Midwife policy question

[Mary-Beth]

Is it standard for midwives to be paid in full prior to the birth? And, to be paid the same even if they don't make it to the birth becasue of quick labor or becasue the patient didn't contact them soon enough.
And lastly, to be paid the same even if we end up going to the hospital?

The midwife I interviewed wants to be paid in full by 37 weeks...sort of seems like I'd pay some along the way and make the fianal payment after the baby's birth.
And, I guess I need to find out more details on what is "quick labor" and "soon enough" to contact her. But just wondering if this is how things are generally arranged.
As for the transfer issues- I guess it makes sense for the midwife to be paid the same since she still did all the prenatal care, attended the birth until it became a medical issue (and hospital care was required) and then stays with us at the hospital for support/consult, then resumes postpartum care. The birthing center charges less though if you do transfer.

What are your thoughts on this?

[MistyD]

My midwife had the same policy. Other midwives I interviewed did as well. It was fine with me.

[georgia]

It's the standard for all the midwives I know. I'm willing to bet that those mws who don't ask for full payment never receive full payment!!

My mw;s transfer rate is very low. I was and am completely confident that if she transfers you---you need it! What you outlined is completely in line with what I feel is fair (and I am a complete tightwad) As far as calling in time, I know moms who don't call mw until they are pushing--and mw has an hour drive! It happens....

IMO, the most important parts of the relationship between you and your mw are communication and trust. Have her spell it out for you---if you don't like her attitude or get a bad vibe, keep searching. Money questions *are* important! If you feel like you're not feeling heard, wonder what else you might not be
*heard* about!

Best wishes!

Amy

[KittyKat]

Just adding another voice to say "Me too!" this was the standard policy of all the midwives I spoke w/ before my homebirth.

Kathryn

[pamamidwife]

This is my policy - and here are the reasons why:


Payment before 36 weeks: I'm willing to work with families and lower my fee, etc., but I have found that if I say I'll accept payments after the baby comes, I rarely see the money! Things always come up with a new baby - lower income, etc. In addition, I pay my assistant midwife out of this fee to attend the birth. Other things like my supplies, gas, telephone, etc., are expenses that come from the birth fee.

If you need more time, sometimes borrowing money from a family member or getting a cash advance on a credit card is available. I also take credit cards!


Payment even if we transport or you have a quick labor, etc.: If we transport care to the hospital during labor, then I have done my job and I deserve to be paid! When clients hire me, they do so knowing that I'm watching out for their safety - and that sometimes a transport is part of that. In addition, I stay with the couple throughout the entire birth, then continue with usual postpartum visits. Not to mention all the on-call time, prenatal appts, etc., that I have done for the family.

In the event of a quick labor, there is nothing anyone can do about that. Would I charge a woman who has a three day labor more money? Of course not! There's no way to tell how long a labor is, and my birth fee takes that into consideration (it's an average that seems fair for my time and experience).

Now, if a client called me and I was late because of my own error or laziness, then I'd work out a reasonable refund.


I sometimes let parents pay me a final payment after the birth, especially if there's money expected for a particular reason. However, I find that it's less stressful to deal with money stuff BEFORE the birth, rather than after.

[StarMama]

Yes I have to be paid up by 38 weeks. If something goes wrong before labor and I can't have a homebirth they will only expect payment for the prenatals they attended (so I'd get a refund of any difference), and they would NOT attend me during the birth. However if something goes wrong during labor and I must go to the hospital they will go with me, even though they don't have any medical rights with my insurance, so they wouldn't be able to delivery the baby at the hospital, but yes they would keep the full amount then. HTH

[miriam]

Yes, I paid up by the 28th week for each of my four pregnancies with the same midwife.

My sister, with the same midwife, ended up with a c-section because of a short cord, breech presentation, and lack of progress, was reimbursed a portion of the fee since the midwife did not do the full delivery.

For her second pregnancy, my sister attempted a V-BAC with a free-standing birth center and had a second c-section because of a transverse lie and placenta previa; the free-standing birth center kept the total fee.

Well worth the entire investment and more!

[Carolinamidwife]

Ahh... I have a lot of thoughts about this. Unfortunately part of my education has included seeing one of my preceptors not get paid for 3 births in the past year. She also has a pay by 36 weeks clause (everyone here does) but did not have the heart to enforce it. As a result one client has dragged out her payments to the point where midwife has to call her and ask her every week, one disapeared after an "accidental" unassisted birth, and one decided midway through care that she would rather go it on her own and therefore did not need to pay for the prenatals she had already received. We even had one client who we transported after spending 3 days at her labor (she was also 42 weeks so had received 2 extra weeks of care) whose husband asked for a refund!

Sadly, some people make it harder for everyone. If the payments are not completed before the birth there may be a tendency to forget or to just have "more important" costs come up. As it was for all of these clients my preceptor was charging about 1/2 her standard fee and she still did not get paid.

Non-payment is a chronic problem in my area, we have many midwives and all of them have a story to tell. Some are owed $10,000 in unpaid clients.

When I start my own business I will have a 36 week clause as well. If you are not paid in full by 36 weeks you will have to find new care unless we have made arrangements previously. It may seem unfair to discharge a client so late in the game but (especially for CPMs) it is important that we be valued for the time and money we spend practicing.

[/rant]

Amy

[Greaseball]

The midwife I was seeing really made an effort to work with me and I have the utmost repsect for that.

I had called around and there was one woman who charged $1300 but if I paid before the birth it would be $1100. I decided I wouldn't be able to afford anything at all and told the one I had originally wanted to go with, thanks but no thanks, I'm going to work out something else. She called me back weeks later and asked if I had found someone and told me she could work out a fee I could afford and that I could make arrangements. She said it was $2000 but she would charge only $1400, and that I could pay $200 or $300 a month. Because of how far along I was, she would not be paid in full until the baby was 2 mos old.

I ended up going to the hospital anyway and she refunded some of the money. She ended up charging me only for prenatal visits.

Part of the payment is for them to provide labor support and catch the baby. If we transferred to the hospital, I would be OK with still paying, but if she didn't show up to provide the support or catch the baby, why pay for that? Whether it's because she didn't arrive fast enough or I didn't call soon enough, or a total accident, why pay for something you don't get? I would not have a UC and then pay someone for not being there.

But because I know not all midwives demand payment in full, next time I will look for one who is willing to make arrangements. I live in a small town and there is one living just a few blocks away, and another one in town as well. It's not that unusual. It really seems that part of the philosophy (of some midwives' websites I have seen) is working with the client and not imposing your own rules and standards. Of course they need to be paid but I really respect those who work with what they are given. If you're in it mainly for the money it's probably not the greatest profession to go into - the hours suck, for one thing!

What other people do who charge and then don't expect to be paid in full right away is just refuse to provide a future service to the one who didn't pay until their bill is taken care of. I plan to be one of those professionals as well and it will do me a lot of good to assume the best rather than the worst about my clients - assume that they will pay. If they don't pay, assume they will later. If they still don't pay, assume my rates are too high or they have some other good reason and try to make arrangements with them. If they still don't pay, let it go and just don't see them again.

There is one counselor I know (the profession I plan to go into) who tells all his clients "Just pay what you can afford." You would think they all just pay $5, but they usually pay $50 to $100 each time!

[Mary-Beth]

Thank you all for your replies!
I didn't get any bad vibes from the midwife but of course, I read through the contract carefully and wanted to ask all these money questions....I'm glad to know these guidelines are consistent with others. I can understand being paid the full amount even in the event of a transfer. Although then we'll really be dishing out money becasue we'll be paying both the midwife and the hospital!
I didn't realize that some people wait to call the midwife until they're pushing as most of us are fully aware- that we're in labor before that point. As for paying in full prior to the birth- I guess I see the point. It's just with most contracts, etc. you never pay in full until the jobs complete. (If I had, my fence still wouldn't be up!) I guess this is a bit different. I would never imagine that anyone would not pay promptly, never mind not pay at all. The midwife did include in her paperwork a statement about the possibility of making special arrangements agreeed upon ahead of time, if necessary. I feel good about this midwife and if I do indeed go with the homebirth I will probably go with her but I need to fully understand what I will be expected to pay and what situations will change the price. I also have to order a lot of things separately (supplies and apt. with back up Dr.) and so I have to get to the bottom line and know what I'm getting into price wise before I commit to this!
Thanks again for all your thoughts!

[birthinglau]

ditto to all the other posters. I paid in full by about week 30. I was very committed to my homebirth, and wanted my midwife to know that I respected the care she was giving.

something else to think about.... in many states direct entry midwives are either illegal(nc) not legally recognized at all(oh).

if client doesn't pay following a birth, that midwife has no recourse.

no hb midwives I have met are in it for the money - even ina may gaskin lives in a modest house and drives an older car.

in our society we put alot of value in money, to pay in full, and in the event of circumstances out of midwives control like transport, shows that you value that service she provides, IMO.

-Lau

[Kirsten]

Our insurance covered all three midwife assisted births - I am feeling very lucky after reading all these posts! First was in hospital (HMO), second was freestanding birth center, third was at home. I think we had different insurance all three times! Not sure what was charged but it was all covered.
But I do think that expecting payment up front is fair. I can imagine that not seeing "after the birth" payments is fairly common, sadly.
Kirsten

[candiland]

No, my midwife still has people paying her back years after the births of their children... she believes that homebirth should be affordable for everyone, and not everyone can pay it all off before the birth.
I do understand the part about paying even if the midwife misses the birth. There are a few women out there who really want an unassisted childbirth but secretly "use" the midwife as a back-up in case things don't go well.

[Greaseball]

I think if a client wants a UC the client and the midwife should work it out together before the birth exactly what the role of the midwife should be. Hopefully the midwife would be willing to serve only as a backup and would also accept a different fee just for being available in case she is not needed.

It would be unfair for an obstetrician to expect to get paid for a birth if the client ended up giving birth at home, whether or not the client had told the OB of her plans. OB's do still get paid if they don't show up at the hospital to catch the baby, though, also unfair IMO.

I've just gotta use a bad analogy here, cause that's what I do: Say you order a pizza and the guy doesn't show up with it. You keep calling and saying "I really, really think it is time you got here now!" Several hours later he is still not there so you give up and make your own pizza. If he shows up later, would you pay for the pizza? I wouldn't!

I would choose a midwife who instead of saying "Prenatal, birth, postpartum is $2000!" would be willing to break down the charges and only charge the client what she received. My midwife told me at 36 weeks she would not be able to attend my birth after all, but she did not charge me for it just because she had been expecting to get that money all along.

I was seeing an OB at the time and was keeping my homebirth plan a secret but if after the birth she had said "You decived me; I was really looking forward to that money and you had a responsibility to tell me I might not get it!" I would say no, I will pay for prenatal visits and not for something I did not get.

The way I see it, midwifery care and home births are real needs and not luxuries. It's illegal for a hospital to turn away a woman in labor even if she says "No way will I ever pay my bill!" There are some midwives who will take clients who cannot pay anything at all. The one I was going to go with, before suggesting a payment arrangement, said she would accept goods or services in place of money.

I think most people will pay what they can, when they can, and are not out to take advantage of midwives. I just paid off a hospital bill from 6 years ago, and the hosptial actually made more money than they would have if they just got it all up front.

Wow, you're still reading this?! One last thought - I personally would never stiff a midwife, or anyone else. I think the overly suspicious attitude of "Well, I have to get all the money now or I might never get it" can get in the way of the atmosphere of perfect trust I would like to have at my birth. It goes both ways, I think: I would have to trust the midwife to provide the kind of birth experience that's best for us and that she woudn't secretly break my water during an exam and go "Oh my gosh that just happened all of a sudden!" and she trusts that I will fulfill my end of the bargain.

Anyway...I am not a midwife, nor have I had a home birth, so it's possible I don't know what I'm talking about here. Just interested, that's all!

[pamamidwife]

There are a million reasons why I am a midwife, and unfortunately (or fortunately, depending how you look at it), none of them have to do with money.

In my state, I pay $2000/year for a license. I am not married to a man that is independently wealthy. We have a mortgage, a family, things like the rest of the world.

Midwifery takes a HUGE amount of time from my family. I am on call 24/7 for clients - even BEFORE their due dates. I spend ALOT of time with clients not only prenatally, but at their births, and postpartum.

I do some births for free. I do reduced fees for those that really need it. And, yes, I have been stiffed by people.

Once the baby comes, especially if ther is a transport during labor, the chance of a midwife getting the remainder of her fee is slim. This is more so if the couple doesn't have insurance to cover their hospital fees. Once a baby comes, moms usually stop working (which I agree with!), but that means less income. Things come up with babies that are not anticipated.

I prefer to pay my assistants before the birth. I like to know that by a certain time, I can count on a certain amount of money. When every month varies greatly, it helps when planning bills, professional fees, etc.

I don't make a buttload of money. I do well, but my education cost quite a bit, and I sacrificed working so I could apprentice for four years.

So, it's not about money. BUT it is about honesty, and unfortunately, not everyone is honest. You can be intimately involved in an event like birth and people will still not follow through with plans and promises.

I have a financial agreement, not so much because I don't trust anyone (because that's far from the case), but because I want to be clear. I have boundaries and I need clients to know what I expect, just as they let me know what they expect.

When my daughter was seven and she cried on the phone because her mom was gone for 72 hours at a birth, or she tells me now that I'm "always on the phone", it makes me realize that no matter how much I love what I do, my time is valuable. My experience is valuable. I know what I'm worth, and it's not something I feel bad about.

(Nor should anyone else!)

My hourly wage is not what you'd expect. Those that can pay help me be able to slide my fee and waive it at times for those that cannot.

Even the minister at my church gets paid more than I do - and he gets three months off during the summer!

[Carolinamidwife]

Greaseball,

About your analogy... what if you ordered the pizza but then ate something 15 minutes after you ordered it and that was your plan all along? My midwife had two clients who planned their UC without telling her, leading her all along to believe she would be attending the birth. That should not excuse them from paying the fee they agreed to. Neither one paid her for the prenatals she had done for them, their labwork, or their birthkits, let alone the birth. We certainly would not charge a client if we did not make it to the birth by some fault of our own.

As for midwifery care being a need and not a luxury wrt to not turning people away the difference there is that the money that care costs for clients who cannot or do not pay does not come from the doctor's pocket. CPMs in my area buy all of their own supplies with their own money and midwifery supplies ain't cheap. Not to mention the value of their education and their time which is usually time spent away from their families. (And when I say "time" sometimes that means 2 or 3 days. Imagine not getting paid for 2 or 3 days of work...) CPMs here do not have the luxury of billing services or collection agencies. When someone does not pay they are actively keeping money from the midwife who most likely has bills to pay.

You may think the attitude of "I have to get what I can when I can" might get in the way of perfect trust until you have been stiffed out of thousands of dollars repeatedly. I don't know a single woman who got into midwifery for the money which is why most of the midwives in my area charge minimally. However, it is ludicrous to not be insistent about the fees we do charge. It is important to the value of midwifery and to each midwife's individual value as a birth professional. You may not see how you personally could stiff your midwife but it is an epidemic here in DFW. Besides, the best way to get that sort of issue out of the way is to find a midwife whose fees you are comfortable with and then pay her without her ever having to ask.

[Greaseball]

Well, yes, I can see how that kind of dishonesty can be a problem and should not be an excuse for not paying. If I ordered a pizza and then left the house and the guy came and I was gone, then it would be unacceptable for me to say "Well, why should I pay; I never ate it!"

But that goes back to my thing with the OB again - I kept my home birth plan secret (for a while) because I knew they would talk me out of it (which they did). I would not pay them for a hospital birth if I had gone behind their backs to have a home birth. I would pay for prenatal visits only.

Some midwives are against the idea of UC, which is why clients may lie about it. If both parties can be up front and open-minded, everything should work out.

Of course, if one is going to have a UC, why see a midwife to begin with? If you think you might have an emergency, you probably don't want to have a UC or any other home birth. And if you do have a UC and have an emergency, you'd go to the hospital. If it were a true emergency I would not be concerned about not having a relationship with the on-call OB.

Some towns may have a shortage of midwives so a client may have to go with what is there. If that were the case with me and she required payment before birth, I would do it, but I would want a contract. If she did not show up in time due to negligence on her part such as oversleeping, running out of gas, or being drunk, I would want a refund. That's reasonable, right?

[Malama]

Aloha!
The difference, as I see it, between lying to your OB about having a homebirth and lying to a midwife about having an UC is this:
Usually OB's have a large practice and each woman who comes is another patient. Usually there is little time for relationship building with your OB-- appointments aren't usually more than 15 minutes (and for many I know, they are MUCH shorter).
A midwife is initmately involved with the birthing couple. The midwife I work with as an apprentice puts a whole lot of time and energy and emotional energy into each mama- as soon as they decide to have a homebirth with her. The committment for her begins right away. That means that if a couple lies about actually wanting to have her at a birth, they are seriously breeching a relationship that should be based on trust.

Also in terms of being paid... since midwives do put so much time and energy into their clients (way before the birth ever happens), don't they deserve compensation for that, regardless of whether the birth is a transport or they don't get there on time?

"I think most people will pay what they can, when they can, and are not out to take advantage of midwives"
True... but there are sure a lot of unconscious people where we live who don't seem to realize that the midwife has a family, bills to pay, etc...

I intend to be very clear about money when I become a midwife. My time and energy are valuable-- and while I will make consessions for those who can't pay, I will expect to be paid for services rendered!

Good discussion!

Karen

[georgia]

There are always extenuating circumstances when the mws will work with families who cannot pay up front. All the midwives I know have their clients sign contracts. I, personally, would never pay someone money for services *expected* without a contract! It protects both parties. As a frugal mom who has homebirthed, I am a huge proponent of payment up-front. It is only fair to me to value and honor the mw's time, energy, etc.

My mw has several back-ups, in addition to her apprentice. As far as running out of gas, being drunk, etc.--the mws I've had the opportunity to work with are professionals. They have a code of conduct which they uphold. They keep their cars full of gas; don't drink while on-call. They do their very best. I trust them with my life and the lives of my babies. The peace of mind which comes from the midwifery model of care is priceless!

The hb grapevine is powerful. Just ask around

Amy

[pamamidwife]

Another issue I thought of is the instance where two clients are in labor at the same time. Then, I pay another midwife to do one of the births...it would suck if I hadn't gotten paid enough from the client to pay this midwife for the birth - and that money would come out of my own pocket.