Paying Midwives: The Real Solution to the Maternal Health Crisis in America

Maternity care in America is in crisis and there are many layers to this problem. Just one aspect of this is the cost of maternal healthcare, driven higher each year by hospitals, unnecessary medical interventions, and a growing cesarean rate. As the rates of intervention and costs rise, so does our rate of maternal mortality. It is absolutely unacceptable that one of the wealthiest countries in the world would also be one of the most dangerous places to give birth in the industrialized world.

But, what is the solution to this?

That answer is actually quite easy. Midwives. In countries with much better outcomes than us, midwives lead maternal healthcare as the primary caregivers during the childbearing year.

The topic of maternal mortality has been at the forefront of recent discussions all across social media and news outlets. We know what the solution to the problem is, but how do we make that happen? We must make midwifery care more accessible in every community across the country, and that includes making out of hospital birth more accessible.

Again there are many layers to this discussion, and today I want to focus on the topic of money. A piece of the conversation which I think midwives have been much too quiet about as of late.

Traditionally, insurance in America has not covered Certified Professional Midwives and Licensed Midwives the same that they have covered Obstetricians. Because of this client's seeking midwifery care with a CPM/LM usually end up paying out of pocket which means that to make care accessible, midwives must keep their prices "affordable". But does that really make midwifery care more accessible? In the long run, no.

If midwives can't run a successful business, they can't afford to stay in business which results in fewer midwives to serve the community.

Recently, my preceptor had to settle a dispute with a health sharing company over her charges. You read that right, a company tried to refuse to pay her the amount they had previously been paying. But why? Was she charging them some astronomical amount? Well..... no. Actually, they even agreed that her price was lower than what they paid for a hospital birth with an obstetrician. But somehow her services are worth less just because she is a midwife. Because she said it better than I ever could, the following is her explanation of why she deserves to be paid fairly, as well as a break down of maternity costs across the country:

Please forward this letter to your supervising manager and to your board of directors.

My current contract with [company] is $8061.30, honoring a discount of $1000 if paid in full before 12 weeks, making the total $7061.30.

My problem with the arrangement is that I included too many expenses paid to other providers in that fee. And most providers have raised those fees.

As I explained to [supervisor], it has proved very difficult for me to keep allocated funds for those expenses and pay those to other providers as needed over a year's time.

My cash discount fee for low-income clients starts at $6000 and my average insurance bill for prenatals, delivery and postpartum is just over $21,000. That does not include ultrasounds, birth assistant fee, pap smear, Rhogham, hearing screen, newborn screens, circumcision or any other expenses.

The average midwife fee in DFW is $7500 plus all expenses, plus the birth center bill of $2600 for baby and $2600 for mother, with an overnight cost of $2600 for each if the birth occurs overnight. I don't do many birth center births, nor do I own a birth center but if my client chooses to birth at a birth center then the birth center bills separately. My fee is for midwifery care.

My fee is paid by [company] and [company], promptly, and they are grateful for the discount, grateful for the 3% c-section rate, low transport rate and excellent care I provide their patients at home.

I am wondering what changes have occurred at [company] for me to even be having this discussion and at such a late date?

Are you unfamiliar with current midwifery and birth fees in DFW and in America?

Have you handled bills from many of the Birth Centers in DFW yet? They have been billing the midwifery fee at over $7500 for years, plus all expenses, plus $2600 for baby and mom, and overnight charges since 2012. A homebirth with me is significantly less.

A homebirth with me is also significantly less than a hospital birth. The average vaginal hospital birth in DFW was over $16,000 in 2016. And that is not all-inclusive. That is just one portion of the fee. Nor do most mothers have unmedicated vaginal births in hospital. Over 95% of mothers at DFW area hospitals have epidural anesthesia. A record 35% have c-sections, longer post-partum stays, the costs associated with complications of surgery and NICU stays. The VBAC rate in DFW and the US is currently 3%. That means that over 97% of women attempting a trial of labor have c-sections. 70% of women who qualify for VBAC don't even attempt a vaginal birth but chose a repeat c-section.

Unlike many midwives, I don't even charge extra for VBAC clients because I am so committed to attending them.

The costs are much the same across the US. Below is an article detailing birth center birth in 2016 at a Minnesota birth center. The cost without insurance was over $12,000.

https://centsai.com/parenting-blogs/birth-center-hospital-cost-of-childbirth/

This is the most recent and accurate article on the cost of birthing in America: $32,093 for a vaginal hospital birth and $51,125 for a c-section. California costs in 2012 were over $37,000 for a vaginal birth and over $70,000 for a c-section. That was 6 years ago.

https://www.theguardian.com/us-news/2018/jan/16/why-does-it-cost-32093-just-to-give-birth-in-america

And still, women die in the US more frequently than any other first world country. Our maternal mortality and morbidity rate is so high that the World Health Organization has taken note of it. We lose 700 birthing women a year to DEATH in the hospital and another 50-60,000 are SEVERELY INJURED in the hospital every single year.

https://eu.usatoday.com/story/opinion/2018/07/31/high-maternal-death-rate-shames-america-developed-nations-editorials-debates/866752002/

I and the other brave midwives across the United States are fighting to change this. We stand in the gap. And we take much, much responsibility on our shoulders as well as fighting and lobbying for the rights of birthing women everywhere.

I provide 60 minute prenatal and postpartum appointments, which often-times run longer. The average face to face time with an OB in America? 7 minutes. The average time I am with a birthing client is 20 hours. 20 STRAIGHT hours sitting patiently by their side safe-guarding their baby and encouraging them that their body was made to do this. My longest birth on record is 67 hours.

I am on call 365 days a year. I have to schedule a vacation 10 months in advance.

I miss Christmas, Thanksgiving, Easter, my children's birthdays and on and on. We all do. Because we are called to serve.

Lab costs have risen sharply, office expenses are higher, the state has required more and more equipment be provided and maintained by out of hospital midwives.

So when asked why my fee is being raised after 7 years to $8000 frankly I am stunned.

I raised my fee to $8000 for [company] and [company] in November 2017. They never questioned my integrity or the value of the work I do. They know it.

In grace,

Maeve Northcross, CPM, LM

Midwives save lives. Pay them what they're worth. It's really that simple.

Sarah DiMarco, student midwife