The Cost of Midwifery Care
Midwifery care in the United States in recent decades has most often been utilized by upper middle class people. Only about 15% of the US population are upper middle class, making more than $60,000 per year. Midwifery care has not been an option for most since it’s resurgence in the 1970s, especially in states like Arizona where homebirth is not covered by state health care. In Arizona, most pregnant people will qualify for the state's medicaid program because they make less than $18,000 per year. That is a far cry from upper middle class.
At a Midwife's Kaleidoscope we use a slide scale model because we strongly believe that midwifery care (or any healthcare) should be financially accessible to everyone, not just people with the means to afford the local going rate. Those privileged enough to be in the upper middle class pay full fees but the majority of folks pay less. This is not a discount, not charity, not pity. It is a well known model and it is a way of balancing out wealth disparities that lead to health disparities.
When midwives say, and MANY do, that anyone who wants a home birth bad enough will find the means to pay the full rate, we can only assume that they have never known true poverty and that perhaps they come from a place of unrecognized privilege. The reality is that most midwives, must like most midwifery consumers, are also upper middle-class. Many midwives have never known the experience of being unable to pay the rent, keep the lights on, or save pennies for food. Most midwives in my area are now, after a few years, happy to have someone more affordable to refer people to and we have noticed others adopting sliding scales or openly offering more flexible payment arrangements. This is a good thing.
Some midwives hesitate to discount their fees, believing that it will get them harder clients. Poverty is hard on people's bodies and spirits. People’s health status is directly related to their income level - and their race, sexuality, and education level and a myriad of other social determinants. People with less money may be less healthy because there is an entire structure set up against them. They have more complications, more emergencies, they transfer more. They experience more overt violence, more complex social situations. They care less about the "mother-midwife relationship" and more about survival. They are NOT upper middle class.
That is okay. Remember the MAJORITY of pregnant folks make less than $1500 per month. Rather than expecting the majority of pregnant folks to adapt to be able to qualify for midwife care, paying fees that may be in excess of two months worth of income, we believe that midwifery should adapt. Rather than being intimidated by folks who may not be able to afford the luxury items of pregnancy, we can offer home visits, hour long appointment, needed referrals, we can do the hard thinking it takes to be innovative in our care.
Knowing how to help create health without relying on disposable income is a gift. Food based vitamins can be replaced by good, balanced produce bought on snap. Beans are high in protein and very inexpensive. Hotel rooms make pretty cheap birth centers for folks with unstable housing. Regular prenatal body work can be a part of midwifery visits. A belly bands can be made out of a scrap of fabric. Birth tubs can be replaced by a kids blow up tub or your apartment bathroom tub.
We have offered an income based sliding scale since the inception of the practice and always will. The scale starts at about 1/3 the local going rate and goes up to insurance rates at the top. It is applied across the board, not just for people who are brave enough to ask for a discount. We offer payment plans in addition, sometime accepting payments as low as $50 a month for as long as it takes. We barter when we can, trading needed services with our clients so their care can continue. This is our way of ensuring that money is never the reason someone does not get quality, professional, caring midwifery services.
(Please note - this article is written from the perspective of a CPM providing out of hospital midwifery care in Arizona. Hospital based midwives (CNMs) are often covered under Arizona state health care and some countries and other US states have health care systems that cover out of hospital midwives.)