Choosing Your Childbirth Provider

Who delivers your baby is of great importance to some pregnant and laboring people. And not just in terms of feeling confidence and trust in your birth provider. Research is just beginning to show that there may be health benefits for moms and babies the more similar they are to their birth provider. The reality is that in most parts of the world, birthing people can’t choose the person who delivers their baby. Suppose you belong to an under-represented part of the birthing community or feel that the person who is supporting you through labor and delivery matters. In that case, you may want to be a bit more selective in choosing your childbirth provider.

Provider-Patient Concordance and Birth Outcomes: What Do We Know?

It is not news that many of us who identify as female prefer to have another woman getting up close and personal with our lady parts. But what about if you come from a racial or ethnic minority? Or identify as a member of the LGBTQ community? Is your birth actually safer for you and your baby if your provider is as similar to you as possible?

It may be. When provider and patient share the same perceived race, it is called race concordance. Most current research examines how racial concordance impacts birth outcomes. Some of the birth outcomes researchers and doctors study are preterm birth, low birth rates, numbers of infants dying in childbirth (infant mortality), and numbers of mothers dying in childbirth (maternal mortality).

In the US, black newborns die at three times the rate that white newborns do. Unfortunately, researchers studying whether having a birth provider of the same perceived race might help save newborn lives do not have a clear answer for us. Some studies show fewer deaths among black newborns when the birth providers were also black, but other studies show no effect.

According to the World Journal of Gynecology and Women’s Health (2019), black maternal mortality is the elephant in the room – a painfully obvious public health crisis that people choose to ignore or not discuss because nobody likes to talk about racism. In the US, black women die in pregnancy, childbirth, or within six weeks after delivery, at four times the rate of non-Hispanic white women.

Doctors, public health researchers, and social justice advocates identify three causes of this devastatingly high rate of unnecessary death of black mothers in the US. First, black women may be more likely to have health risk factors (heart or cardiovascular) before becoming pregnant. Second, black women may have complications during pregnancy (like problems with gestational diabetes or high blood pressure) that makes birth more dangerous for them. The third reason is the one nobody wants to talk about – providers’ racial bias and patients’ perceived racial discrimination that corrodes black women’s trust in their providers and the medical system at large.

Patient-Provider Mismatch a Barrier for LGBTQ Birthing People Too

Despite greater acceptance of same-sex marriages and parenting and research showing positive benefits of LGBTQ parenting, lesbian, gay, bisexual, transgender, and queer individuals face challenges in accessing reproductive health services. As a result, they can also experience worse birth outcomes.

Challenges include stigma, discrimination, fear, inequity in health care insurance and reproductive healthcare coverage, and provision of “substandard care,” according to the Kaiser Family Foundation’s 2015 Issue Brief. Even well-meaning professionals who lack an understanding of how to provide compassionate, respectful, and culturally appropriate LGBTQ-inclusive care can cause harm.

Research suggests that some subgroups of the LGBT community have more chronic conditions, higher prevalence, and earlier onset of disabilities than heterosexuals. LGBTQ people are less likely to access preventative reproductive health care such as routine sexually-transmitted infection screenings, pap smears or mammograms.

One study of almost 20,000 US pregnancies from 2006 to 2015 found that, compared to heterosexual women having sex with men only, bisexual and lesbian women were more likely to report miscarriage, a pregnancy ending in stillbirth, or very preterm births. Lesbians were more likely to report low birth weight infants than heterosexual women.

A Biological Explanation For How Provider Concordance Could Affect Birth Outcomes

Unhealthy levels of anxiety or mental distress during pregnancy and childbirth may burden pregnant people who have survived racialized or gender-based trauma. While not yet proven by research, doctors hypothesize that chronic stress and anxiety in marginalized or under-represented pregnant people could put mothers and babies at risk.

Human and animal studies show that activation of the human stress response (also known as the fight-or-flight response) can cause changes in brain chemistry and hormonal communications in pregnant people and their fetuses – and that these changes then are passed down or inherited through generations. The intergenerational effect of trauma, racism and gender-based discrimination is only just beginning to be understood.

The known effects of chronic anxiety during pregnancy include a higher risk of delivering early (preterm birth), being less likely to attend prenatal care appointments, and a greater chance of delivering a low birth weight baby. In addition, people with prenatal or chronic anxiety, depression, or post-traumatic stress disorder (PTSD) are also at higher risk for postpartum depression.

We also know that fear, stress, and anxiety during childbirth can increase rates. Black women in the United States are more likely to deliver by cesarean section than white women. People are three times more likely to die in childbirth via cesarean than vaginal delivery. The human stress response releases chemicals that can slow labor progress, making labor longer and more dangerous for birthing people and their babies.

Having a provider of a different race, culture, or sexual orientation or even a provider whom a laboring woman perceives as biased or racist can cause fear, anxiety, and re-traumatization. Survivors of past trauma (racial, sexual, or gender-based) might be less likely to attend prenatal care visits if they do not trust the medical system or have had past negative experiences. In these ways, it can be critical to find a provider you can trust to have a healthy pregnancy and safe birth.

How to Choose the Right Provider for You

Unfortunately, for many birthing people, health insurance status, geography, or the health care system itself chooses their provider for them. It can pay to do your research, however, and find out just what your options might be.

  1. Talk with your health insurance provider to determine which doctors or midwives your health insurance plan covers.
  2. Talk with family, friends, and coworkers you consider allies about their childbirth experiences. Make sure to ask them about all the other providers they saw in the practice and whether their hospital or other birth setting (and other staff) felt inclusive.
  3. Interview several different providers at several practices. Before your interview, list 5-6 of your biggest fears about pregnancy and childbirth. Then, talk through the questions with each candidate. This can help you figure out if you share the same birthing philosophy.
  4. Consider all of the birthing optionsMidwife or doctor? Hospital, birth center, or home birth?

And remember, you can change providers mid-pregnancy. It might be a bit of a headache or a paperwork hassle, but your mental and physical health are worth it. Childbirth providers are professionals, so you do not need to worry about hurting their feelings. You deserve to be cared for during your pregnancy and childbirth by someone you trust, who makes you feel supported and understood.

How To Have A Good Birth Even Without Your Chosen Provider

Finding a provider that fits your needs, that you trust, and who you feel confident will keep you and your baby safe with is just one way to overcome the fear of childbirth. Unfortunately, there is no guarantee that you will have your chosen provider for your labor and birth. However, taking some of the following steps can prepare you (and your partner) for the possibility that you don’t deliver with your chosen provider:

  • Hire a doula who matches your inclusivity needs and who can commit to attending your birth, no matter what.
  • Find inclusive childbirth classes or look for ones customized for LGBT families, black birthing people, in your native language, or culturally representative ones.
  • Surround yourself with a rock-star pregnancy, labor, and postpartum support team of only your chosen friends, family members, or allies. Don’t invite people who stress you out or who won’t support you.
  • Create and discuss your need-specific birth plan with your birth support people, your doula, and your provider. Consider choosing an inclusive birth plan like these Anti-Racist Prenatal Care Preferences, developed by Erica Chidi Cohen, doula and founder of LOOM.
  • If you have a history of trauma, anxiety, depression, or other mental health vulnerabilities, consider finding a therapist or counselor to start seeing through pregnancy. Look for professionals trained in Cognitive Behavioral Therapy (CBT), mindfulness, conscious conception, pregnancy, and birth.
  • Consider taking classes during pregnancy to learn anxiety-busting techniques such as relaxed breathing, progressive muscle relaxation, meditation, hypnobirthing, or yoga

Even the calmest mother-to-be with a concordant provider will have pre-childbirth anxiety. Regardless of your race, culture, or sexual orientation, birth, and the hospital is a foreign land – strange and unfamiliar territory for most people. While you can’t control everything about your pregnancy or childbirth, researching ahead of time to find the right provider for you could help you have a safer and healthier birth – especially if you identify as part of a marginalized or under-represented part of the pregnant population.

Amy Harris
Amy Harris is a certified nurse-midwife with a Master's Degree in Maternal and Child Health from Harvard Chan School of Public Health. Her passions are health literacy and women's reproductive health. A recent two-year sabbatical with her family in Spain was the impetus for becoming a freelance women's health writer. An exercise nut, she is happiest outdoors and on adventures abroad.

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