Kimberly Spencer, CPM

Frequently Asked Questions

Midwives and home birth
About our practice
Financial information
Prenatal care
Labor and birth
Water birth
Postpartum care
Newborn care

Midwives and home birth

What is a midwife?
A midwife is a professional health care provider who is trained to care for healthy women during pregnancy, labor, and the postpartum period, and to care for the newly born infant. A midwife focuses on the natural processes of pregnancy and birth while recognizing the warning signs of potential complications that require medical intervention.

How is a midwife different from a doctor?
Midwives are trained as experts in normal pregnancy and birth, including recognizing when a situation is not normal and referring the client to a physician for evaluation or treatment. They provide care only to women with low risk pregnancies, normal labors, and healthy babies. Physicians are trained in the prevention and treatment of disease and often view pregnancy and birth as a potential complication that requires routine medical intervention to proceed safely. Midwives are safe and qualified care givers for healthy pregnant women whereas physicians are the appropriate care givers for women with high-risk pregnancies.

What is a CPM (certified professional midwife)?
A certified professional midwife is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care.

What is a CNM (certified nurse midwife)?
A certified nurse midwife (CNM) is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse Midwives.

Why are there different types of midwives
All midwives are typically adherents to the Midwives Model of Care, though there are different routes of midwifery education and different credentials. A certified nurse midwife (CNM) begins her career as a nurse then receives further training in midwifery through a special nursing program. This training is different from that of a direct entry midwife (DEM), who enters directly into her career as a midwife through a midwife training program rather than as a part of nursing education. By definition, a CPM is a direct-entry midwife. The term “lay midwife” refers to someone who is practicing midwifery and has no credentials; she may or may not have any training or education.

Why choose home birth?
A hospital is a facility where sick or injured people go to receive medical treatment. Because birth is a normal, natural event, there is no need for women with healthy pregnancies carrying healthy babies to seek medical care. Many women simply feel more comfortable at home, away from the beeping machines, tethered to monitors, and undergoing mandatory medical interventions that interfere with the natural process. They welcome the opportunity to make their own decisions, wear their own clothes, eat and drink as they desire, and be surrounded by their loving families. They also do not want to expose themselves and their babies to the germs and “super bugs” that are so prevalent in hospitals. Sometimes pregnant women or the babies they are carrying are not healthy and it is a wise choice for them to delivery their babies in the hospital. However, birthing at home with trained midwives is a reasonable and satisying choice for most women.

Is home birth safe?
The largest, most solid scientific studies conducted on this subject have consistently revealed that planned home birth with trained midwives is a safe, satisfying, and cost effective option for women with low-risk pregnancies. The most recent of these studies examined the outcomes of over 5,000 home births. The study paired the outcomes of all the women who chose planned home births with CPMs in the year 2000 with a similar number of women who planned to have their babies in the hospital. The results showed that the outcomes of the births were the same in both groups as far as healthy mothers and babies, but that these safe outcomes were achieved with far fewer interventions than those women who chose to be cared for by doctors in hospitals. For example, the rate of cesarean section was only 4.3% among mothers who chose home birth compared to a rate of 30% in the hospital group. You can read the full text of the study here.

More home birth safety resources.

About our practice

Do you provide home visits?
If you live in the Nashville area we will come to your home for an initial consultation meeting. We perform a customary home visit at the end of pregnancy, and home visits during the first 2 weeks postpartum. All other visits will be provided in our office. Home visits may be requested for an additional fee. This fee varies depending on how far away you live and is not likely to be covered by insurance.

Do you have office hours?
For regular appointments we have office hours on Mondays from 12:00 pm - 8:00 pm and Tuesdays from 10:00 am - 5:00 pm, with time for make-up appointments on Thursdays. Postpartum home visits are scheduled as needed according to what day and time you give birth. If necessary, we will try to schedule initial meetings in your home at a time that works best for you and your family.

Do you have an apprentice?
We do not train novice apprentices. Our assistant, Jennifer Vines, is a professionally trained midwife's assistant and doula with years of birth experience and is an invaluable asset to our practice and your care. She is currently training to become a midwife and may provide some of your care with your permission.

Do you work with a doctor?
Midwives are autonomous care providers of complete maternity care for low-risk women, therefore it is not necessary for you to also have regular prenatal care with a physician. We have relationships with doctors in the middle Tennessee area who will consult with us and see our clients when needed. You will be asked to schedule a consultation appointment with one of the backup physicians in order to establish a relationship with them. Meeting with the doctor is not mandatory, but strongly encouraged; such a meeting is in your best interest as it ensures the best possible care for you and your baby in the event of a complication.

Do you attend water births?
Yes, and we have birth pools available for our clients at no charge. Please see the water birth section for more information.

Do you attend VBACs (vaginal birth after cesarean)?
Unfortunately, VBAC is not a service we are able to provide at this time.

Do you attend breeches or twins at home?
Tennessee practice guidelines require that a midwives consult a physician when a client is pregnant with twins or expecting a breech delivery. We do not currently have a relationship with a physician who would support these deliveries at home.

Financial information

How much do you charge?
The global fee for midwifery services is $3,500. The fee is reduced to $3,200 when paid in full before delivery (required if you do not have insurance).

What services are included in your fee?
The global fee includes routine prenatal and postpartum office visits; attendance of your labor, delivery, and immediate postpartum period; home visits during the first week postpartum; and dedicated availability 24 hours/7 days a week from your 37th week of pregnancy through 1 week postpartum.

Are there any additional fees?
Additional expenses may include lab work, travel fees for additional requested home visits, non-routine visits or procedures, and medications such as Rhogam or antibiotics. Initial lab work is $150; you may have this performed by another provider. Additional lab testing during pregnancy is determined according to each client's individual needs.

The global fee does not include any services not performed by the midwives, including physician consultation, ultrasounds, or visits to other outside providers.

Do you accept insurance?
We are not contracted as network providers with any insurance company, but we will bill your insurance for you and accept payment from any company that provides benefits for out-of-network providers. Part or all of our services are usually covered by insurance, though at a lower level than in-network providers. Clients are responsible for paying any remaining balance after insurance is applied.

A minimum deposit of $1,750 (50% of the total fee) is required to be paid before delivery when insurance is to be billed for our services. This deposit may be greater than 50% depending on the terms of your insurance plan. In the event of an over-payment, a refund will be issued minus any deductible and co-pay amounts. Additional information about insurance billing and policies is provided in our Financial Agreement (pdf document).

Blue Cross Blue Shield of Tennessee and Aetna insurance plans have official homebirth exclusions. They do provide benefits for other services, including prenatal and postpartum care and lab work. However, because it is difficult to anticipate how much reimbursement will be provided, if you are insured through one of these companies you will be asked to pay all fees in advance and receive a refund when insurance payment is received. You will be eligible for the prepayment discount, plus any additional costs of insurance filing.

Do you offer payment plans?
If you are paying out-of-pocket, the global fee is due by 36 weeks. If you have insurance, the agreed deposit amount is due by 36 weeks. Fees are usually broken up into monthly payments over the course of prenatal care but an alternate payment schedule may be agreed upon provided payment is complete by 36 weeks.

Do you offer a discount if I transfer care to you later in pregnancy?
No. Sometimes clients begin prenatal care with another provider but decide later they would prefer to have a home birth, or they may experience other circumstances that result in a transfer of care, such as re-location. We do not offer fee discounts in these situations. A fulfilling home birth experience is dependent on a trusting relationship between midwife and client, and in these situations we must work extra hard to "catch up" on lost time in addition to working extra hard in a shorter amount of time to ensure we provide you will all necessary education and information.

What is your refund policy?
If you transfer care out of our practice before labor begins, we will itemize fees for each service we performed and a refund will be issued for any amount paid in excess of the itemized charges.

Sometimes safe midwifery care means recognizing complications and transferring care to a hospital during labor. This is not a usual occurrence, but when it happens we are fulfilling our duties as midwives to ensure a safe delivery and no refund will be issued. We will accompany you to the hospital and remain with you through the birth, continuing to provide midwifery care at the highest level possible in conjunction with the care provided by hospital staff.

Detailed information about our refund policy and other financial matters is outlined in our Financial Agreement (pdf).

Prenatal care

What lab work do you perform?
The initial prenatal lab work tests your blood for information that is important for maintaing a healthy pregnancy (complete blood count, blood type and antibody screen) and tests that are required by law for all pregnant women (HIV, hepatitis B, syphilis, and rubella immunity). Screening for Down's syndrome and other genetic disorders is available if desired. Testing for vaginal infections and performing a pelvic exam and pap smear are recommended as the standard of care but may be declined or deferred. We will order a urine culture if you develop symptoms of a urinary tract infection. We can also refer you for an ultrasound if desired or indicated. Other recommended prental lab tests may include a repeat CBC for checking your iron level, gestational diabetes, antibody screens for mothers with Rh negative blood type, or a beta strep culture performed at the end of pregnancy. We will regularly check your urine for sugar, protein, or other factors in the office and may periodically suggest a finger-prick check of your iron level.

What will happen if I develop a complication during pregnancy?
Midwives focus on supporting the normal, healthy aspects of pregnancy while recognizing the development of conditions that may not be normal. If this happens we will consult a physician about the best way to maintain your health and the health of your baby. Usually this means simply collaborating with the doctor to make sure you receive the best possible care. Sometimes it means transferring the responsibility for your care to the doctor while we continue to provide midwifery care in a supportive role.

How early should I start prenatal care?
You may start care as early as you like, though there is not much we can do to assess the baby until the end of the first trimester (12 weeks). At this time we should be able to feel your uterus above your pelvic bone and hear the baby's heart beat. This doesn't mean that you shouldn't have prenatal care before 12 weeks; we can schedule our first visit earlier to provide nutrition education and counseling, answer questions about your pregnancy and midwifery care, discuss your medical and obstetric history, and perform lab work.

How often will you see me for prenatal visits?
Prenatal visits are usually conducted monthly until the third trimester (28 weeks), then every 2 weeks until a month before your due date; then weekly until your baby is born. There is an alternate acceptable prenatal schedule that advises visits take place during certain key weeks of pregnancy rather than at certain time intervals. We may follow one or the other, or a combination of the two in order to provide customized care to meet your specific needs.

What will happen during prenatal visits?
Prenatal visits are times when we assess the progress of your pregnancy and the growth and well-being of your baby. Prenatal visits generally take about an hour, and most of that time is spent on discussion, education, and counseling. During these meetings we will also perform the standard checks of your weight, blood pressure, urine, the growth and position of your baby, and listen to the baby's heart beat. We will ask a lot of questions about how you're feeling to monitor for any developing complications and provide plenty of time to address any questions you or we might have.

Labor and birth

What equipment and supplies do you bring?
You will receive a list of supplies to gather before your birth. Most of these items are things that you already have around your house, with a few that you may need to pick up at a local store. You do not need to order a special birth kit since we bring all the necessary medical supplies. In addition to routine supplies like instruments, cord clamps, and gloves, we also come prepared with equipment to manage emergencies, such as oxygen, IV fluids, and medications to stop a hemorrhage. These emergency items are very rarely needed but are always on hand "just in case".

What will happen if I develop a complication in labor?
One of the reasons that home birth is safe is because the hospital and medical care is available when needed. Before your birth we will discuss an emergency plan in case you develop a complication during labor. This plan will identify a consulting physician, the nearest hospital to go to in case of an emergency, and the preferred hospital to go to if we need a non-emergent transport. Most home birth transports are not emergencies, but situations where labor is taking an exceptionally long time, the mother is exhausted, and the baby just is not coming without additional help. In the rare event of a true sudden and unexpected emergency, we are trained and carry the proper equipment to deal with emergencies while waiting for EMTs or paramedics to arrive.

Do you provide labor support (doula services)?
One of the benefits of midwifery care is a continuous presence during your labor. We provide appropriate labor support as part of our duties as your midwives. Many times this means patiently waiting for our services to be needed, while helping your partner or other loved ones to provide the most hands-on support during your labor. Marecha Jackson and our assistant, Jennifer Vines, are trained doulas with years of experience of hands-on labor support and are an invaluable asset in this area. Marecha and Jennifer also provide private doula services if you are looking for support for your planned hospital birth.

What will happen if I tear?
Generally, perineal tears do not happen as often during home births as they do in the hospital. This is because most midwives allow you to push with your body rather than directing you, allow you to birth in positions that minimize tearing, deliver the baby's head slowly, and do not perform routine episiotomies. Most of the time, when our clients do experience a tear it is not deep enough to require stitches though we are prepared and able to suture most tears ourselves. If a tear is severe we will go to the hospital for repair. This is a very rare occurrence.

How long do you stay after the birth?
After the baby is born, we will stay with you until we are sure you and the baby are well and recovered. Generally this is a minimum of two hours but may be as long as needed. During this time we will perform a thorough newborn exam as well as constant monitoring of your bleeding and vital signs. We would like for you to have something to eat and know that you can walk to the bathroom and take a shower without assistance before we leave.

How do we get a birth certificate?
We will file your birth certificate with the state of Tennessee within 10 days after the birth.

Water birth

Is water birth safe?
Generally, yes. Babies who are born under water do not breathe until they are exposed to air. No one is sure exactly why this is; some say it is the difference in temperature that inspires the first breath while others believe is the difference in atmospheric pressure. When a client delivers a baby under the water, we gently yet quickly guide the baby into your arms above the water level. There are reports of some babies who have gotten sick from water contaminated with bacteria that is commonly harbored in whirlpool jets. For this reason it is very important that the tub or pool that you birth in has recently been sanitized. There are certain rare instances in which it is safer not to deliver the baby under water. If we have any concerns about your baby's safety we will suggest that you get out of the water to deliver. We are very experienced and comfortable with water births and do not ask you to leave the water unless we feel it is necessary.

What are the advantages of water birth?
You probably already know that laying in a tub or pool of warm water is very relaxing and can help to calm nerves and loosen tense muscles. Being submersed in a tub of warm water has the same effect on a laboring woman. Mothers who have had labors both in and out of the water report that being in the water made their labors progress faster and with less pain. Women also find it easier to move around and find comfortable positions while in the water. For these reasons, many women choose to labor in the water even if they do not wish to birth there. Other proponents claim that being born from the bag of waters into a pool of warm water makes for a gentler transition to life for the baby. Some midwives report that mothers experience less tearing and perineal trauma when birthing under water.

What is your water birth experience?
We have been attending water births for as long as we have been attending births. Over half of the home births we have attended took place in water, with even more clients who used water to ease labor before getting out to deliver.

What kind of tub do you recommend?
You can receive benefit from relaxing in any kind of tub, or even the shower. Studies show that to fully benefit from water during labor, the water level must be deep enough that your entire belly is submerged. We have attended births in every size and kind of vessel, from a small apartment bathtub to an 8-person Jacuzzi (even once in a cattle trough!). Having worked with them all, by far our favorites are the deep, oval inflatable pools such as La Bassine or Birth Pool in a Box. We have several La Bassine pools available for our clients at no charge.

Postpartum care

How often do you see me for postpartum care?
We will stay with you for a couple hours after the baby is born, as long as it takes to know that you and the baby are stable and healthy. We will also check in with you by phone later that day or the next morning. Usually we return the next day, and often again in the first week. We like to see you again in our office around 2 weeks and a final visit between 4-6 weeks. If there is a need we will see you more often.

What do you do during postpartum visits?
Postpartum visits are a time to check on your health and also to offer support for any problems you may be experience as you adjust to life with a new baby. We will perform the standard checks of your blood pressure, monitor your bleeding and recovery, help you with breastfeeding, and be available to answer any questions you have about the birth or parenting. We will also examine the newborn if he or she is not yet under the care of a pediatrician.

How long does postpartum care last?
The final postpartum visit usually takes place at 6 weeks after the birth. At this visit we will make a final check on any healing that was necessary after the birth and offer family planning information if needed. We offer a well-woman exam at this visit though we do not perform pap smears until at least 12 weeks after the birth; you may return after 12 weeks for an annual well-woman visit with pap smear.

Newborn care

What does a newborn exam consist of?
At one and five minutes after the birth we will perform cursory examinations of the baby to assess overall wellbeing - this is the Apgar assessment, or Apgar score. In the following hour we will perform a thorough newborn exam, just like the exam the baby would receive in the hospital. This exam covers all of the baby's body systems, including checking for any heart or lung anomalies, neural tube defects, skin problems, reflexes, signs of illness, general appearance, and whether or not the baby's appearances and signs match the baby's gestational age. We ask that you continue to monitor the baby closely for fever or other signs of infection in the first few days.

What newborn procedures do you perform after the birth?
By Tennessee law, newborns are required to receive antibiotic ointment in their eyes within an hour after birth. This is to prevent the baby from developing a sudden, serious infection after coming into contact with bacteria in the birth canal. We do have a waiver you can sign if you object to this treatment. We also offer vitamin K supplements, either by injection or oral drops. Vitamin K is routinely given to babies to help blood clotting. We will discuss these procedures in depth during your pregnancy. If the baby shows signs of a blood sugar problem we will check his or her blood sugar levels but we do not do this routinely. We do not provide the hepatitis B vaccine at birth. We do not perform or endorse circumcisions.

When should the baby see a pediatrician?
Generally, this decision is between you and the baby's primary care provider. If a baby is healthy (as most are), most doctors like to see the babies from anywhere between a few days to a few weeks old. We can provide well-baby care for the first 2 weeks. If we suspect the baby has any problems you will be referred to a pediatrician right away. You may want to consider using a family doctor or nurse practitioner as your baby's care provider.

Do you provide newborn metabolic screening (PKU)?
Yes, we perform the newborn metabolic screening tests. This requires a blood sample obtained by poking the baby's heel. By law, this test is supposed to be performed between 24-48 hours after the birth. You can read more about newborn screening at the Tennessee Department of Health Newborn Screening website.

Do you perform newborn hearing screening?
The state of Tennessee recommends that every baby receive a special hearing test soon after birth. If your baby were born in a hospital, he or she would receive the test before going home. Unfortunately, the test requires a special machine that home birth midwives do not have access to. You will be provided with more information about the hearing test and where to have it performed if you wish. You can also find more information at the Tennessee Department of Health Newborn Screening website.