"This time honored model of caring for families and welcoming the next generation is outside of the current dominant system of industrialized healthcare. When it comes to the structure of care as well as payment and insurance coverage, private midwifery care and home birth do not fit the mold. Parents often have questions about how the two models differ regarding what they entail, how they function, and fee structures and insurance coverage.​

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Midwife led care and home birth have much lower costs overall compared to hospital birth, as well as increased client satisfaction, and clearly proven healthy outcomes for birthing people and their babies (especially those from marginalized and oppressed groups such as BIPOC and LGBTQ people). However, the industrialized, for-profit insurance system incentivizes and favors hospital birth and hospital based providers. Despite the fact that most insurance plans include benefits for hospital birth, families are often surprised by large, unanticipated medical bills after their care is complete. There is little to no transparency from hospitals and insurance companies about expected out of pocket costs before care is received.

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In the private midwifery model, families are asked to pay the fee up front over the course of pregnancy, but the fee is fixed, and costs are known ahead of time. This allows for planning and budgeting, and avoids the shock of unexpected or higher than expected bills after the fact, when it is too late to consider other options or change course. The cost of midwife care can sound high at first glance, but in truth it delivers far greater value in time spent and scope of support than the standard offered in hospitals today.

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So why is it so hard to get insurance to cover midwife care and home birth fully? Part of the issue is that the insurance billing codes are the same for hospital based providers and independent community based providers like me, but the reality of the services provided are quite different. For example, there is one fixed code for a prenatal visit, but with a physician that equates to about 10 minutes of face to face time, covering just the basics, whereas with a midwife a prenatal visit lasts about an hour, takes place in your home, and goes well beyond basic assessments to include lots of time for health education, informed choice conversations, emotional support, sharing of additional resources, and so on. These two prenatal visits are not really the same service, but insurance recognizes only one code - the one that was created for the dominant system and does not adequately reflect the value of midwife care.

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The following lists are a reference for understanding what these two models of care offer and the associated costs. There are of course variations and exceptions. These lists represent typical care and costs.

• Approximately 10 prenatal office visits, 10-15 minutes each.

• Birth attended by physician on call, frequently not the main physician seen for prenatal care. Face to face time with physician during labor and birth is typically less than one hour. Most care during labor and birth is provided by nurses on rotating shifts. Multiple doctors, nurses, and other staff members are likely to participate in care for short periods. Usually three to five or more staff members present in the room for the birth. Limited freedom of mobility. Deep water labor tubs and water birth not available.

• One to two postpartum office visits (24 hours and 6 weeks postpartum), 10-15 minutes each.

• No newborn or well baby follow up care is included beyond the hospital stay. The pediatrician relationship and fees are separate.

• Limited to no detailed informed choice collaboration with physician.

• Patient care subject to hospital and physician group standard policies, procedures and routines. Limited opportunity for individualized care. Interventions are the norm.

• Large institutions are inherently slower to adapt to and implement updated evidence based care management practices.

• Physician and hospital fees are billed separately, are not disclosed up front, and may be covered at different rates by insurance. Insurance typically does cover some portion, small or large, of physician and hospital care.

• Total time spent face to face with the physician: approximately 2.5-4 hours

• Cost of care: The average bill for a full course of care before insurance ranges from about $30,000 to $100,000 or more, depending upon the specific events of the pregnancy, birth and follow up care. Cost to families after insurance varies massively, from close to $0 up into the tens of thousands of dollars. It is not uncommon for a family’s out of pocket cost after insurance to equal or exceed the average cost of midwife care for out of hospital birth.

• Approximately 10-14 prenatal home visits, 60 minutes each.

• Birth attended at your home by the same midwife/midwife team who provided prenatal care. Two midwives and possibly a student or assistant attend each birth. Face to face time with midwife during labor, birth and immediate postpartum is typically 8-16 hours or longer as needed. All hands-on care and assessments are done by the midwives. Freedom to move, eat, rest as you wish. Labor and birth in any position in any area of your home. Deep water labor tub and water birth available. If a transfer of care from home to hospital is needed, midwife provides detailed records, facilitates the transfer, accompanies the parent(s) and acts an an advisor and support person throughout the remainder of the labor and birth. Midwives may take breaks or take turns staying with the family if the birth is very long.

• Six postpartum and newborn care home visits, including lactation counseling, 60-90 minutes each. Birthing person and baby are seen as linked, and are cared for in relationship to each other. Both are evaluated and supported at each visit for clinical factors as well as mental and emotional health. Newborn care through six weeks is part of midwifery scope of practice. There is no need for new parents and new babies to leave the house in the first days and weeks to access care, reducing stress, speeding recovery, enhancing breastfeeding, and reducing exposure to pathogens.

• Continuity of care with same 1-2 midwives throughout the childbearing year.

• 24/7 direct access to midwife during due date window and early postpartum period.

• Individualized care based on birthing person’s values, desires and choices.

• In depth informed choice and collaborative decision-making is ongoing. Client autonomy is central. Minimal intervention is the norm. Care is subject to some legal restrictions.

• Independent providers can be very agile in updating practices and recommendations based on new evidence and research, as well as client preferences.

• Cost of midwife care is fixed and is known up front. No surprise charges. Midwife fee does not increase if additional visits are needed or care becomes more complicated. (Deep water labor tub is included in midwife fee. Lab work, ultrasounds and birth supply kit are additional costs.)

• No facility/hospital fees.

• Payments can be planned and budgeted in advance.

• No payments to make after the birth.

• Insurance coverage is not guaranteed, and LMs are out of network providers for all plans. However, clients can rest assured that even if insurance does not cover midwife care, their out of pocket fees to the midwife are capped and will not exceed the predetermined retainer amount. If insurance does cover some portion of midwife care, clients may receive a refund.

• If a transfer of care from home to hospital is needed, client is responsible for the additional costs.

• Total time spent face to face with the midwife/midwife team: approximately 24-40 hours, or longer as needed. No time limit.

There are advantages and disadvantages, benefits and risks to both planned home birth and planned hospital birth. Each family should carefully weigh these against their own values, desires and abilities as they make important decisions about providers and planned birth locations." -Redwood Midwifery