I wanted to write an article about the costs of midwifery care because it is something that we get many questions about from potential clients. Specifically, people who come late to care wonder why most midwives don’t offer a discounted rate–after all, these clients take less of our time–shouldn’t they just pay for the time we spend with them?
Well, maternity care, whether it happens with a homebirth midwife, hospital-based CNM, or OB/GYN, is provided at what’s called a “global rate.” That is one rate for the complete package of care. I couldn’t really tell you when this practice began, but it is very different from other medical services. For instance, the anesthesiologist at my son’s surgery billed for 206 minutes–pretty precise! But, as we know, birth isn’t so precise, nor does it really seem fair for those people who have long, slow labors to pay more than those who have what we call “butter-births”–smooth and easy. Indeed, I’ve often thought if anyone should inquire about discounts it should be those easy birthers!
In Colorado, the typical midwife charges somewhere between $2500-4500 for the midwifery care package–the difference is generally due to locality and practice volume. Let’s use $3000 as a typical rate. This includes approximately 11-12 prenatal visits, the labor/delivery, a birth assistant, and 4 postpartum visits in many practices. If you break each of those prenatal/postpartum visits down to an hour each, a client coming into care as late as the 6th month would only have not utilized 3-4 prenatal visits–only saving about 3-4 hours of clinic time for the midwife. On the other hand, most of those 3-4 hours are recouped by spending more time together in visits so that you can get to know one another better in a shorter time, requesting (and hunting down) previous records, entering those records into the new chart, etc. Those 3-4 hours are easily reinvested.
Additionally, there are many costs that are not apparent in terms of “woman-power.” Our practice provides the vast majority of the disposable supplies. There is equipment to be purchased, maintained, and replaced. I drive quite a lot–incurring both fuel and car maintenance expenses. And then we have a great deal of certification/licensure/professional association fees to pay. In Colorado, midwives paid between $958-1124 to renew their registrations this year. Compare this to Colorado nurses who pay little more than $100 for a two-year renewal. We have to keep several certifications current, and there are continuing education costs associated with that (and, really, you WANT a midwife who invests in her education). Some midwives rent office space, and those who have home offices may still have furnishing costs or even need a larger home to accommodate their practice. Some midwives include fees like labs and waterbirth supplies (though our practice does not). Some midwives have childcare expenses, and some need additional support people from accountants to house cleaners depending on their own needs and skills. For me, pizza for the kids on the night of a birth is nearly inevitable. In short, it’s expensive to be a midwife! And on those occasions that clients don’t pay (including discounts for family and friends), midwives are left footing many of these expenses on their own.
And, while homebirth midwifery care is seeing some progress in terms of third-party reimbursement, it is far from the norm. Unlike doctors’ offices, we just don’t have the volume to wait for the uncertain reimbursement from insurance companies–many of whom refuse to consider homebirth coverage at all. That’s why midwives (all that I know of, anyway) require payment before the birth. And, don’t forget, that many insurance plans have significant co-pays, deductibles, and co-insurance. For example, by the time you pay $25/office visit, a $500 deductible, and 20% of hospital costs (not to mention costs that you might want to incur if you were planning a hospital birth like a doula and lactation consultant), you may very well be looking at $3000 out of pocket with complete insurance coverage.
No midwife is in this profession for the money. The rewards of our amazing career are intangible, non-monetary, but real nonetheless. That being said, we still need to make a living–your fee is our salary! I hope this clarifies that sticky money issue and sheds some light on how and why we do business like we do.