Choosing a care provider in NYC

Last year my former doula partner attended an induction at a large practice at a private hospital in Manhattan. She texted me as she was leaving the birth that during pushing, an older man stood behind the care provider repeating “maybe we make a little more room.” 

“Wondering if it’s the same guy,” she wrote. 

Doulas often text each other throughout births, usually just strings of numbers and acronyms (“AROMed at 5/80/0”, “pit at 4”), sometimes to vent, sometimes to ask for moral support when it’s hour 22 and 3 am and contractions have spaced to every 15 minutes and you’re crusty and dehydrated and trying to sleep on the floor between the delivery cart and the partner’s recliner. Often, we are information sharing. At a birth I’d supported six months earlier at the same hospital, an older man stood behind the OB saying, “Maybe we make a little more room,” becoming more and more insistent. I assumed he meant that there were too many people standing around her bed (there were). When the OB quickly and quietly cut an episiotomy, I realized the implication was that the woman’s vagina, not the woman herself, “needed” a little more room. (Episiotomies haven’t been recommended since the 90s, when research showed that they heal worse than spontaneous tears and are significantly more likely to lead to third and fourth degree tearing.) Nobody from the hospital mentioned the episiotomy to her at any point. It was left to me to tell her that she had had one, and how to take care of it. And, as it turned out, the same OB was at the birth Shelby attended. Thankfully there was no episiotomy at that birth, but Shelby was prepared to speak up if she needed to prompt a conversation about the risks and benefits of episiotomies.

I tell this story to illustrate that doulas are uniquely situated to see how different providers across different hospital systems are practicing off paper. Hospitals are not transparent about their intervention statistics, even though most people giving birth indicate that they would like to avoid unnecessary augmentation. And of course they’re not transparent - almost all of these hallowed institutions have cesarean rates that are double to triple the 15% cesarean rate that the World Health Organization cites as the ideal rate of a functional healthcare system. Transparency would mean accountability for the ways they are failing. 

If you ask any doula, they will (or at least should) tell you that the answer lies in provider alignment. Not in hiring a doula, which is not financially viable for many people, and not in brand new facilities (I’m looking at you, Weill Cornell), and not a high risk provider for a low risk birth. Most doulas have developed encyclopedic knowledge over the years about hospitals and practices in their city. What hospital doesn’t allow cord clamping past 60 seconds? What hospital has waterproof wireless monitoring? What hospital has nitrous oxide? Doulas don’t have any financial incentive for you to deliver with one provider over another, but we do have incentive to not witness dozens of traumatic births. And we have incentive to set reasonable expectations about what will and will not be possible at your hospital birth. There’s nothing you can do to guarantee a straightforward and trauma-free labor. But you can do due diligence around providers who are aligned with your birth preferences. 

If you don’t have access to a doula, you can still do some research around current evidence-based practices and ask questions to get a sense if you’re aligned with your provider. You will get information from their answers, and you will get information from how they answer your questions. Were they rushed and annoyed? Or did they take time to explain? Here are a few questions you could ask, and why they’re important: 

When would you induce me if I didn’t go into labor spontaneously?

Robina at Small Things Growing gives a great explanation of why inductions rates have skyrocketed over the past 5 years here. There are a number of scenarios, like preeclampsia or cholestasis, in which an induction is the safest way to deliver a baby. I have seen beautiful inductions that resulted in uncomplicated vaginal deliveries, and inductions where each step was well-explained and consented to by the birthing person. 

But. 

Inductions are not an off-ramp to avoiding complications. Like physiologic labor, they can be long and painful. They involve multiple steps - often cervical ripener to soften the cervix, a Foley balloon to manually dilate the cervix, Pitocin to create contractions, and artificial rupture of membrane (breaking your water). Contractions on Pitocin (synthetic oxytocin) are more powerful than the contractions caused by your natural oxytocin. It is not unusual for inductions to take two days. So it’s important to understand why induction is being recommended. Your personal risk factors are something your doctor will consider when recommending induction, but it’s worth noting that many people spontaneously go into labor after 41 weeks, which is past the threshold many providers will “allow.” Are your doctors giving you enough information for you to understand what you’re consenting to? 

What is the likelihood that you will be at my birth, and who are the other people who could be there?

Find out how often your provider is on call. Prenatal care is important, but if you are counting on the relationship you’ve built for the birth itself, you may be disappointed to learn that they are only on call for a small percentage of the week. Make sure you’re comfortable with the other possibilities too. Also, if you’re choosing your OB because she’s a woman, that does not mean that she won’t have on-call colleagues who are men. 

Can I ask for intermittent monitoring if I am low risk? Do you have wireless/waterproof monitoring?

Continuous electronic fetal monitoring, according to the American College of Obstetrics and Gynecology, American College of Nurse Midwives, Society of Obstetricians and Gynecologists of Canada, and the UK’s National Institute for Health and Care Excellence, is not recommended for low risk labors. EFM leads to more cesareans, dissuades movement in labor, and leads to less contact between patients and providers. Why is this guidance fastidiously ignored by hospitals? For legal reasons, of course. Many hospitals don’t have wireless monitoring, or they only have a couple of wireless monitors. 

Anyone who has been on wired monitoring can tell you how annoying it was to have a nurse come in every ten seconds to readjust the monitor. It’s seemingly a small thing, but it’s one that can really change the quality of your experience.

If you are seeking an unmedicated birth: how often do your patients deliver unmedicated?

Some providers have never even seen an unmedicated birth because their hospital and practice is so oriented around medicalized birth. If your provider doesn’t know what a physiologic birth looks like, they won’t know how to support yours. 

What percentage of your patients tear during delivery?

The majority of hospital births result in tearing, and many home births too. But a big red flag is if your provider says “all women tear during their births.” This is not true. This tells you that they exclusively deliver epidural patients in lithotomy position, which leads to increased rates of tearing. The NYC Homebirth Collective reported a tearing rate of 27% in 2022. The statistics of home births are not replicable in a hospital system, but it does reflect that birthing without tearing is more than possible, and that your provider has a narrow standard for what birth will look like. 

I don’t believe questions about if they follow evidence-based practices or their cesarean or episiotomy rate are helpful. Most doctors will say “we avoid cesareans whenever possible,” or, my favorite, “We take a lot of high risk patients so our overall cesarean rate is not reflective of your chances.” And evidence-based is a broad term that could be applicable to any number of flawed studies. 

There is no way to guarantee a “good birth,” with “good,” in this case, meaning a birth that adheres closely to your stated preferences. It can be difficult as a layperson to evaluate whether someone’s c-section was necessary. For example, if the doctor breaks someone’s water and that causes a cord prolapse, that is a medical emergency necessitating a stat c-section, but it was a doctor-caused medical emergency. On the other hand, a certain number of c-sections is a sign of a functional healthcare system. Asking your care provider these questions doesn’t scratch the surface of changes needed in the healthcare system, but I still believe there are small things you as the consumer can do to minimize - not eliminate - your chances of a traumatic birth.