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What Do You Get for Your Money

On another blog, there is a discussion about why midwives charge so much... how can they possibly justify the $2500 they charge for a birth. (In my practice and location, the average is more like $4000.) The implication is that midwives make far more than a doctor does for a birth - with barely a whiff of the education.

Reading the comments, women have defended the cost mostly with speaking about the time a midwife spends with her clients... how midwives drive all over hell and tarnation... how long prenatals are... things like that.

Because I am not commenting on that blog, I thought I would share what exactly one gets for the $4000 when they come to me and my practice. Time is but a small part of the entire picture. Some things, of course, overlap with physicians... other things, however, do not come out of a physician's direct pay from a client. They do directly come out of the money paid to a midwife.

- a clean and well-maintained office
- a receptionist that answers the phones
- linens provided by a professional service
- medications including pitocin, methergine, Vitamin K, erythromycin, antibiotics, IV equipment and fluids, syringes, needles, suture equipment, clamps, instruments, doppler, nitrazine paper, urine dip sticks, toilet paper, bottled water, drapes, speculums, gel, bandaids, cotton balls, oxygen... you get the picture. Anything that goes in or on a client is provided by me - the midwife.
- Electricity to keep the office cool/warm year 'round
- Costs of making and maintaining charts including paper, copy machines, toner, etc.
- Office supplies that assist in client care including pens, pencils, appointment books, highlighters, notepads, etc.
- cost of pager and cell phone
- Gas to drive the 60,000 miles a year to tend to women around the county and beyond
- Tires, oil, insurance and upkeep of the vehicle I drive that carries the $10,000 worth of equipment I own and use for births
- Food to eat on the road going to and from client's homes
- CEUs, on-going education and learning via the Internet, journals, midwifery magazines, etc.
- Conferences where to obtain said education and CEUs
- Books
- $500 to an assistant at the birth

I'm sure I am missing a slew of things a midwife provides that comes out of the midwifery fee, but reading what I wrote above, I think it offers a pretty good idea of what is spent to maintain a midwifery practice. Most midwives don't have out-of-home offices, but it still costs money to maintain an in-home office.

Moving to the time issues, it's important to note that midwives do everything from beginning to end and inbetween. We take blood pressures, do phlebotomy, client education, schedule appointments, do follow-up phone calls, chat with the lab, chats with radiologists, email with each of my clients (I have at least 6 emails a day with clients alone - not to mention the emails with my apprentice, other midwives and other professionals - all with regards to my current practice), make charts, copy papers, pull and re-file charts - ALL of those things physicians simply do not do because they have a staff that does those menial things for them. The cost of hiring staff to do these things and to maintain an office are spread between as many doctors as are in the practice... in my area, averaging about 6-12 docs. In my world, it is the midwife's sole responsibility, so we do it - but it does take time.

A prenatal visit is about 60 minutes long. Home visits (at 37 weeks, one day postpartum, three days postpartum [where the Newborn Screen is completed] and sometimes two weeks postpartum) are at least 2 hours long. I average 13 prenatal visits with clients, then the home visit, the two postpartum visits and two more postpartum office visits before formal care ends.

I answer all my own phone calls. There is no one to take call for me. I answer at least 2 middle of the night calls every single night. I can't imagine any physician tolerating such intimacy.

Many midwives do not have malpractice insurance to spend money on (it isn't an option for many of us), but some states require it so add that to the mix, too. Doctors, of course, have exhorbitant malpractice insurance bills, but more and more docs are going bare (without insurance) to compensate for having to contend with the cost and liability of carrying malpractice insurance.

The median salary for an obstetrician-gynecologist is $220,000. A midwife taking 4 clients a month for 10 months out of the year - taking in $2000 a birth (unlikely!!!) - would make $80,000. HARDLY $220,000 a year. How anyone could say midwives make more than physicians is beyond me. One quiet site on the web states many OB-GYNs make $200 AN HOUR. Yeah, midwives certainly make more than that, don't they? snort

I've worked in an OB-GYN group's office. It isn't unusual to see upwards of 30 patients a day - per doc. 70 births a month - PER OB. 30 GYN surgeries.

The busiest midwives I have ever known to be paid saw about 6-7 births a month. The average in my world is 4 births a month - and hardly anyone gets 4 births month after month after month.

All we really need to do is look at what midwives and doctors drive. That alone answers the question of who makes more money.

Should doctors make more money than a midwife? Of course! Hell, their education is infinitely more dramatic and their skills far more complex than a midwife's basic knowledge of normal birth. But that wasn't the issue. The issue was why do midwives charge so much?

As a midwife, monitrice or doula I have been paid in full probably a dozen times in 23+ years and over 850 births. I have traded services (web design/upkeep, moving my household goods, housecleaning, etc.) and have received beautiful gifts of organic vegetables for a summer, pieces of art, fruit from the orchard and other similar benefits of being able to barter. Never in my life can I imagine a doctor remotely entertaining the idea of trading services for babysitting. A car, maybe. But fruit from the migrant camp? Not so much.

One of my standard lines is to not allow price determine where you have your baby or who your care provider is. There is always a way to work out having a homebirth if money is an issue. I have women paying $20 a month more than three years after their babies were born. (Most women who set up payments actually quit paying anything once the baby arrives. Priorities change. And it isn't too likely that a midwife is going to hire a strong-arm service to force the client into paying. I believe women will pay if they can. If they can't, I will be paid in some other way - not always monetarily.)

It is also important to note that I do bill insurance companies and am paid fairly well that way. We bill globally unless a woman transfers care and delivers in the hospital or with another midwife, then we bill appointment by appointment.

Because I own the practice, I ask the client for their deductible and their co-pays, due before 37 weeks. We bill globally once the baby is 6-weeks old.

When midwives do not want to just take the deductible and co-pays, but instead choose to have the money up front from the client and then bill insurance globally, the law states that the client will be reimbursed up to the amount they have paid. Any extra would go to the practice. That has, by the way, never happened.

We use a billing specialist and the rate of return on insurance billing increased 30% over when the apprentice midwives were doing it themselves. (It was the first thing I dumped when I bought the practice - no billing crap for me!)

Many midwives charge the client and then will give them an itemized list of services received so the client can bill their own insurance and handle the headache themselves.

Sometimes, I don't know what would be easier on my nerves. Insurance issues are certainly just as frustrating for docs as they are for midwives.

A complex topic... much more complex than the other blog makes it sound. It's good for me to put it down on paper, though. A great piece of information if a client ever asks, "Where does all that money go to?"

Let me show you.

References (9)

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    - Navelgazing Midwife Blog - What Do You Get for Your Money
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Reader Comments (15)

Very enlightening. You are worth every penny!

So, where do the doctor's costs come from?

August 13, 2006 | Unregistered Commenterwanderglow

I think part of the misperception comes from the fact most folks have insurance, and yet that insurance alost always will not pay for midwifery care....and care seems so "affordable" with insurance, or perhaps, we've paid so much already, we'll go with "the plan"...

Had I been able to use a homebirth midwife, I would have paid $4000 out of pocket, the out of pocket costs for my hospital birth and all associated prenatal care was a total of $75.00 ($25 for the big university hospital, $25 for all services provided by my OB/Hospital team, and $25 for a dietician referral for GD..

So my 2nd cost us $75 out of pocket, my first cost us around $650, excluding doula/montrice fees...a $15 co-pay for each appointment, a $250 hospital fee, and a 2nd $250 for my emergency care....

If you look at it purely on economic basis, it's far cheeper to use a hospital, and it just isn't easily understood why midwives seem so much more expensive...

Query: What can be done to encourage insurance companies to reinburse for midwife care, and/or for a doula or montrice?

Or is that a pipe dream that will never happen, because it threatens the OB's "bread and butter" so to speak....one would think the insurance companies would LOVE to cut their costs by over 50%, even if a substantial number need transport, the savings should more than offset the costs for those who do end up needing to transport.

dd #2's hospital got around $9000 for her birth, and around another $5000 for my complications, and that doesn't even cover the ob's fee....

August 13, 2006 | Unregistered CommenterOpening Pandora

The site you refer to is a great big load of hogwash. I can't bring myself to read the bloody thing anymore.

I would cheerfully pay my midwife whatever fee she requested of me. Why? because the services I am looking for are worth that. I'm not just paying for her education and experience but also her time and her passion. Something that many OB's have shed somewhere along the way...

It's so insulting that midwives are somehow expected to have to justify their worth.

I just dug out my itemized bill from baby #1 ('02) for giggles.I kept it because it spells out where every cent of some $21,467.28 which We (and our insurance) payed for long but otherwise uncomplicated vaginal delivery with all hospital bells and whistles (I bought the hospital ticket and so went for that ride...). For the record my OB took home $3600 of that, the anesthesiologist $1500 for placing the godforsaken epidural. Right down to the $6.00 for every single, little vicodin and midol tablet I consumed every four hours for days...

Midwife = more loving care and value for money and everything else you noted.

August 13, 2006 | Unregistered CommenterLouisa

I'm not sure why insurance companies are so hesitant to pay midwives. That other doctor chick would say because we aren't safe... that it doesn't have anything to do with money, but everything to do with safety. I agree, though, that even if there were tons of transports, the money saved would be enormous.

I'm glad so many of you feel a midwife is worth it. Heck, I do, too! However, I was extremely cash poor when I was pregnant with #2 and decided at 8 months along to birth at home. I couldn't find a midwife to save my life (and was angry about it for years!) and instead chose to UC... a decision that could have killed my child. I vowed to never allow money to keep me from a woman really REALLY desiring a homebirth.

It is that desiring part that is a challenge to decipher.

August 13, 2006 | Unregistered CommenterNavelgazing Midwife

So curious about this website/blog you are referring to. Would love to read. Can you point me in the right direction. Thanks

August 13, 2006 | Unregistered CommenterAnonymous

Somebody else will have to utter the phrase/site... I won't anymore.

August 14, 2006 | Unregistered CommenterNavelgazing Midwife

I would also say that regional cost of living plays into this--
did you say long term storage of medical records?
how about other office supplies like- sheets or towels or what ever you cover your table with and cleaning- do you do your own office cleaning or do you pay someone ?
I also have astromical milage on my car brand new I had 10,000 miles in 3 months and I don't go all over the country!

August 14, 2006 | Unregistered CommenterAnonymous

pandora my second cost me $5 out of pocket in the days of good insurance- but all said and done the doc nearly killed me and left me with trauma that is "priceless" as it drove me to find a better way--
and I walked in and had the baby within 1/2 hr --

I would also say that locally the hospitals are huge water consumers and one hospital uses water as a means to heating and cooling- they put chemicals in that water "super slickers" that allows them to get 3x the use out of the water but then it is toxic waste... and this is just one way it is yucky...
insurance and physicians--what a nightmare marriage-- how many administrators ride on the back of each physician right now?

August 14, 2006 | Unregistered CommenterAnonymous

That 60,000 miles is from driving all over the COUNTY... not countRy.

My county is huge!

And yes... table paper, cleaning supplies and people to clean (staff and me do that)... forgot to add that, you are right.

August 14, 2006 | Unregistered CommenterNavelgazing Midwife

Interesting breakdown! Thanks. :) I'm greatful my DEM was cheap ($1500) as that made it so we could pay her in full both times but I certainly believe she was worth much more.

I imagine that gas prices are really affecting costs for midwives!

Michelle- aspiring midwife

August 14, 2006 | Unregistered Commenterbusybusymomma

I always wondered how you could charge so little for all you do.

August 15, 2006 | Unregistered CommenterAnonymous

We were lucky enough that Medical Assistance would pay half the cost of our midwife-attended birth. We had to come up with the other half – about $2000 – and even though we had to scrape it together in dribs and drabs from odd jobs and kind family members, it was absolutely the best money that I have ever spent on anything in my life. Not only did we get everything that you mentioned, but we got labor support, in the form of the assistant midwives, we got lactation help as long as we are breastfeeding; when my nine-month old stopped nursing mysteriously, my midwife was the person I called. We got a fantastic community of other mothers through the midwife-run e-mail lists, drop in mother’s groups, and reunion picnics in our community, and most importantly, we got a safe place to grow and birth and bond with our baby without having to constantly be scared that we were going to be attacked or forced into some kind of violent intervention we didn’t want. People who think that isn’t worth $2000 – or $4000, or any amount of money seriously need to sort out their priorities.

August 15, 2006 | Unregistered CommenterAnonymous

You are an amazing writer. Enlightened, honest, raw. You inspire me! I found you via my midwife's website and I'm hooked.
Keep up your quest for truth and conscious, vibrant living.

August 16, 2006 | Unregistered CommenterLeigh

I can't even imagine complaining about $3000 spent for my midwife vs. the untold dollars that would've been spent with an OB to be brushed off by him at each appointment. The truth is that the time I spend sitting in her office babbling to her and her assistant about my every worry and concern which they take seriously, listen to, and answer to the best of their knowledge... that is PRICELESS!!!! Vs a birth center nearby where prenatal appts are limited to 15 minutes a piece!

And I must really be doubly, triply blessed, because my insurance is going to cover the birth.

Thank you for all that you do!

August 18, 2006 | Unregistered CommenterAnonymous

Very interesting. Here in PA my midwife was covered by medical assistance(I was so thrilled with that!) Unfortunately they refused to pay for anything if I wanted a homebirth. It would have been $3 000, all at once(no payment plan). There was no way I could do that. What you are saying is that basically insurance companies pay separately for many things that come directly out of a midwife's salary, correct? And that physicians share many costs with the other doctors there. I think it would have cost the insurance company so much more had I been with a regular ob for my last two births-the cost of all the equipment they (unnecesarily) use, the drugs and procedures they try to force on you. (heck even the testing during the pregnancy that they told me was mandatory. Testing I skipped with my midwife births-those tests cost money and were unnec. for me) Though I do have to say, since I wasn't a first time Mom my prenatal visits with the midwives were rushed. Not as cozy and friendly as I would have liked-I like the picture you paint in your blog of how much time you spend with your clients-visits, phone calls and emails. It's nice to know that that does exist.

August 21, 2006 | Unregistered Commentersajmom

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