Interview questions to ask your homebirth midwife

I'm going to write this with the assumption that you have chosen to have a homebirth. I will assume that you have done your research, carefully weighed the pros and cons, and are comfortable with that decision. I am going to assume that you have decided to take responsibility for who you will hire, and for your part in the decision making that comes with having a homebirth and out of hospital care. I'm going to assume that you are a competent adult with no prior medical history that would rule you out of homebirth care with a midwife.

First let's start with a breakdown of important terms when it comes to midwives. There are different types of midwives, and if you scroll down you can see what those types are on this page from MANA. What they leave out of those definitions, and I think this is important, is that only the CNMs and CMs are required to have a masters degree in midwifery. The CNM is also licensed in all 50 states. The CM is only licensed in three. (I'll be honest, I've never quite understood the CM designation because it is only licensed in three states but if you live in one of those states I suppose it makes sense?) Also, only CNMs and CMs can prescribe medications legally. 
CPMs can often administer and carry meds, depending on the state and how licensing and regulations are in their state. CNMs and CMs are the only midwives that serve high risk women in the hospital setting.

CPMs and DEMs do not. CPMs receive all of their training with a more holistic model, geared specifically towards homebirth and possibly birth center practices in certain states. CPMs who are entry level have attended a minimum of 40 homebirths before becoming certified. They must also show proficiency in 43 pages worth of midwifery skills, take a second skills verification, and then sit for the NARM exam. CNMs often do not attend homebirths during their training but that varies. CNM schools also vary in the amount of births needed before the graduate can sit for her final certification exam. Some schools require 20 births, some 40, some are in between or more. All CNMs have extensive experience in labor and delivery as most schools require 2 years of labor and delivery experience before they will accept a student into their CNM program. All CNMs are certified by the AMCB

.

Here in PA, we have an association called the midwives alliance of pennyslvania, or MAP. They have a section called know your local midwife, which is a starting point of questions to ask when interviewing a midwife. Some of what I say here may differ or repeat what they have on that site. If you are interested in promoting midwifery and safe homebirth options in PA, please get involved in the varying state midwifery organizations to make that possible. There is also Pennsylvania Families for safe birth. 

So here are some good questions to ask and why they are important. This is geared towards birth in PA, but could be utilized in other states.

How long have you been a midwife?

• You may not mind if you have a relatively new midwife, but this is good information to know. More experience may mean better, or it could mean stuck in their ways, it can be bad on both ends or good. A midwife with under a hundred births to her name is likely not as experienced in identifying and managing difficult situations. If your midwife has 30+ years of experience that can be amazing, and it can be a bit scary if she practices alone. Most homebirth midwives start practicing when they are around 30-35 so if she is advancing in age she could tire more easily and it is possible to have memory lapses or questionable judgement particularly at long births. If she practices with a partner or has another younger midwife with her this is less of a factor. I am not saying this is true across the whole of midwifery but this is simply the facts of life and aging.

Why did you become a midwife?

• Usually you will get the same types of answers for this one, but it speaks to the philosophy of birth that your particular midwife has.

Are you certified, and if not, why?

• In PA, no certification is required. Some women prefer that, some midwives have political differences with the certifying agencies, some don't want to be held accountable.

Are you licensed? If not, why?

• Unless she is a CNM, she can't be licensed in PA. If she has her CNM and is no longer licensed, it's a good question to ask why. The political climate towards all midwives can be tense or difficult to navigate for all types of midwives in PA. She may be licensed in a neighboring state.

How many births (approximately) have you attended?

• Again this goes to how much experience your midwife has overall.

Have you had any bad outcomes? If so, without revealing identifying factors, can you describe what happened?

• Every provider at some point if they practice long enough is going to have a bad outcome. If they deny this happening, I would strongly suspect that they are lying unless they are fresh out of school/training. A bad outcome may or may not be their fault and sometimes a baby has a defect that would result in its demise regardless of setting. 

Where did you go to school to become a midwife?

• Whether college or online, accredited or non, the school they attended is going to influence their birth philosophy. If they attended one that they no long ascribe to their philosophy hopefully they will make this known.

How many births did you attend before becoming a midwife?

• This is more important information relating to how experienced she/he is in birth.

How many births do you attend per month?

• If your midwife is in a solo practice, without another midwife who attends regularly with her, it's not wise to attend more than 4 births in a given month. The exception to this might be if she is at a birth center where more than one woman can come into the center to birth her baby.

Do you carry malpractice insurance? If no, why?

• Unless she is a CNM, midwives in PA cannot get malpractice insurance. Bear this in mind should something go wrong at your birth. You will have no recourse to collect damages. If this is important to you, do not hire a direct entry midwife, hire a CNM and birth in a hospital.

Do you have any medical conditions or mental health conditions that would influence your care of me?

• This is a big one. You may think you are prying or being too personal but you aren't. If you apply for any job don't they ask you if you can lift "x" amount of pounds, sit, stand, etc. for so many hours a day? For example, I have rheumatoid arthritis. I've had it all of my life. For the most part, it doesn't affect me and if I have achy days usually some aleve does the trick. My condition does not at this time, affect my ability to perform my job well. The mental health one is a bit trickier and if your midwife has a history of depression that may not preclude her from being a good midwife. If however she has NPD or is bipolar or has a personality disorder and is not receiving care, that can come back to bite you later. Unfortunately most people who have personality disorders don't think that they have one so you need to educate yourself on what the signs are.

Is homebirth as safe as a hospital birth?

• The correct answer to this is no. If you have a midwife who tries to make it seem like it is just as safe, do not stay with them. Homebirth has many perks and is generally less invasive than a hospital birth. Most of the time everything goes great. However there is no OR, NICU, blood products, pharmacy, or anesthesia available at a homebirth. So, if anything is amiss that can't be easily handled at home, you are not as safe as you would be in a hospital. If you are ok with taking that risk, fine, but beware the midwife who paints homebirth as safe or safer than a hospital birth.

Do you offer waterbirth? If so can I rent a tub? How many tubs do you have?

• Waterbirth is a great coping tool for dealing with labor pains. It can diminish, but not entirely remove, the birthing pains. If she is taking on multiple clients, she should have multiple tubs.

I'm an abuse survivor, are you experienced in supporting abuse survivors?

• If this doesn't apply to you then you of course don't need to ask it. But, if it does apply to you (one in three women it does), it is a good question to ask.

Are your currently certified in neonatal resuscitation and basic life support?

• Every two years these courses need to be taken for recertification. It can be difficult to find an NRP course but it can be done.

What types of emergencies have you handled at home?

• Common emergencies are shoulder dystocia, hemorrhage, and resuscitation of the newborn. Your midwife should have handled all of these competently at some point in her career.

What equipment do you bring with you to a birth? Do you carry herbs, medications?

• She should be able to rattle off a list of items that she brings including sterile instruments, doppler, stethoscope, blood pressure cuff, etc. Some midwives carry a small herbal formulary with them and some just a few or no herbs. Some carry homeopathics. Some are not permitted by law or do not feel that they should carry medications. Some carry them no matter the law because they would rather face the fine from the state than risk your life.

What was the last continuing education course or module that you took and when?

• For all certified midwives, continuing education is required to maintain their certification. For non certified midwives it is not, but is still just as important. The evidence and science behind obstetrics and midwifery is ever changing and it's important to stay on top of what the latest science says about care.

What does a typical prenatal visit look like?

• For a homebirth midwife, visits should not be rushed. At least a half hour and preferably and hour should be set aside to care for you and your baby. Vital signs, fetal heart rate, measuring your growing uterus, and assessing the position of your baby are staples of care. The rest of the time is spent on education, getting to know you and your family and developing a trusting relationship.

What prenatal testing do you require?

• There is going to be some differences here. Some midwives require all the testing, some want the minimum, most are somewhere in between. Waivers, education on types of testing, and informed consent on all testing should be offered.

Do you work with another midwife as a partner?

• In some practices there is more than one midwife. This is the ideal, but is not always available due to large geographic areas that are underserved by midwives. Also, not all midwives get along and would make horrible partners.

Do you have apprentices?

• Most midwives have an apprentice or an assistant that you will get to know over the course of your pregnancy. Find out who that person is (hopefully they came with her to the interview) and what her/his background is with birth.

Do you have a backup midwife?

• If she doesn't have one, be wary. What would she do if you and another client go into labor at the same time?

Do you participate in peer review? How often? How many midwives participate?

• Peer review is an important part of accountability and keeping good relations between midwives. Beware the midwife who only does peer review with her apprentices or partners. She is probably not getting a diverse perspective on her practice. In this age of facetime and skype there is no excuse for not having additional midwives in a peer review. If other midwives refuse to particpate in her peer review, something is amiss there. Midwifery is fraught with interpersonal infighting and politics so I can't say why that happens in every case but it's usually messy no matter the reason.

Are you the best midwife in the area?

• The answer to this should be "no", or "I don't know?" or "we have several great midwives in the area and I happen to believe I am one of them." Unless she says yes sarcastically (I'm known to have more than a touch of sarcasm.) of course that's different. A midwife who touts how great she is and puts down all other midwives as inferior has a goddess complex and isn't worth your time or money. A midwife should be sure of herself and competent but should not be boastful or brash. We are all human, there is no competition or award for "best midwife".

If you don't have malpractice insurance, and I am not satisfied with my care, who do I make a complaint to? 

• If she does not participate in peer review and is not licensed, you have very few options for lodging a complaint in PA. If she is a CPM, you can lodge a complaint with the North American Registry of Midwives. If she is licensed or a CNM you can lodge complaints with the board of midwifery or the medical board, depending on your state.

Do I have to hire a doula?

• Who you have at your birth should be entirely up to you. You are hiring her and while a doula is in my opinion, a worthwhile expenditure for your birth, it should not be required.

Do I have to take childbirth education classes?

• If you are a first time parent, this is a must do item for your list of things to do before the birth. Your midwife should have suggestions of courses to take and people with whom you can take them with.

What is your policy regarding children at the birth (if you have children of course)?

• Your kids live with you, they should be welcome in your house. It is fairly standard to ask that you have someone to care for your child other than yourself or your partner during the birth. Whether or not you want them in the house or out of it should be your choice unless something happens where their removal is optimal.

What is your preference regarding my pets?

• Some clients really love their pets. I get it. Some of you think they are your children. Especially those of you without actual human children. While I don't pretend to understand that, I get that it is a fact of life. None the less, pets at birth can be a very bad combination. Especially dogs or territorial cats. You will be making noise while birthing and you don't want your midwife to be attacked when she is helping you because your furchild believes that she is causing you to be in pain. Also, cats + inflatable tubs = deflatable tubs. Another thing, some midwives are fine with pets of all kinds and love them. Some don't for a myriad of reasons so if you are having your midwife come to your home for prenatals be sensitive to your midwife's needs as well.

If I am sick, do you have a physician that you can refer me to or should I see my family physician?

• CNMs have prescription privileges and can likely write you a script for what ails you. Other types of midwives legally do not have this authority. They may however have a collaborating or sympathetic doctor that they refer moms to. If your midwife states that she has a collaborating or backup physician, don't take her word for it. Call and ask the physicians office.

Do I need to have a pediatrician lined up before the birth?

• Yes, yes you do. A homebirth midwife is not a pediatrician. Even a CNM is not a pediatrician. You should secure a pediatrician and find out from them how soon after the birth they want to see your baby. This varies from pediatrician to pediatrician but most want to see the baby within 48 hours of the birth.

Do you carry resuscitation equipment with you for the birth?

• They need to carry at the very least an infant bag and mask. There is debate about the safety of oxygen use during labor and delivery. Room air is generally used for resuscitation except in the hospital where they have a special oxygen mixing machine for resuscitation. So your midwife may or may not carry Oxygen.

Do you "trust birth"?

• If your midwife is a "trust birth" midwife. Please don't hire her. Respecting birth and believing that women can safely birth their baby most of the time without interference is not the same thing as blindly trusting the birth process. I used to be part of the "trust birth" movement. I'm not proud of this. It made me reckless and I didn't even realize it. The "trust birth" movement has harmed so many families and midwives. Stay away.

Are you a hands on or hands off midwife?

• This one should be conditional. A good midwife knows when to back away and observe, hold the space, and not interfere. She also knows when to jump into the fray to prevent disaster to the best of her abilities. She should not be inflexible when it comes to this. Some women want more support physically from their midwife and some don't like to be touched or spoken to. You're the boss, but she is the supervisor of the health department so to speak in this working relationship.

Can I have access to my chart and test results at any time?

• It's your chart, they are your results. You should be able to access this information when needed. If your midwife does paper charts, you should be able to have copies when requested. If your midwife does electronic charts, you should be able to access your chart online.

How often do you transport?

• This answer should not be never. Transport is not a failure. Not transporting when needed is a bad idea and can end in catastrophic loss. Transporting during or after labor is not a failure. If they have more transports than home deliveries that can signal that something is wrong as well. A decent rate of transport is around 10-20 percent. Any more than that might show a failure to screen out higher risk women.

What happens if I want to go to the hospital, for any reason, during labor?

• The answer for this should be. We go to the hospital.

Who is most likely to transport in your practice?

• Some midwives leave out the fact that first time moms and first time vbacs typically have longer labors and higher rates of transport. Most transports are for non emergent reasons to get pain relief or for further assessment of a baby who shows signs of potential distress.

What is the most common reason for transport?

• Usually, as stated above, it is maternal exhaustion. However, some midwives place the onus on a transport as the mother's fault. A mother doesn't make a transport happen. It usually just happens through nothing that she did at all, unless of course she requested it.

Are you able to accompany me to the hospital if I need to transport? 

• This is going to depend on the midwife, the state that you live in, and her relationship with the area hospitals.

What is your standard of care for: breeches, twins, vbacs, vbamcs, GBS + moms, past 42 weeks of gestation, prior to 36 + weeks of gestation, prolonged labor, meconium, maternal fever, herpes, prolonged rupture of membranes, vitamin k, eye ointment?

• There is a lot in this question, but it should be discussed at your initial consultation or in the first email that you send to your potential midwife. Some of those things may not be applicable for you (If you don't have herpes and are a first time mom you don't need to ask about vbac or herpes for example.).Truly all of it should be in her informed consent documents. Some midwives are comfortable taking more risks than others. This is not always a good thing. No homebirth midwife is an expert in high risk mothers. Only CNMs, OBs, and perinatalogists in hospitals can stake such a claim. Any homebirth midwife that says otherwise is practicing foolishly and boasting of a title that is not available to her. There are inherent risks in all of the above situations. Some you may be comfortable with (like a vbac after one section) and some you may not be or you may not know a lot about. If you aren't aware of the risks, ask her, and then double check what she says later. Another example would be breech. Some midwives have a lot of breech birth experience and others like myself, have none. While it's true that many breech babies can be born vaginally, you want a provider who has experience in that mode of delivery attending you and you need to be completely informed of the increased mortality and morbidity risk involved. Unlike the popular slogan, breech is Not a variation of normal. Breeches occur 3-4% of the time in all births, including multiples. If something occurs only 3-4% of the time then it does not fall under the heading of "normal".

Can you guarantee me that I will have a homebirth with you?

• There should be no hard and fast guarantee. We cannot foretell the future. Any midwife who boasts otherwise is a fool and is likely to take chances with you and your baby.

I've been told that I'm too high of a risk to homebirth by other midwives and my obstetrician. Will you attend my homebirth?

• I shouldn't have to say this, but if you have had other midwives tell you that you do not qualify for a homebirth, then you shouldn't plan on a homebirth. I see this sometimes with moms who have had multiple surgical deliveries in particular. Years ago I did vbamc at home without batting an eye. (thanks "trust birth"!) I no longer offer this unless the mom has had a prior vaginal birth after c-section and even then they must be getting co care with an OB or CNM.The only rupture I have witnessed was to a mom who was attempting a vba2c. I transported as soon as I suspected a problem, we were at the hospital for a few hours after the transport and when they finally did a section, she had ruptured. She lost her baby. She almost died on the table. She would have died at home. I won't go through that again. I won't take that chance with anyone again. If you are that dead set on a vaginal delivery at home then please do us midwives a favor and have a UC. If you want to take risks, fine, but leave us out of it because we will face the legal repercussions if something goes wrong.  So please, if you want a vbamc, hire a doula, don't consent to a repeat section at the hospital, insist on a TOLAC and birth in a hospital. It's sad that women have to fight for that, but a vbamc is best monitored and handled in a hospital in my opinion. Same goes for special scars vbacs.

How do you monitor my baby and myself during labor and how often? 

• All midwives should carry a doppler and fetoscope with her to births. Intermittant monitoring at regular intervals (every 30 minutes, then every 15 as labor progresses, then every other contraction) is the best way we have at a homebirth to monitor your baby's health. Asking you if you can feel the baby moving is helpful, but is not definitive. Both are pieces to the puzzle and both are important to know.She should also listen a few times during your birth during a contraction to determine how the baby is handling contractions.

How often do you do vaginal exams?

• There are often two extremes to this. Midwives who refuse to do them and midwives who do them like clockwork, every two hours. A mother should always have the right to both request an exam and to refuse one. Midwives should be capable of doing them and know when it is time to check and when it is time to wait.

Do you do delayed cord clamping?

• Most midwives do this at a homebirth and it should be standard of care.

How long can I wait to birth my placenta?

• This is often situational as well. It depends on your bleeding, how well you are contracting, and how you are feeling overall. Most placentas will detach and can be birthed within the first 5-15 minutes after the birth. Some come out earlier, some a bit later. A retained placenta is considered one if it has not detached and birthed after 30 minutes. I have waited longer than this, if the moms uterus is clamped down tightly and there is no bleeding, but at some point a hospital transfer is likely should the placenta not come. It's not meant to stay inside after the birth of a baby.

What happens to my placenta after the birth?

• The placenta is yours so you should have a say in what happens to it. Some moms want to keep it, some want to have it encapsulated, some want to plant a tree over it, some don't want to see it, some just want it chucked into the trash.

After the birth, how long do you stay?

• Some midwives stay a very short period of time, but generally they stay between 2-4 hours after a birth.

When do you come back after the birth?

• This is also going to vary, but generally most midwives come back within 48 to 72 hours after the birth, again at two-three weeks, and again at six weeks. Some CNMs in particular do not do the 2-3 week appointment.

What do you expect from me during my pregnancy, birth, and postpartum in terms of responsibility?

• Homebirth and birth center birth and hospital birth all have their own unique frameworks to navigate. I wrote earlier of how the safety and both home and birth center births have higher rates of morbidity and mortality than hospital births when we look at national statistics. This is true regardless of type of provider. If you are choosing to have a homebirth, with an unlicensed provider or a licensed provider, you are taking on a great deal of the responsibility (barring outright willful negligence on the part of your midwife of course) for that decision. This is both the beauty and the hard reality of out of hospital birth. You are the one in charge, no one makes you have a homebirth. You sought this out, educated yourself, interviewed several midwives, went to an obstetrician or family doctors office at some point, and decided that being at home was where you felt that you needed to be. If you have a midwife who coerces you into having a homebirth or paints it as risk free then she can be held culpable as well should things go badly. 
• You should be responsible for being honest and forthright with your midwife about any changes in your health.
• You should be responsible for eating healthy and keeping your stress levels to as low as possible during pregnancy.
• You should be responsible to maintain a low or moderate exercise regiment.
• You should be honest and forthright about any changes in your mental health.
• You should be honest and forthcoming about any drug use.
• You need to keep a tidy home and clean space for birthing.
• You need to purchase a birthkit or misc. items contained in a birthkit by 36 weeks of pregnancy.

Do you have payment plans?

• Most midwives do and that possibility should be listed in her financial agreement.

Do you offer refunds and if so under what circumstances?

• Again, this should be in the financial paperwork, but at the initial interview it is a good time to get all of the business side of things cleared up.

Can I contact some of your former clients for referrals and can I talk to at least one that you had to transfer care?

• It's important to include that transfer client. Those are the clients that are most likely to not have had as good of an experience. However, if the client seems happy with the decision to transfer and feel that they were a part of that decision, that makes a big difference. Realize that the midwife is not going to give you names and numbers of disgruntled former clients. This is because A) they may make her look bad and really who is going to admit to that and B) sometimes disgruntled clients aren't happy in spite of her best efforts and due to privacy laws she can't defend herself to you.

What is your preferred method of communication?

• Some want a phonecall, others a text or email. Most it is a combination depending on the situation. Please do not abuse this with your midwife. If it is a non emergent situation, please wait to call or text us until normal business hours. We sleep with our phones next to us and although we may sleep through your text...we likely will hear it beep and check in case it is urgent. While your heartburn or restless legs may be keeping you up, it shouldn't keep us up. Google can be your friend or please call in the morning and we will give you suggestions.

For yourself, after the interview: Talk it over with your significant other or support person and get a feel for how comfortable both of you were with the midwife. Do your due diligence and check up on any subject matter that came up that you were unsure of. Remember that you are your unborn child's best advocate!