point between four and six weeks, and they will see their GP for baby’s six-week immunisations. 

Points to ponder
There are a number of topics to discuss with a potential LMC. Their qualifications, recent experience and childbirth philosophy are a good place to start, but also whether they’ll be available after hours and throughout labour, and who the backup carer will be, if required. Don’t be shy to ask about all the possible costs prior to treatment. If you’re planning a natural birth, you could ask about their intervention rates. You may also want to discuss the place and timings of your appointments and postnatal visits, as well as where you’d prefer to give birth.

A new baby marks a whole new chapter in life. Your baby’s journey into the world is a story your family may reflect on for years to come. Your Lead Maternity Carer plays such an important role in that journey – educator, advisor and confidant – that it’s imperative you choose someone you fully trust and feel comfortable with. Women all have differing needs, as do babies. Our concerns and medical histories are also unique so it's important you don’t feel obliged to emulate other’s choices. It’s your prerogative: LMC also conveniently stands for Let Mama Choose.

Megan is pregnant with her second baby. For her first pregnancy, following years of fertility treatment and specialist intervention, she was after a relaxed, 'normal person’s experience', so for her, a midwife was a perfect choice. Megan admits she was probably an exhausting patient, with all her questions, comments and suggestions, but recalls her midwife being patient and kind in dealing with her insecurities. This time round Megan has a private obstetrician and shares with OHbaby! the reasons why:

Why have you changed your LMC second time round?
I started off with a midwife, the same lovely and capable lady I had with our first baby, but following several bleeding episodes, I decided to switch to an obstetrician, purely for peace of mind. Given the struggles of conceiving our first baby, as well as the added complications of the bleeding and a high risk for miscarriage, we wanted to give this 'surprise' baby every possible chance. Even though we knew choosing an obstetrician over a midwife wasn't going to ultimately change the outcome, the information and answers were invaluable.

My check-ups with the obstetrician started off three weekly until the clot in my uterus had disappeared. He came highly recommended and has a lot of experience, so I felt comforted by his opinion that the bleeding would pass and baby would be fine. He has continued to have a brief, confident approach, which is reassuring, and seeing our baby and her ticking heartbeat each appointment is nice too.

Two sides of the coin
My midwife was approachable and kind-natured, and became someone I looked forward to seeing – a calm and consistent companion from 10 weeks pregnant until our baby was six weeks old. In the midst of a significant haemorrhage and emergency surgery, she had a wonderful bedside manner, quietly explaining what was going on. Plus, she was free.

On the other hand, when faced with a medical complication and high-risk symptoms, I did not feel 100% reassured by my midwife’s support. If I called her in the midst of a scary bleeding episode, she would tell me to go to the hospital (where I would be seen by an obstetrician).

I took confidence in the fact that my obstetrician had specialist knowledge and has dealt with complicated pregnancies like mine before. He was direct with his opinion on the best birth plan, given my situation and history. I like having a scan every visit to be sure baby is okay. I have peace of mind that if something serious comes up, I have a specialist doctor on the other end of the line.

However, he’s fast and frank. It feels like I shouldn't ask too many questions and should understand his explanations for what means what, and why. I’ve missed the less-formal freedom to vent all my queries and the close relationship I’d developed with my midwife. My midwife allowed 30 minutes to an hour for my check-ups, yet each appointment with my obstetrician is just 15 minutes.

And of course there's the money factor – my private obstetrician is expensive!

What advice do you have for others trying to make a decision?
Don't be afraid to ask questions and share your concerns. The responses you get can help you decide if you need a different style of LMC. I got worried when I didn't know what was happening and wanted specialist advice. Moving to an obstetrician gave me the security I needed. Your needs may differ with each pregnancy and you are allowed to choose the care that makes you feel best at the time.