Monday, June 02, 2008

Calling all midwives...

A commentor has got me thinking. She mentioned how midwives are compensated less than physicians, which got me thinking- should this be so? What parameters are used by midwives (of all types) to set their fees. Is it years of education, years of experience, the going rate for your community? The reason I ask is because I get the impression that doulas, midwives, childbirth educators and the like are expected to get less than 'market value' for their services.
So Dear Readers, who fall into these categories, don't leave me to my ignorant guessing. How do you feel about clients asking you to reduce your fees or even asking you to serve them for no fee at all? What criteria do you use to set your fees. Do you feel that you get fair compensation for the work you do? Midwives, should you be making less than your physician collegues? (I once saw a 60 minutes segment where nurse practitioners made a compelling case for charging the exact SAME fees as physicians.) Do you feel your service is valued by the community you serve and is that value reflected in the fees you recieve? (What about that good 'ol Americanism, 'you get what you pay for' where a higher value is assigned to a higher price tag?) Do you feel yours is a spiritual calling and therefore don't feel right taking money for it at all? I would love to hear your thoughts on this topic. Then perhaps I'll chime in from a nurse's perspective, but for now, the floor is yours.


Navelgazing Midwife said...

Non-Nurse Midwives should absolutely NOT get the same fees as Physicians or CNMs - the education value doesn't translate.

Granted, we spend a lot more time with clients, but it isn't *clinical* time except on the periphery. Our skills are in the normal range of pregnancy and birth, we don't prescribe medications nor take the responsibility that goes along with that. We don't do surgery or assist in surgery. We don't tend to women with epidurals, pitocin or sedatives/narcotics - it isn't our skill, but CNMs, RNs and docs have those more technical skills. I see our skills as "soft" and theirs as "hard." Our society pays for hard skills.

I charge the going rate in the community. Well, I actually charge less to be more competitive. I charged slightly more for years, but found client after client asking for payment plans and reduced fees.

Now, clients generally pay in full, sometimes at the first visit, or I barter (am bartering for photography lessons and my tattoos right now) a part of the fee.

I *have* to get a certain amount to pay my apprentice/assistant cash after the birth. I have to get another portion to cover expenses (medications, O2 masks, sutures, etc.), but my own portion I can waive or bargain with. I try not to, though.

Insurance often pays for services, but after years of allowing folks to pay their deductible and co-pay while waiting for insurance to pay the balance, we have recently stopped that because sometimes insurance takes a year (or more!) to pay and we are too small to be able to wait that long to be paid. Now, we have clients pay up front and then we reimburse them when insurance pays. That is how 95% of the midwives in the area do it.

Sometimes I think I get a fair price, while others, for some difficult/challenging clients, I don't think I get nearly enough. When I fear a lawsuit, I think I would sure like more!

Also, most LMs/midwives have no malpractice insurance, so we shouldn't be charging clients for that compensation. As far as I know, only in FL and WA do LMs have insurance.

This is my take anyway.

Kristina said...

In my area, doulas only charge a measley $300 a birth, and have been doing so for ten years. Since I'm the newbie, it's hard to charge more next to those more experienced. However, I'm charging a sliding scale starting at $300 and going up to $500 for now - and guess what - most people end up paying me the $500 (or close to it).

I agree with NGM that the value isn't placed on the outcomes or the level of care in this society - but the experience, education, and hard skills. I think, though, (or at least I hope) that if we let the market sort itself out, eventually the playing field will be closer to level - once people realize what skill midwives bring to the table. There aren't enough midwives - and think back to econ 101 - if demand goes up, and supply is limited, what happens to price? OBs are the specialists and have skills for high-risk, which always pays more...but I think eventually midwives will get a fairer piece of the pie.

Molly said...

I understand NGM's point about being reimbursed at a higher rate for the greater time/money investment of longer training/education (in fact, as an underpaid Ph.D., I think we should extend that logic from the sciences to the humanities so that I can buy a freakin' house!). What bothers me, as a doula and a natural birth lover and a mother who had an AMAZING midwife-attended birth, is that people question the comparatively little midwives DO charge--"Why do they charge so much?"--as though they lacked this incredible value of knowledge, experience, skills, and human caring (aka trust in birth, aka the risks they take in offering us the rare opportunity to escape medicalized birth and the 'patient' role).

Setting aside ignorance of what midwives actually do and why one might want to escape hospitals, I think that sticker shock is largely due to our abysmal health/insurance system, which so often doesn't cover out-of-hospital midwifery. To insured families, in other words, home birth and in some cases birth center birth means paying a midwife much MORE than they'd pay a doctor, even though the midwife is actually making a lot less.

Midhusband said...

Hi Sherry,

I’m not a clinician, but I am the CFO of a home birth midwifery operation.

I think there are lots of ways to look at this, but on one topic I absolutely disagree with NGM (but I love you anyway, Barb). The level of traditional education is irrelevant between a CNM and a CPM who attend home birth. The effort a CNM puts into her education is terrific and they should be very proud of their investment, but is a CNM going to pull out a vacuum, or forceps…at a home birth? The answer is clearly no. We recently had a gap analysis performed on clinical skills and the CPM is comparable to the CNM and exceeds in a number of areas. Either way, the quality of maternity care for healthy women is clearly not correlated to education level (in fact it is inversely proportional).

In a purely capitalistic sense, if a CNM can get a higher wage for providing maternity care by virtue of her credential, then I think that is just fine. At the same time, an autonomous CNM has a broader scope of practice than a CPM and can therefore do more things and should be compensated accordingly.

As for physicians, I do believe they should make more money (a lot more money) if they are doing what a physician should. They have more problem solving capabilities and have invested a lot in obtaining those skills, but we know they generally do not have the aptitude, nor inclination, to provide home birth midwifery care. The quality of care provided to healthy women by a midwife is better than that of a physician. In that sense, a midwife should make more. If a physician is working in a hospital and solving lots of problems then she should be compensated accordingly.

In our situation, my (mid)wife gets paid about half the time and does just a little bit better than break even. I think a full time midwife ought to make ~50 K$/year (and overall healthcare costs would go down). At the end of the day, however, I will be happy when she is licensed and not illegal.


p.s. For a terrific article, have a look at this.

Morag said...

To the best of my knowledge Licenced Midwives (CPM's) in Washington state are reimbursed for prenatal care and births at the same rate (global fee) as physicians are for uncomplicated courses of pregnancy care and vaginal delivery.

Docs and midwives alike will tell you that they are underpaid.

Insurance companies are required by law to reimburse licensed midwives for their services and out of hospital delivery. WA Medicaid pays LM's for their services to low income women, as they do Physicians and CNM's who accept these clients.

I disagree with NG midwife. there is no good reason why LM/CPM's should be compensated less than their CNM/MD colleagues for the same (and in many cases, more) care. Uncomplicated midwifery care during pregnancy, birth at home, and postpartum care by a LM in Washington State is absolutely equal to the care provided by a CNM
or a physician.

Admittedly if you practice in hospital, and have access to more interventions and bells and whistles, then it makes sense that you would bill for those too, just as birth centers charge a facilities fee.

Mid-life Midwife said...

I don't believe we midwives should be paid the same as MDs or CNMs, mostly because we don't pay the insanely high cost of malpractice insurance, but also because we didn't pay thousands of dollars for schooling that would teach us skills we don't use in the home setting.
Our overhead is generally fairly low in comparison to a MD: gas, office rent, supplies, paying apprentices, childcare, etc.

I also don't want to be paid like an MD. I am not a surgeon. I don't use nor do I want to use, any equipment other than my hands at births. When there is a need to transport, I appreciate the fact that there is a hospital with folks trained in other-than-normal birth and emergency care that can do what is needed to keep a mom and baby safe.

Like NGM I charge the going rate in our community. I also incorporate a sliding scale based on income so clients can figure out what they can pay. Most pay by figuring out a payment plan, and almost everyone has paid in full by their due dates if not sooner.
Since insurance reimbursement is so sketchy and very unlikely where I live, we have clients pay us in full and then we send a claim to their insurance companies after all care has been completed. Every once in a while they get partially or fully reimbursed. But like NGM said, we midwives can't afford to wait months for a yes or no from an insurance company.
There are midwives around me that charge nearly twice my lowest fee and that's fine. It's my personal desire and goal to make homebirth an affordable option to all women, not just the white, upper-middle ladies.

Navelgazing Midwife said...


Doctors and midwives are not just paid for what they/we do. We are paid for our POTENTIAL.

I explain this to clients who think a midwife "just sitting there" isn't doing anything when, in fact, she is watching, listening and ready to act/react should the need arise. Oftentimes, midwives end up doing nothing technical and I have heard clients complain, asking, "What was I paying her for?"

Her potential.

We are paid for what we CAN do, not just what we DO do.

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