Ep 109: Choosing the Right Hospital – Updated

Ep 109: Choosing the Right Hospital - Updated

Nicole: In this episode, I'm updating you on what you need to know when choosing a hospital to give birth.

Nicole: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, competent, and empowered to have a beautiful pregnancy. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello. Hello. Welcome to another episode of the podcast. This is episode number 109. Thank you. Thank you as always for being here with me today. Understanding what you need to know when choosing a hospital to give birth is a topic that I did very early in the podcast. It was like maybe episode three or four, something like that. And although I know people often binge a lot of episodes when they find the podcast, with over a hundred episodes at this point, it's hard to listen to all of them and keep up with new episodes. Also, some podcast players don't even go back that far, so you can't even get to those early episodes without going directly to my website and looking for them. Also, some topics just need to be updated as time goes on. So from time to time, I'll be revisiting and updating some of the earlier episodes, especially on those really important topics like this one.

Nicole: So today I am revisiting and updating how to choose a hospital to give birth, including information on how COVID may affect that. Now, before we get into the episode, let's do a quick listener shout out. The title of the review is fantastic and it is from U S fan and the review says this podcast is a perfect mix of stories and medical information that all work to empower you to understand the process of birth, your options, how to navigate the process and how to feel competent making birth choices. Well, thank you. Thank you. U S fan for that lovely kind of review. Of course, that is at my heart and at my core of my service is ensuring that folks are calm, confident, and empowered to have that beautiful pregnancy and birth. So I appreciate you taking the time to leave that lovely review.

Nicole: All right. So let's talk about how to choose the right hospital to give birth. Now, I feel very qualified to talk about this subject because one, I have now been in brag bus- this is my 15th year. I finished residency training 15 years ago. And if you include my residency, that's four years and it's 19 since I've graduated from medical school. So I have a lot of experience in this topic, not to mention that I have delivered babies at six different hospitals during my career. So I've had a wide range of seeing different, um, birth, uh, settings during my career. So of course, I feel very competent again, to talk about this topic, but even more than that data actually shows that the hospital where you give birth has a huge influence on your birth experience. Things like if the hospital has the high cesarean birth rate that can increase your chances of having a cesarean birth independent of your doctor's individual cesarean birth rate.

Nicole: So it's really important that you choose a good setting where you give birth. Okay. And I will also say that I know that this matters just based on people's lived experiences and the stories folks tell me the stories, folks, you know, DM or email about their experience at a specific hospital. So again, I'm saying all that to say it's really, really important that you pay attention to the hospital where you give birth. Now, one of the reasons that this is important and why the hospital itself has a big influence, not even, I don't want to say more so than your doctor, because they both have a huge influence. As a matter of fact, how your doctor approaches birth and how the hospital approaches birth, those are the two things that will be most influential in your birth. But during your birth, your doctor actually isn't there for most of your labor.

Nicole: They typically come maybe in the beginning, check on you two or three times during your labor, maybe less, and then they are there for the delivery. So it's a really the hospital staff, specifically your labor nurse, who is with you during most of your labor. And that is why the culture of the hospital and how the hospital approaches birth plays such a significant role in your labor and delivery experience. So again, you want to be certain you're in a place that supports you and your vision for your birth. So when you're choosing a hospital to give birth, the first thing you want to do, and this is going to sound like, wait, what, is check with your doctor? Okay, you need to check with your doctor and see what hospitals that they actually deliver at most. OB GYN only have privileges at one or two hospitals, typically where they, um, are able to do deliveries.

Nicole: They're not going to have privileges at all of the hospitals in the area. That's too much to maintain and be going back and forth between different hospitals. So it's usually one hospital or two where they may go. Okay, so you want to first, if you don't have an idea of where you want to have your baby, then starting with where your doctor delivers is a great place to start and then check out that hospital or on the flip side, if you know exactly where you want to give birth, and you need to confirm whether or not your doctor gives birth there. So definitely check or attends deliveries there, I should say. So check with your doctor, for sure. Also know that if you're in a big group practice, it may be that the group says that they deliver at all of the hospitals or many hospitals in the area, but usually what happens is that it's certain doctors in the group go to one hospital.

Nicole: So like three or four doctors may go to one hospital, three or four may go to another hospital, three or four to another. And you have to see if your doctor goes to the hospital where you want to go. It may be the case that your own doctor doesn't typically deliver at the hospital where you want to give birth, but because their practice does, you can still give birth in that hospital. You're just going to have whatever doctor happens to be on call. And it's not going to be likely that it's someone that you've met before. That is something that, you know, happens as part of being in group practices. I talk about it in the episode on prenatal care models that I did a few weeks back, but just know that that is a possibility as well. All right, next thing you want to do is you want to check with your insurance company.

Nicole: You may be surprised to hear that your insurance might only cover births at certain hospitals in your area. I've seen it happen many, many times, unfortunately, that a woman doesn't realize this until she's well into her pregnancy. Okay? Some of the common ways that this shows up is that if you're employed by a large healthcare organization in the area, they're really going to want you to deliver at hospitals affiliated with that organization, or if your spouse is employed by that health care organization and you're on that insurance. Okay. And it doesn't mean you have to be a healthcare worker itself. You can just work for the organization. So say for example, you do, you know, IT related to the hospital then, and your insurance is through the hospital. Then you may have to give birth at that hospital. So do check with your insurance early on to see what hospitals are covered.

Nicole: It's also really confusing because the insurance may cover if you have an emergency visit at a different hospital. So say for example, you, you know, have something happen and you stop at hospital a and get seen, and the bill gets covered. It doesn't necessarily mean that they will cover the birth at hospital a okay. It may mean that for the actual birth, they want you to give birth at hospital B. So do check and ask specifically, where are the hospitals that you will cover me giving birth? All right. Now, once you have an idea of where your doctor is going to practice or the options there, or an idea of what your insurance will cover, then it's a good time to check out procedure rates at the hospital. And specifically, I'm talking about episiotomy rates and cesarean birth rates, okay? Knowing these numbers can give you an idea of if you're at an increased risk of having them happen to you.

Nicole: Because again, even if your individual doctor has a low episiotomy rate and cesarean birth rate, just being in a facility to has higher numbers can increase your chances of those things happening. And part of that may be because like, especially with our system these days, you may get whatever doctors on call and not necessarily the doctor you were seeing for prenatal care, all of those kinds of things. Now, a website that reports public data is something called leapfrog. And the website is ratings.leapfroggroup.org. And we will link that in the show notes, of course, but the leapfrog group, and this is taken directly from their website as a nonprofit watchdog organization that serves as a voice for healthcare consumers and purchasers using their collective influence to foster positive change in us health care. The leapfrog hospital survey is a free annual survey that assesses hospital performance on national measures of safety, quality, and efficiency of both inpatient and outpatient care.

Nicole: The survey covers a broad range of hospital processes, outcomes, instructors in many clinical areas, including maternity care. Okay? So you can go to this website ratings.leapfroggroup.org, and you can look up the hospital cesarean birth rate. Now you have to be careful with the data because there are a few caveats to it. One is that the data can be inaccurate. Sometimes it's outdated. Our hospital recently had to submit to get our data updated because it was inaccurate, it was old. Also the survey is yearly. So it's gonna be, you know, a year behind in terms of the reporting potentially before the data's updated. And then also it's optional to participate. So it's not something that has to be done, but it is still a good place to start. All right? And they reported a number of factors related again, to all different areas in the hospital.

Nicole: And specifically in maternity care, they report on cesarean sections. And they define that as first time mothers giving birth to a single baby at full term in the head down position, delivering their babies through a C-section. Hospitals should have a C-section rate of 23.9% or less. I have no idea why it's 23.9 exactly, but 23.9% or less. And then episiotomies they define that as mothers having an incision made in the perineum during childbirth. Hospitals should have an episiotomy rate of 5% or less. So you can go to that site, look up the numbers and see what is available for the hospitals. Again, remembering those caveats that I talked about, but this gives you a good place to start. If the numbers that are reported are really high, then, um, you know, that may be potentially cause for concern. Or if the hospital doesn't participate, then maybe it gives you some pause to think like, why don't they participate?

Nicole: Did they not want to report those numbers? Now J Co the joint commission, that's the organization that credentials hospitals, they will start reporting whether hospitals are higher than that cesarean ideal cesarean birth rate of 23.9%. I don't think it's quite publicly easy to access quite yet, but J Co will be reporting that data on whether or not a hospital is higher than that rate. So you can look for that as well. Okay. Next thing I want to talk about is, do you want an unmedicated birth and unmedicated often referred to as natural? I say unmedicated because all birth is actually natural. So if you want an unmedicated birth then you definitely want to do your homework about the hospital, because you really want to be in a place that is comfortable with supporting women who have unmedicated birth. So you can both ask your doctor and you can also just call up to the hospital labor and delivery unit.

Nicole: You can speak with one of the nurses. You can speak with the manager of labor and delivery. You can also check the hospital website for some of this information as well. You want to ask, what do you do to support women who want an unmedicated birth? Uh, am I going to be able to move around? Do you have intermittent monitoring? What about wireless monitoring? What about tubs or showers to support hydrotherapy? Okay. You can ask what equipment they have to help support women who want an unmedicated birth, like birthing balls or birthing bars. Do they have birthing stools? Not a lot of places have birthing stools. I will say that most places have birthing balls or birthing bars. And then just to kind of get an idea of how many women there have an unmedicated birth, you can just ask what percentage of women give birth there without medication or the flip side. What percentage of women give birth there and receive an epidural. On average, about 70% of birthing people will have an epidural during labor. Um, but you can ask the hospital and get an, a more accurate number. And you can just get a feel for, like, when you talk to someone, like, how do they feel? How does the doctor feel about supporting a unmedicated birth at the hospital? When you talk to the nurse? Are they like optimistic? Oh yeah, we do this all the time. Yeah. We're really comfortable with that. Are they like, well, yeah, we have like, you know, one room with a tub and not sounding very enthusiastic about it. That can give you some clues. And if you get the sense that the hospital is not particularly supportive of unmedicated birth, then you may want to consider even looking for another hospital.

Nicole: If you have options around you that are more supportive of unmedicated birth, even if it's a little bit further from your home, you know, driving within an hour is certainly reasonable in order to find the hospital. That's a supportive environment, but if you can't go to another hospital, if you don't have that option available to you, then do be prepared to have your own strong support system for an unmedicated birth. Uh, right. That may include, you've decided to read books. You've decided to take a specific class. Uh, you maybe bring your own birthing ball, definitely consider hiring a doula. Um, those are all really important things that you want to do. If you want to have an unmedicated birth and you believe you're in an environment where the hospital may not be supportive. I mean, those are all great things, period, but they'll be extra important if the hospital isn't known to be great for folks who have an unmedicated birth, okay. Now, next thing you want to do when you're thinking about where you want to give birth is ask other folks in your community. Ideally, you want to ask some other moms who've given birth within the last year or two, what their experience was like. And you should ideally ask more than one because you know, one is just not enough to get a good sense. Folks can sometimes have a bad experience and it may just be a fluke. Maybe, you know, they got the bad nurse, that kind of thing. You really want to ask, like two or three folks, if you can, in your community about what their experience was like giving birth at specific hospitals. And a really great resource is to ask doulas in the area about the specific hospitals, doulas have the unique advantage that they often see hospitals in different, different hospitals in different, um, in the city.

Nicole: Okay. So, whereas I, for instance, I have privileges at one hospital in the area. I used to work at another hospital in the area, but I only have privileges at one. And there are, um, two or three other hospitals in the area where you can give birth that I don't know anything about because I haven't been, however, a doula can go and be at different hospitals. And they may be able to give a lot of insight in terms of what it's like at different hospitals in the area. They may charge you for a consult visit for some of that information, but they may not. So it's worthwhile looking at doulas in your community, calling, asking about that information. Okay. Speaking of asking, next thing you want to find out is about the COVID visitation policy. What is the policy for visitation during COVID? Some hospitals are only allowing just one visitor, some hospitals are permitting one visitor plus a doula or one or even two visitors.

Nicole: If even if the second person is not a doula, okay. Often there is no switching out though. Like you can't have people coming in and out. It's that one person, the whole visit. Now, although folks are getting vaccinated and things will definitely get better. I don't think that for the perceivable future, there will be a huge change in the visitation policy. It certainly will not be the case that, you know, five people can be in the delivery room, that those days are going to be gone for a while, until we have a much better firmer solid hold on, controlling COVID. But especially if you want to have a doula or maybe you want to have your mom and your sister there to support you during your birth, definitely ask about the COVID visitation policy at the hospital. Now keep in mind that that may change, right?

Nicole: Because it changed like 50, 11 times during the course of, of COVID. So you may have to ask and then ask again, it may get better. If the rates in the community get better, um, it may become more restrictive if the rates in the community go up. So ask, ask again closer to your birth, but do know that visitation policy, as it relates specifically to COVID. Now I used to tell folks to ask, does the hospital support rooming in like keeping your baby in your room or does the hospital have a nursery? But these days with COVID, most often babies are staying in the room with mom. All right. They're not putting babies in the nursery together. And your baby should be with you during your hospital stay exams, procedures. All of those things can be done right in your room with the pediatrician. Okay.

Nicole: But sometimes if you're tired, sometimes if you've had a long labor, a long birth, then you want to have the option to send the baby to the nursery. And honestly that may not be possible because either there's no nursery there or because of COVID, they're not doing the nursery. So you may want to ask like, you know, what are the options for the baby after the baby is born related to COVID as well? None, none of this is like a deal breaker. All right. But it is nice to know like, Hey, can I have one visitor? Or like, what are you going to do to help me? If I'm having a long birth, will you watch the baby? Those kinds of things. All right, next up is a question to ask If you are really, really certain that you want an epidural, all right. There are some folks out there and no shame, no judgment who are like, I want an epidural.

Nicole: And I want to like before the first contraction starts, all right. So if that is you and again, no shame, judgment. Then I want you to listen to this. You need to ask about the availability of an anesthesia provider. In some hospitals, that anesthesiology is an anesthesiologist rather is not in the hospital, 24 seven. That means if it's the middle of the night, you will probably have to wait for someone to come in to place the epidural, like during more daytime hours. Okay. An epidural is considered an elective procedure. It's not something that is medically necessary. So you may have to wait for the anesthesiologist to come in. Also sometimes anesthesiologists have other responsibilities, like caring for trauma patients, ICU patients, and sick patients who need care will always take precedence over an epidural placement. Because again, it's elective now because of that, if there's the possibility like yeah no, we don't have anesthesiologists in the hospital.

Nicole: And usually we do like IV pain medication, things like that. You really want to be sure you have some techniques for coping with pain before you get the epidural. So whether that's breathing techniques, movement, massage, um, you can ask if there's nitrous oxide available, most hospitals will have IV pain medication available, but you definitely want to be certain so that you're prepared to know ahead of time that you can manage for a bit until the anesthesiologist can come. Now, I have put a whole new lesson in the Birth Preparation Course on managing pain without medication and includes a beautiful downloadable guide. That was one of the updates that I was really proud of of the course. You can check out all the details of the completely updated Birth Preparation Course at drnicolerankins.com/enroll. All right, now the next three situations are, if you have like certain things that you want to do, then you need to ask about these situations.

Nicole: So let me just go through them. Number one, is, are you thinking about a VBAC and more appropriately, a TOLAC T O L A C is trial of labor after cesarean. So if you had a previous cesarean and you want to have a vaginal birth, it's not actually a VBAC until the vaginal birth happens. So during the course of labor, it's a trial of labor after cesarean. And if that trial of labor is successful, then it's a vaginal birth after cesarean or VBAC. And I say that because we will often say, Oh, you want to TOLAC we don't say, Oh, you want VBAC. Okay. All right. So not all hospitals support VBAC/TOLAC okay. It can often be challenging in smaller communities. This usually relates to the anesthesiologist not being in the hospital 24 seven, because of some recommendations that the hospital needs to be equipped to do an emergency cesarean section within a certain amount of time for folks that are trying for a TOLAC.

Nicole: Okay. So that means anesthesia has to be in the hospital. And if they are not there 24 seven, and that can be because of finances. If it's a smaller hospital, they don't have a lot of deliveries. It's expensive to have an anesthesiologist stay in the hospital, then they may not support VBAC. Okay. So if it is something that you are strongly considering, you definitely want to ask about this early in your pregnancy and do check with the hospital as well as your doctor, because not only are there hospitals that don't support VBAC, some doctors don't either, and unfortunately you may have to travel some distance to find a hospital that supports VBAC. A great resource for those who want to do VBAC is something called VBAC Link. And I had Julian, Megan from VBAC link on my podcast a little while ago. I can't remember the number.

Nicole: I'll link it in the show notes. They also have a great Instagram page. So VBAC Link. So if you're thinking about TOLAC VBAC, 100% ask if the hospital where you plan to give birth supports it. All right, next up. Is, are you interested in getting a sterilization procedure, AKA getting your tubes tied? Well, I will say that in general, we're doing fewer post-partum tubal ligations so BTLs bilateral tubal ligation. So what used to happen is after a vaginal birth, because the uterus is still big, it's shrunk down to about the level of your belly button. All right. So we would do a little surgery where we make an incision right underneath your belly button, because the uterus is big. We can move around, find the tubes, take out a little piece of the tube, and then that's a tubal ligation. Okay. However, those aren't being done for a couple of reasons as much anymore.

Nicole: One is that I shouldn't say it's like an inconvenience, but it's, it's something that's like an add on procedure. So to speak, it's considered elective. So a lot of doctors are just choosing not to do it instead opting to do a laparoscopic sterilization six weeks after birth. The other reason is that there is very good evidence that we should not just remove a segment of the tube. We should actually take out the entire fallopian tube because that will decrease your risk of ovarian cancer. Actually it works. There's very good data to show that that, that, that happens. And it's harder to take out your tube with that little incision in that postpartum tubal ligation. So, um, I said all that to say that for a vaginal birth, it may not happen as much. I'm more specifically talking about if you want to get your tubes tied and you know, you're having a planned cesarean birth.

Nicole: Okay. Because in that instance, for lack of a better way to put it, you're like wide open. So, uh, it doesn't add much to get your tubes tied if you're interested or tubes removed, if you're interested in sterilization. Okay. However, most Catholic hospitals only permit sterilization in very, very rare circumstances where it's a threat to the mother's health in order for her to get pregnant in the future. And you typically have to petition for an exemption for that. So if you're planning on having a repeat cesarean birth and you want to get a sterilization procedure, then be sure that you're not going to a Catholic hospital because you will not be able to get it done there. All right. And side note, if you are having a cesarean birth and you're planning to get your tubes tied or get a sterilization procedure, actually asked to have your whole tube removed, that again, will decrease your risk of ovarian cancer in the future.

Nicole: The theory is there's some thought that maybe ovarian cancer is actually something that starts in the fallopian tubes. It's not exactly clear why it helps, but it does. Now um, I will say that if you get your tubes removed, then that makes it impossible to get what's called a tubal reversal. Uh, right now you should never get a steer a sterilization procedure. If you plan to have a reversed in the future, you should consider a sterilization procedure, permanent. However, some folks do have regrets and they decide that they want to get a tubal reversal, which is essentially like sewing the tubes back together. Not a lot of doctors do that, but if you have your hole tube removed, do know that that takes the possibility of a tubal reversal completely off of the table. But again, you should not get sterilization if you think you want to have babies in the future.

Nicole: All right. And then the last situation is, are you giving birth at a teaching hospital? A teaching hospital is one where there are medical students and resident physicians. Medical students are in school getting their medical degree, their MD, which is a medical doctor or D O doctor of osteopathic medicine. They are functionally the same. Resident physicians are doctors in training. So they've graduated from medical school, but they are learning to be OB GYN. Now I get it. It can be unsettling to have learners in your birth. Nobody wants to feel like a guinea pig, but they can also be very, very rewarding. Medical students can be so enthusiastic about being a part of birth and it can make you feel good to know that you've played a part to help doctors in training. Now know that whenever there's a place where there are medical students or resident physicians understand that there's always an attending physician there, an attending physician is one who has completed residency and is able to practice independently on their own by the rules and regulations of medical schools and residencies for OB GYN.

Nicole: Specifically, an attending physician always has to be in the hospital, always actually has to be present at every single birth. All right, so they're not just running around all willy-nilly, that'll help you understand how medical students and residents may be involved in your birth. I've created a free download of questions you can ask. So go to drnicolerankins.com/med-students. I will link that of course, in the show notes. All right. Now, once you have settled on the hospital, you've done your research, you've taken into account your unique circumstances. Please take a tour. Of course, these days is going to be virtually, where are you going to have to look online. But most hospitals I think are many have converted to doing like videos and things like that. So it's not quite the same, but it still gives you an idea of what the facilities look like and will also help you understand exactly where to go when it's time.

Nicole: Some hospitals are now even offering like Zoom Q and A sessions or webinars sessions type thing where you can hop on one and talk to a nurse on labor and delivery, ask your questions about labor and delivery. So look for those things at the hospitals that you're considering. Alright. So that is it. Just to recap, when you're thinking about a hospital where to give birth, check with your doctor, check with your insurance company, check those procedure numbers. Leapfrog is a reasonable place to start. I'll link that in the show notes. Ask a few moms, ask doulas in the community, ask those more concrete, specific questions if you want an unmedicated birth, ask about the visitation policy, as it relates to COVID, if you really, really want that epidural, make sure it's available for you or understand what your options are. And then if you're considering a VBAC or vaginal birth after cesarean, if you want to get a sterilization procedure, or if you are giving birth in a place with medical students or residents, then ask those specific additional questions as well, alright, so there you have it.

Nicole: Do me a solid and subscribe to the podcast in Apple Podcast or wherever you're listening to this right now, whether it's Google Play, Spotify, any place that you can get podcasts. And I so love it when you leave those reviews in Apple Podcast in particular, I just love hearing your thoughts about the show and it helps other women to find the show. It helps the show grow, uh, recently crossed half a million downloads. As I said I'm actually close to 520,000 now I believe. And I so appreciate you all's support in that. And a big part of that is those reviews. So do leave that honest review. If you don't mind, I really, really appreciate it. Also, one more resource for you. Um, in addition to understanding the hospital, I have some questions in my free online class on how to make a birth plan to help you understand that other factor, how your provider approaches birth. This online class is great. It's about an hour. It's called How To Make A Birth Plan That Works, again totally free. You can register for the class at drnicolerankins.com/birth-plan. Lovely class folks really, really love it. Packed with information, do check that out. Because again, in addition to the hospital, you need to understand your, how your provider approaches birth as well. That free class will help you do it. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth.

Nicole: Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast, head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.