Because it’s the right thing to do.
That ought to be the end of this post, really, but I’ve had so many interesting conversations and experiences with people lately about payment for my services that I’m starting to feel a need to clarify a few things. Let me start by saying that this post is not targeted at any particular individual, but it does consist of points I think need clarification based on my real-life experiences with real clients. My apologies if any of it sounds snarky; my intention isn’t to offend. To the other birth workers I know who think these same thoughts but don’t share them publicly for fear of being accused of being “all about money,” you’re welcome.
A week or two ago, I posted on my Facebook page a link to an article about the cost of giving birth state by state. The article didn’t cover homebirth with a CPM; it was about hospital birth costs. While the cost of a hospital delivery varies widely both by region and by how the birth goes (vaginal versus cesarean, what interventions are used, etc), there is *nowhere* that the actual cost of a hospital delivery–just the birth itself, not including prenatal or postpartum care–isn’t at least three times what most homebirth midwives (I refer to CPMs here) charge for a global fee that includes an average of 10-12 prenatal visits, labor and birth, and 6 weeks of postpartum primary care for mother and baby. (For more on what is typically included in midwifery care, see my blog post on that subject, or my fees and services page).
Midwifery care is much cheaper than OB/hospital care. Anyone who is uninsured or is part of a health share ministry can tell you that. The tricky part is that most insurance companies will not allow a CPM to be an in-network provider, and many still won’t cover our services at all. So for many people with otherwise excellent insurance coverage, homebirth with a CPM involves more out-of-pocket expense than OB care and a hospital delivery, which leads to the misconception that homebirth is expensive. It’s not; it’s a steal considering what you get for your money. It’s just not well-covered by insurance.
It’s to be expected that many prospective homebirthers are unhappy with this situation, and it is completely understandable that no one wants to pay a few thousand dollars out of pocket if they don’t have to. People whose insurance companies won’t cover the type of care provider and birth setting they would choose need to protest long and loud, change insurance companies, fight the good fight in order to have access to their full range of options. If enough people did this for long enough, more companies would change their policies in response to consumer demand.
Instead, what happens all too often is that people expect their midwife to absorb the cost in some way. I have had three situations in the last few years where a client deliberately conned me (and my then business partners). In two of the three situations, it was repeat clients who had paid for their first birth, liked our services enough to call us back the second time. The third mom was a friend of several other clients, and not someone from whom we expected difficulty with payment. All three times, these families delayed, made excuses, and then just flagrantly refused to pay for services rendered and walked off. At that point in time, my partners and I took the loss and moved on, rather than taking legal measures. We joked about repossessing the babies, wished back labor and hemorrhoids on the moms with their next births, but underneath we were shocked, hurt, angry, and struggling to juggle our family’s budgets to work around lost payment.
Fortunately, scenarios like that are rare. Most people are essentially honest and decent, and I really believe that when they haggle, ask for discounts, or delay on payments, they aren’t thinking the situation through. I don’t think they are fully considering the repercussions of their actions.
Occasionally at a consult, a family will ask me if I’d consider reducing my fee for them. Before I go into what is wrong with this, let me just say that I make an effort to help (pro bono) one or two families per year who are truly in crisis financially. I attend around 20 births per year, maximum, so that in my mind is essentially tithing, and it is all I can afford to do by way of volunteer births. In addition, because Virginia Medicaid has recently changed its policies in a way that makes coverage for CPM services extremely hard for most moms to get, I offer a discounted rate for certain moms at that income level. Outside of those two situations, I don’t offer a discount.
It’s interesting to me the situations presented when people are trying to tell me why I should reduce my fee for them: they are trying to save for a vacation (so is my family), trying to remodel their home (I’d love to be able to do that), trying to become debt-free (again, so is my family), saving so mom can stay home with the baby instead of working an outside job. I understand and sympathize with all of these situations, but I have some difficulty understanding how they are supposed to translate into my being willing to shortchange my own family. I’m willing to bet almost no one who has ever haggled with their midwife stops to think that that is exactly what they are asking.
CPMs are almost exclusively small business owners. Our practices are typically solo or very small groups. We see a small number of clients. Most of us are working because we have to help support our families, and midwifery, while it is certainly a calling and definitely has a spiritual component, is also our trade. In that respect, we are no different than a veterinarian, mechanic, contractor, or dentist. We may love our work, and we do–deeply–but there aren’t many midwives who can afford to do this job for love.
There seems to be a stigma attached to a midwife expecting to be paid fairly and promptly for her services. I wish I had a nickel for every time I’ve heard “But you do this because you love it; you’re not about the money, right?” Right before someone starts telling me why I should accept half my fee so they can put away money for a new car or vacation or their college tuition.
Recently, I was dealing with a situation where I had some pricey car repairs to pay for, and was waiting to receive payment from a client, and had to remind her repeatedly that it was due. In the meantime, I couldn’t pay to get my car fixed, because the money she owed me was what I had budgeted for car repairs! (In my line of work, it’s kind of important to have a car in reliable working order.) I joked with my assistant that people must think that midwives have a fairy godmother who waves her wand and pays all our bills for us.
PSA: we don’t.
When a client asks for a discount, fails to pay, or pays late, they are literally taking income directly away from their midwife’s family. It isn’t the same as making a late payment or asking for a reduced rate from a large hospital system where a couple of thousand dollars is barely a drop in the fiscal bucket. A thousand-dollar discount off a midwife’s fee is half her mortgage payment for a month, or a large chunk of her kids’ college tuition for a semester, or most of a year’s worth of music lessons for another child. It might be the payments on her own family’s medical bills. It might be her car repairs, her continuing education and recertification fees, or the cost of some new equipment (our stuff wears out, too!). f you ask your midwife to reduce her fee because you were hoping a homebirth in her care would cost less, realize that you are asking her to give up or find an alternate source of payment for one of these things.
I can honestly say I’ve never had a client who was a small business owner herself, or whose husband was, give me a hard time about payment.
If your midwife’s fee is too expensive, if your insurance won’t cover it, you have options. You can opt for a different midwife with a lower fee, if there’s one available. You can opt for a hospital birth this time and save for a homebirth next time. You may be able to change insurance companies in the meantime. You can look into paying with a credit card or a small loan. (Been there, done that.) You may be able to sell something (or things) you’re not using, or tighten your budget in some way. Friends and family may be willing to forego typical baby shower gifts and help pay for your homebirth instead. There are options.
Asking your midwife to forego payment for her services is not one.