I've been reading this thread off and on for a while, but this is the post that's going to get me to comment.
Originally Posted by Buzzbuzz
A midwife in my area earns between $3500 and $4500 for the prenatal care and birth (usually whether or not she actually makes it to the birth). A doula is paid between $300 and $500. I would note that an OB in my state gets paid around $800 for the prenatal care and birth of a Medicaid patient.
I believe overhead costs are relatively low compared to doctors -- frequently no brick and mortar office, no or only one secretarial staff, no r.n.s on staff, some disposable supplies (and sometimes food) being provided by the patient, no malpractice insurance costs and no or extremely limited continuing education costs and licensing costs as compared to doctors.
Assuming payment of $4,000 per birth and 2 patients a month, a midwife would be earning around $96,000 less her operating costs for a career that does NOT require a college degree (and until the last month or two did not require a high school degree or GED). This assumes she does not earn additional income by offering placenta encapsulation services, moxibustion, etc., etc. I have also heard second-hand of a midwife in our community that received "referral payments" for directing her clients to certain alternative medicine providers (acupuncturist, herbal medicine supplier, placenta encapsulation specialist).
The median income in the United States is around $45,000. To pretend that there is no money to be made in natural childbirth and its various accessories is simply crap. It is a business like any other.
I think you really have no idea what costs may be behind the scenes for a MW. Have you ever been self-employed? Do you have any idea of the costs associated with being self-employed? From what you typed here, the answer is obviously no.
Here a LM earns roughly $4000 per birth (sliding scale though, that's the higher end). A doula earns $1000. An average MW or MW team might take 2-3 clients per month. That's maximum, that's not a guarantee. In an average year, that might mean 18-20 moms, not 24-36. Very few MWs fill up every month. Some MWs will have more, some will have less. I know a few MWs who only take 1 client per month. Around here there are always 2 trained professionals at a birth. Sometimes that means a MW and an assistant (paid), a MW and a late-in-training apprentice (paid), a MW and a back-up MW (paid). These people are all paid out of the MWs pocket. My MW with my last pregnancy had an apprentice. This pregnancy (a different MW), she'll have a back-up MW. I don't know what it costs her, but I know they're not doing it for free. In addition to the cost of hiring a 2nd pair of hands for the birth, there are other costs involved, both for the birth and throughout the prenatal care.
The cost of the copying and binding she does for all the paperwork involved in the client packet (list of resources, birth questionnaires, new client questionnaires, birth supply lists, etc.). Kinko's doesn't make copies for free. Many of the MWs here hand these out at initial consultation interviews, before they're even hired, so they have to make way more than they ever get reimbursed for. Cost of transportation to and from every visit, around here might include tolls for the bridges, includes parking meters or garages, parking tickets, and I know at least one instance where a MW had to double park to catch a precipitous birth, and then you have to deal with the cops and impound fees and all that lovely jazz. Not to even mention that gas is about $4.50/gallon ATM, she has to have a reliable car (including regular upkeep), and decent insurance on it, so that she's never stranded. Any visit that involves testing - test strips aren't free, neither are gloves. If you have an internal exam (prior to labor), the cost of those supplies comes out of her pocket as well, not out of the birth kit. Every piece of paper that you have to sign has a cost attached to it... I've had to sign several, one each time I decline a test to cover her butt that she did in fact offer it to me. Requesting copies of records from other practitioners, not only costs for the paperwork, but then for the stamp, the phone calls to follow up, and if they fax it back, the supplies for printing it out. On the other end, if she gets a request for records on a former client, she has to pay to copy those records and get them to the new practitioner also, and that money comes off her bottom line, since that client may have been years ago. There's also the cost associated with billing insurance companies, which she doesn't do herself, she hires someone (who knows what they're doing) to do, on the off chance there might be a few dollars to reimburse the parents. There are in fact continuing education costs, there are professional conferences to attend, there are books to buy, there are certifications to keep current, there is equipment to update or replace when it fails. And then there are the birth supplies that are not provided by the parents. Oxygen tank is a big one. Suturing equipment, extra everything, just in case. Sterilization fees. There are some things where the costs get passed along to the parents, but she still has to eat them up front, like lab fees or drug fees (RhoGam comes to mind). And then there's basic overhead, like my MW is right now switching over to paperless chart keeping. She has to pay for that system, the software, the subscription service, the online support, the hardware. She has to pay for her cell phone plan AND her beeper so that she's available 24/7. And when it comes down to it, she also has to pay taxes. Being self-employed, she has to pay a LOT of taxes. And I'd be willing to bet that in my 39 wk pg haze I'm forgetting any number of costs. And all of that is assuming that she didn't barter for part of her fee, take the low end of her sliding scale, and that she actually gets paid in a timely manner, which doesn't always happen.
In the end, I'd be surprised if she were keeping even half of her global fee per client. And this is for a person who answers the phone when I call at 2 am a few days pp and comes over in her pjs, regardless of how much/little sleep she's gotten. Who easily spends 2-3 hours talking to me at every single prenatal visit, just to make sure that I'm comfortable, prepared, and have any concerns addressed. Who likes me to keep her updated via email with what is going on with me - when I had my tooth extracted last week we kept in touch via email so that she could support me through the pain, give me advice on keeping the baby inside until I heal, without making it worse (by talking on the phone). Heck, my MW and I discuss what books we're reading, so that we have a mutual frame of reference, and she brought me 2 books at yesterday's visit so that I have something to read while I'm waiting for labor to start. How many doctors do you know who will make that sort of effort with a patient?
I'll also point out that while the median income in the US may be around $45K, in this area, that income would barely be enough to keep a roof over your head. They're not in it for the money. In no way shape or form is this about the money.
And yes, my MW does do encapsulation. She's not charging separately for it, though. Any more than she's going to charge me separately for the PP smoothie she'll make me, or the BFing support she's going to be giving me. Even though she would be within her right to charge me extra for the encapsulation (around here it goes for $250 on it's own).