Arrangements” for Access to Medical Care
Good care requires that each childbearing woman have as much access to medical services as her circumstance allows and her family is willing to utilize.
For the last 30 years community midwives have been making specific ‘working arrangements’ for each and every mother, depending on geographical location and her health insurance or MediCal status (or lack of thereof). These arrangements generally fall into one of the following 5 categories and represent the various types of backup /referral/ transfer of care.
Mother-initiated / HMO -- The most mutually satisfactory arrangements are for families who belong to HMOs, especially Kaiser, as they simply see their HMO caregiver in early pregnancy for lab work and to create a hospital record of the pregnancy. These mothers subsequently receive the bulk of their antepartum, intrapartum and postpartum/postnatal care from the midwife. If there is any need for additional lab work or diagnostic tests they return to Kaiser. If a transfer of care during labor is necessary, the midwife simply accompanies them to the Kaiser facility and provides a report (and chart records) to the admitting physicians or nurse midwife. HMOs likes this as it save them money.
Mother-initiated / Tandem or Concurrent Care-- Families with good healthy insurance coverage may arrange for concurrent care -- seeing an obstetrician through out the pregnancy, independently of the midwifery care.
Mother-initiated / Family Doctor -- A small number of client families have prior relationship with a physician who is willing to see them occasionally during the pregnancy and has agreed to provide care for them in the hospital should they change their mind about laboring at home or need medical services.
Midwife-initiated Informal Arrangements with Specific Physicians - In some communities there are specific obstetricians willing to take referrals, occasionally consult by phone and accept a transfer of care during labor. Most of these doctors do not want to see the patient ahead of time as that creates vicarious liability. They will only make themselves available in event of a transfer of care in which they had no prior contact with the expectant mother before she is admitted to the hospital.
Hospitals as Proxy -- In some communities there are such a small number of options due to geographical circumstances or hostility by the medical community that no physicians are willing to consult or accept a transfer of a mother who planned a home birth. In those communities families must agree to be transported to a specific hospital and cared for the resident staff or on-call physician in the event of an emergent circumstances for either mother or baby.