Congratulations, you’re pregnant! You’ve been reading birth stories and waiting for it to be your turn. You knew you’d like to give birth at a birth center so as a responsible patient, you’ve submitted your referral paperwork to get all your ducks in a row. You call the birth center to schedule your first appointment.

Stevi: Wichita Falls Birth and Wellness Center, this is Stevi, how can I help you?

You: I’d like to schedule my first appointment, I’m six weeks pregnant. You probably already received my referral.

Stevi: Yes, we did. But first I need to ask you some questions.

After answering our questions about your health history, Stevi tells you some crushing news: I’m sorry but according to our risk assessment your pregnancy is not low risk enough for us to safely take you.

It’s crushing, we know. It’s not easy on us either. Midwives are by nature helpers. We know our style of care is unique and our practice is set up to give you more individualized support than any other practice in the area. We want that for you! We know your birth may go off without a hitch but we don’t get to make decisions based on what we want at the end. We have to make them first based on what your history and current situation look like.

Read that again: We can not make decisions based on what we want the end to look like.

Once we had a woman contact us who had three C-sections and then 3 VBACs (vaginal birth after Cesareans). There was no one in the area who would “allow” her to have another vaginal birth. We knew she could do just fine with a vaginal birth but we couldn’t take her as a client due to our accreditation rules. We knew that if she started care in town, she’d receive an automatic C-section. This grieved us deeply. But we could not take her just because we wanted a vaginal birth for her, even though we knew she wouldn’t get it if we didn’t take her. It’s heartbreaking.

What is the risk assessment anyway?

The risk assessment is a list of diseases or conditions and the current and past social/physical situation, based on current evidence. Basically that convoluted sentence means that we are asking about any health problems you have now or in the past such as chronic diseases (epilepsy, heart conditions, cancer, kidney disease, high blood pressure), especially if you must be on medication to manage the disease or condition. We also look at your current general health-weight, eating habits, exercise habits. Eating junk food won’t be a factor that keeps you from our care but if you have a high BMI, had gestational diabetes in your last pregnancy, hate exercise, and refuse to change your diet, you probably wouldn’t be a good candidate for our practice.

There are some items on our risk assessment that mean you absolutely can’t give birth with us. Some of these are: high blood pressure, VBAC after more than one Cesarean, asthma that requires frequent medication.

Some items are okay if they’re managed or if they don’t stack up to a high number. For example, if the only risk factor you have is a previous postpartum hemorrhage, we can take you. If you have a high BMI but are otherwise healthy, we can take you. If you have thyroid issues that are under control and managed by another provider, we can probably take you. If you combine too many of these “little” things, we have to talk about it and make sure the combination doesn’t put your pregnancy in the medium to high risk category. If some of the factors are manageable with lifestyle changes and/or supplements, we may be able to take you if you agree to actively make those changes.

From time to time, women decide on their own that their pregnancy is too high risk for us to take care of or a well meaning OB/GYN will tell them that. In reality, the risk assessment is a complex tool that has to be looked at from several angles. Does the mother have the ability, time, and resources to make changes or is her condition permanent? Is her BMI high because she’s a muscular athlete and it’s a terrible tool (that we have to use, sadly)? Does she have some issues that could be remedied IF she had good support but she reports no support? Also, OBs don’t know all of our tricks, protocols or access to tools (like anti-hemorrhage medications), so please speak to us directly before deciding you don’t qualify.

If you are not eligible for care with us, we highly suggested one of the other wonderful midwives in town at group practices. We’d also suggest you plan to attend our childbirth class and explore your doula options from our Doula Alliance. If you’d like to make an appointment for a consultation for nutrition and birth advice with me (Wendy) I’d be happy to help you navigate your care during your pregnancy. In other words, we’re still here to support you, even if you can’t give birth with us.

One final note, since we have such a low volume practice, even those who have zero risk factors may not be able to start care with us because we are full. Before sending your referral, call and make sure that you fit the risk assessment AND we have room for you.

Written by: Wendy Fowler

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