Midwifes: where does all the money go?

[carlasher]

The average cost of a homebirth with a midwife in this area is about $3000-$4000 including pre-natal care.

Most of the midwifes I spoke with dont do more than 3 births a month. At about $3000 per birth, that is $9000/mo. Besides insurance, where does the rest of the money go besides a salary for themselves?

[laurata]

It does seem like a lot of money when you put it like that. :-) But really, lets break it down, I'm curious to see if we can figure it out. (And I'm sure some of our midwives around here will post.)

Most of the bay area midwives I've spoken to DON'T have malpractice insurance. But maybe they are paying for insurance for themselves. Also transportation to and from home visits and births. Equipment- O2 tanks, stethescopes, fetoscopes, Dopplers, etc. Plus bills- phone, cell phones, pagers. Plus assistants, in some cases, or back up. Plus everyone deserves a vacation. Self-employed need to make more than most so they can have paid vacation every year. Many by birth kits for each birth, in addition to supplies the mama has to acquire. Some also have birth tubs....

[pamamidwife]

Well, in San Fran, I guess the monthly income would just barely cover a mortgage! lol

I charge from $2000-3000 a birth and I usually have anywhere from 1-3 a month.

My state license is $2000/year

I spend, on average, about $2800 a year on supplies

I have an office, which is another expense

My gas for my car and car repairs is outrageous!

I pay for an assistant at all the births, which ranges from $150 (my apprentice) to $350 (when she's not available for whatever reason) per birth

I pay about $1400 a year in advertising, between local papers and the Yellow Pages

For office supplies, I spend about $600 a year

For conferences and continuing education and my state midwifery organization dues, I spend about $500 a year

For other misc expenses (like food when out at appts, etc), I spend about $600 a year

I also have other expenses, like TAXES, my cell phone and pager and my accountant, my website hosting and stuff. I'm sure there's more, but I don't have it in front of me.

All these things add up. I also have set my fee to enable myself to do some births for nearly nothing, so the my income does vary.

I can't speak for other midwives, but if done right, there's no reason why you cannot live on a midwife's income. However, just like any other profession, I earn my money - every bit.

[srain]

I'm betting a lot is insurance-
and also consider what it's like to always be on call-
and consider what OBs make!

[Malama]

I'm a newer mw and don't have a lot of personal experience with getting paid and figuring where "all" the money goes, but I CAN say that I don't know a single mw who's making very much $$ at all. Many are not making their bills, needing to supplement with other things, or rely on a partner for support.

Even when the mw I've worked with was at her busiest, many times she had clients who couldn't pay, didn't pay, or paid slowly.... so it's not like there was a huge amount of $$ every month. In fact, her family has been struggling while she serves the women of our community.

[kavamamakava]

Originally Posted by Malama

I'm a newer mw and don't have a lot of personal experience with getting paid and figuring where "all" the money goes, but I CAN say that I don't know a single mw who's making very much $$ at all. Many are not making their bills, needing to supplement with other things, or rely on a partner for support.

Even when the mw I've worked with was at her busiest, many times she had clients who couldn't pay, didn't pay, or paid slowly.... so it's not like there was a huge amount of $$ every month. In fact, her family has been struggling while she serves the women of our community.

My daughter was born in Hawaii and my midwife was practically in tears when I paid her in full BEFORE the baby was born. She didn't get paid by the family after me because the husband lost his job right before the baby was born. I don't know why they hadn't been making payments though. Hrmm. And my sister still owes her money too I've never known of a midwife to be so inexpensive either!! She was only $1200.00

[pamamidwife]

I think that there is a belief that in order to be a good midwife you shouldn't focus on the business aspects of your practice. However, I believe that in order for me to be a GOOD midwife, I need to have that part of my practice in order.

I love midwifery and cannot imagine doing anything but this. I'm certainly not in it for the money, but I'm very clear with my financial agreement and my expectations around money. I'm not going to hem and haw about what I charge because it is what it is. If someone wants to hire a less expensive midwife, they can certainly do that. If someone is seriously experiencing financial difficulty, then I work with them - I just expect openness and honesty about what they can afford. My time is worth getting paid what I ask and before the birth.

I think, too, that many midwives live in a state of scarcity - that they don't have enough clients or make enough money. I think that, as women, we undervalue our work and our skills. It's hard to love families and midwifery, feel called to this living and be clear about boundaries from the business aspect. I've found that there are very few times that I don't get paid my full fee before the birth.

Definitely, some midwives live in areas where few people choose to homebirth. Some midwives are single mothers or the main breadwinners. These affect the ability to make "enough", but I still choose to live in a place of always having "enough" - enough clients, enough money. When I interview with families, I will not undercut other midwives in my community to "get" this family. I am honest about what I charge and let the families make their decision. Some will choose based on what the fee is, while many more choose based on that personal connection.

I think there is a growing trend of younger midwives with some good personal and professional boundaries in regards to their worth. I have bartered with clients and, like I said, have done nearly free births. However, when it comes down to it, I have a specific financial agreement that all my clients sign at the start of services. It has worked well and I'm pleased to say that I feel very successful in the heart matters of midwifery as well as the business aspect.

[Ravenmoon]

My midwife doesn't have a license and runs her meetings out of her home and she charges $2700.My dh ran out of work and i can't go see her until i have $500 to give her.It makes me sad but those are her rules.

[doctorjen]

Just commenting on the OP, even if a midwife did 3 births a month at $3000 and collected easily from each family, that is $108,000 a year. That's not a lot if you need to run an office, pay your assistants, buy equipment, stay educated, AND be on call nearly 24/7 all year long. If you wanted to make money, there are an awful lot easier ways to do it, I think. Factor in delay in getting paid, and sometimes not collecting as much or at all, and it's probably on average quite a bit less than that estimate.
Interestingly, as a physician, I bill about $2500 for "global OB care" which is all prenatals, birth, and postpartum visit. Tests are not included. Most insurance companies pay me somewhat less than that, and medicaid significantly less than that. I attend more births than the average midwife, though, 60 so far this year. I have the advantage, though, of having labor and delivery nurses available to do a lot of triage and early labor stuff for me, so even though I am on call 24/7, they can take a little of the load off me.
I totally agree with Pam about needing to be savvy about the business aspects and not devaluing yourself as a midwife. I think many traditionally female occupations struggle with this. Not the same, obviously, but I'm always trying to convince my daycare provider that she should make her clients stick to her contract more strongly. She's so goodhearted she has a hard time making people pay up!

[carlasher]

Originally Posted by Malama

I'm a newer mw and don't have a lot of personal experience with getting paid and figuring where "all" the money goes, but I CAN say that I don't know a single mw who's making very much $$ at all. Many are not making their bills, needing to supplement with other things, or rely on a partner for support.

Even when the mw I've worked with was at her busiest, many times she had clients who couldn't pay, didn't pay, or paid slowly.... so it's not like there was a huge amount of $$ every month. In fact, her family has been struggling while she serves the women of our community.

Thats pretty much why I wanted to know. Because a lot of MW I know are not "livin' large", and some that that great at all. But that is just the way things are for alot of people in the BA.

[chiromama]

I dont' think they need to justify their fees at all. 3-4K to help you bring a baby into the world? I think it's worth more than that. I think a lot of times we forget that the people we pay to help us maintain our health, our families and our lives deserve to be paid for what they do. And besides, loans from schooling also take up more than half of many health care providers paychecks ( at least mine!! )

[Seeking Refuge]

My midwife charges on a sliding fee scale and I feel that she is worth every penny. We are struggling to pay the $1600 that she charges for a family that makes $20,000 to 30,000 a year even though we my husband is unemployed and we are living on temp positions that don't pay nearly that much. We are doing this because she is providing us an invaluable service and it the least we can do. We live in Iowa and the cost of living here is a lot less. An OB/GYN will charge about $2000.

[carlasher]

Originally Posted by chiromama

I dont' think they need to justify their fees at all. 3-4K to help you bring a baby into the world? I think it's worth more than that. I think a lot of times we forget that the people we pay to help us maintain our health, our families and our lives deserve to be paid for what they do. And besides, loans from schooling also take up more than half of many health care providers paychecks ( at least mine!! )

I never implied they are not worth more than what they charge or that they should not be paid for what they do. I asked because I have seen many MW with full birth schedules struggle with money.

[MomInCalifornia]

*Also in the Bay area*

My midwife charges $4000 and personally, I feel as though I am not paying her enough. She is wonderful, and by far earns every penny of her fee. If I were to add up the hours she is spending with me, both in person for appointments (many of which are 1-2 hours and often in my home so I don't have to worry about child care) as well as the time she will spend with me during labor and delivery, and then post partum, I figure her hourly rate is pretty low.

She also maintains a comfotable, homy office, has a pager and cell phone so we can reach her when ever needed, has supplies etc.

Anyway, while I understand the fee is high, my husband and I feel like we are underpaying for the quality of service we are recieving.

[chiromama]

Carla.. sorry, didn't mean to make you feel defensive. I just know what it feels like to have someone question your fees... and I also know what it feels like to barely pay the bills with those fees.
I understand now why you were curious. Thanks for clarifying!

[Malama]

Originally Posted by kavamamakava

My daughter was born in Hawaii and my midwife was practically in tears when I paid her in full BEFORE the baby was born. She didn't get paid by the family after me because the husband lost his job right before the baby was born. I don't know why they hadn't been making payments though. Hrmm. And my sister still owes her money too I've never known of a midwife to be so inexpensive either!! She was only $1200.00

Hi Nipuna!
We're talking about the same mw- this is Karen, the apprentice.

Nice to "see" you here and congrats on the new baby.... We're having one as well in Jan.

And, BTW, Rox is raising her rates after we've all been hounding her forever to do so. $1200 is just not enough for what she gives to her mamas!!!

Much ALoha,
Karen

[carlasher]

Chiromama, its OK. I know what its like to be asked too, but understand the reasons behind the question sometimes. I didn’t feel comfortable asking one directly for fear of offending her...

[mnnice]

Well I don't find it suprising that a midwife would need to charge 2 to 2 1/2 times what we were recently quoted in my area (NE Wisconsin) than the Bay area. Just about everything else looked to we that much more expensive when we visited this summer.

[wtchyhlr]

I don't have the piece of paper with me... but the agreement I signed w/my midwife (in Colorado, so middle of the road living expense wise) was that if I paid in full by 20wks (i did), the fee was $1800 - that her time. I have some misc. lab tests i pay for, and if i want ultrasound, thats extra too. (the fee slid up to where if you paid at 40 wks it was like $3500)

What that covers -
* 1+ hr long appts every 3 weeks to week 28, then every 2 to 37 then weekly (the pee strip tests, doppler, prenatal advice etc)
* her being on call 7x24 for me from the day we picked her (and i did have a dehydration episode around week 10 that i called her during)
*Her and a backup midwife in attendance at my birth (since i'm a first time momma, they want 2 midwifes, not a midwife and apprentice)
* If we have to transfer, she goes with me in a doula role
* Post partum care (1 day, 6 days, 2 weeks, and 6 wks, i think)

There's a few lines about if i leave her care...up to 34 wks, I'd be reimbursed my fee minus $75 per appt. I'd attended. After 34 weeks, no reimbursement, and post partum care could still be with her. I would assume that someone transfering at 34 wks would've figured out they didn't like her by then and would only be transferring due to medical reasons to an OB

I actually think I'm getting a heck of a deal.
And there's a chance i'll get some back from insurance when its done, but i'm not holding my breath. i think its worth every penny to be able to have a gentle home birth.

[Ragana]

Remember that self-employed people have to pay income taxes and the "self-employment tax", which is both halves of Social Security (the employer's half and the employee's half). That's a lot. And, if they don't have a partner with health insurance through a job, that's another huge expense. I'm not a midwife, but am self-employed, and our health insurance is $600 per month (for a family of 4)!!!