Monday, September 26, 2011

The Truth about Midwives.. Part I

There is a lot of misinformation out there about midwives. Generalizations about their character, why they choose midwifery and how much money they make, have all been misrepresented.  I think we deserve to know the truth about midwives and all the different areas of concern. There's a lot of ground to cover and there is a lot I have to learn, so I am beginning this post as Part I and will continue with Part II in time. I want to discuss where there is room for improvement, as well as the best aspects of midwifery care. I am also interested in interviewing a CPM, so if anyone reading is interested, please let me know. In this post I'd like to look into a misconception I've been seeing a lot lately..  the salary of the CPM.

For awhile now, I have watched silently as people discuss the very large amounts of money CPMs must make. The theory, is that they make 4k a birth, do 4 births a month and therefore make 16k a month, which would almost be 200 thousand dollars a year. I'm assuming that the people who claim this about midwives must not know any. It's a nice thought but entirely unrealistic. When I had my homebirth I had two midwives attending. These women usually spent at least two hours with me at every appointment. Looking back, they were very kind to let me ramble on with my questions and concerns, well past my time slot with them, every time. I never felt rushed, I never felt they had somewhere more important to be. They both have three children each and are part of a large, busy practice, yet I always felt like I was their only patient. They each made $1500 from my homebirth. Probably less because a third midwife also helped with my prenatal care and I know some of that money went to her. That is $1500 for the six and a half months of  pregnancy care, the 5 hours they stayed with me during labor and giving birth and the 5 hours afterwards where they cleaned everything up- which included doing our laundry. That included the 6 weeks postpartum care and the time when I called at nine at night, crying  because I couldn't get my baby to latch and my midwife rushed over to help me. I could go on and on about everything they did, all the time and effort they put in to giving me the best care possible, and I still don't think I could do an accurate job of displaying how amazing and dedicated these women were.  In all honesty, I actually think they were underpaid for all the time and effort they put into me and my family.

Now compare that with the 2 or 3 months I saw an OB, had 15 minute appointments each time and still had to pay him $1000 after insurance. I understand this is not everyone's experience with midwives or with OBs but it was mine and I thought I'd share it. I do think OBs are getting a bad rap and I don't think that's fair, considering there are many compassionate and caring ones out there. I think part of the problem is that OBs are very busy and if someone is wanting more one on one time, they might be disappointed with their OB experience. I am also well aware that there are some really negligent midwives out there. I have heard horror stories that absolutely no woman should ever have to encounter. But I'll get more into that later.

However, I think it is really inaccurate to tell people that midwives, in general are in it for the money or that they make more than OBs. Yes, I have even heard that one being claimed!
According to this link, OBs make around 200 thousand a year.

It's more difficult to know exactly how much midwives, CPMs specifically, are making a year because there can be a pretty distinct difference in what each midwife charges. Also,  there isn't always a guarantee a midwife will be paid in full or even paid at all. 
Here is a discussion between those who think midwives are making a killing and a woman who is in her early trainings to become a midwife. 

I thought it was interesting to read first hand knowledge of how much midwives are making and what that money goes to.  My feeling is, if most midwives were in it for the money, if they only saw their clients rarely or always showed up late for births, homebirth would die out. Word spreads pretty quickly and I don't think we'd be seeing such an increase in homebirths if the majority of midwives, as it has been suggested, are just in it to make a buck.
To be continued...


  1. Oy. I'd LOVE to be making $16K a month. What solo practice homebirth midwife is that busy and that well-compensated??!! Thank you for this. Also, many clients cannot afford self-pay, and Health Insurance companies are loathe to reimburse non-nurse midwives without many hours spent submitting appeals. LMs and CPMs working in a home setting save thousands of insurance dollars PER BIRTH. Seems a no-brainer to support that model. Seems awfully politically motivated not to...

  2. I wish we had more midwives. I wish I had been able to have one back in the 1960s when I had my first 3 children. Oh how I wish that I had been able to have that level of care.

    I was lucky because in those days my doctors appointments were longer than 15 minutes. I had the first two babies in Charlottesville VA and my doctors were supportive but NOT in the way that midwives are.

    My third baby was born in Washington DC and my doctor was my favorite of all time when I was visiting in the office. But for birthing, I never got what I really wanted which was a home birth.

    My last two babies were born in as unassisted a way as possible in a hospital. NO interventions, no IVs, no drugs. Nothing. But it was still a hospital. I got out of there as fast as they would let me. But in the 70s when those last two were born they were still trying to keep us a few days. I got out fastest with the last one at one and a half days (but it was close to 48 hours total time spent there.

    Midwives trust birth, as a rule. I don't classify all of them the same way. Some of them are MED-wives and they are sometimes more like doctors than the doctors themselves. Be careful of these types. They may sound OK when talking to them, but if they start telling you all the things that could go wrong and explaining why they want to do sonograms or induce a baby, run in the other direction.

    Your baby will come out whether you use a doctor or a midwife or birth unassisted. Trust your body. And if you wish for help having your baby find a midwife who trusts your body, too.

  3. I loved the post, but some of the comments quoted made me mad. First of all, I doubt most people know how much prenatal care and delivery in a hospital REALLY cost before insurance.

    I bet if you broke down what a midwife charges, minus her expenses, then divide by the number of hours she spends with you either in person or on the phone, their childcare expenses and any time they are preparing things for you in their home, I'd be surprised if they even bring home minimum wage.

    There are also things that you can't put a dollar amount on, like the fact that for each client there is a 5 week window in which they can't make any significant plans or vacations.

    I highly doubt that any midwives have 4 clients a month 12 months a year, but if they do, then they are not taking vacations or spending holidays with their families.

    I don't get how people think midwives make $200k and only work a couple of hours a week. If they have 4 clients a month and we'll say they see each client for 7 months, that's 28 clients at once. That's about 15 hours per week JUST from prenatals. That's using the average of 90 minutes per visit (I've never had a visit less than 2 hours) and that clients birth at 40 weeks. That does not include any travel time (which can be significant, as some midwives have clients 1-2 hours away and she is visiting the clients due that month once each week for prenatals), labor, clean-up, time spent gathering and sterilizing supplies, post-partum visits, paperwork and continuing education and training. I'm sure it comes up to be well over 40 hours per week.

  4. Ha! I wish I could expect to make $16k a month profit as a CPM. I know my preceptor doesn't, and her practice has stayed pretty busy since I've been with her. We're in a very heavily populated urban area and her official fee is $2800 per birth. It is not unusual at all for clients to end up paying much less than that though.

    An average week (for me, an apprentice, who doesn't attend consults or random drop in check ups, only prenatals, births, and postpartum visits) is a minimum of 20 hours plus travel time. Depending on when women go into labor and how long it lasts, 80+ hours in a week isn't unheard of. Plus, equipment doesn't sterilize and reorder itself, nor do office toilets and floors clean themselves.

    Then there is the training. NARM does require ongoing education, and, even an uncertified lay midwife is probably (or should be) continuing her education in some capacity. This may involve workshops on specialized topics, or workshops to practice and perfect infrequently used skills (as NRP and and CPR should be).

    Then there is gas money. I know most of my income (from a second job) ends up going to my fuel costs. I drive a small, high miles per gallon car. My senior midwife drives an SUV to carry all her equipment. I would imagine she pays twice what I do, if not more, to get around. We live and work in a highly populated area, but suburban sprawl is crazy and going an hour away to a woman isn't unusual.

    Then there is oxygen, herbs, homeopathics, meds (if they are in a state where they can carry them), and single use items (amnicot, syringe, delees, oxygen masks, bulb syringe, etc.). The reusable equipment must be maintained and, occasionally, replaced. Lab work is normally paid for by the midwife with the expectation that client will reimburse her. That doesn't always happen though. Also, a few midwives do, in fact, carry insurance.

    It all adds up, and I can't stress enough how often births end up being done for barely enough to cover basic costs. On top of that, if care gets transferred, even at the very last minute, the standard rule here is the get a refund of everything except a small fee for each prenatal that was performed.

    If there are homebirth midwives out there getting rich from it, they aren't local to me.

  5. *That should read "..the client gets a refund of.."

  6. Ok, honestly-even if they WERE making a "killing", who cares? Why is it ok for dentists, obs, and doctors to get paid more than fairly for their jobs, but not midwives? For many women, a midwife is their most valued medical professional.
    If anything, when you think about all the work and hours that they put in for a woman's care leading up to the birth, and insurance, they're probably underpaid.
    Here in ontario midwives are regulated, and therefore (I think/hope) paid fairly. I wish midwives everywhere could be as lucky.

  7. My midwife is charging me $2800, $2600 if paid in full by week 36. That includes up to 15 hour-long prenatals, attendance at the birth (which I would guess averages about 8-12 hours total, including the minimum 3 hours immediate postpartum care), and up to 6 postpartum visits on the usual schedule. That is a total of approximately 27-33 hours of care. My midwife splits her fee with a partner CPM, which means each woman is earning about $50 per hour BEFORE taxes and other expenses, such as equipment, supplies, gas, insurance (if applicable), childcare, continuing education, and fees associated with belonging to professional organizations, subscribing to academic journals, maintaining neonatal resuscitation certification, etc. I would be surprised if they make half their gross after expenses and taxes. And they are required to be on call and available 24 hours a day, 7 days a week, even if that means leaving weddings, funerals, birthdays, school functions, family gatherings, etc. And what do I get for my money? In all three of my pregnancies, I have received the best, most comprehensive, compassionate, respectful, professional, and holistic health care of my life, hands down. I have been educated, informed, empowered, supported, and nurtured. I have had attendants at my births who knew how to do nothing, when nothing was needed, and, on the other hand, could calmly, competently, efficiently handle comlications, if the need arose. I have had no unnecessary interventions or non-evidence based protocols thrust upon me. I have, instead, been given the gift of an empowered, ecstatic, gentle, natural, normal, physiologic birth (for mother and child) twice...and hopefully, a third time this year! The care provided by my midwives has been skilled, competent, and professional, and I am tired of non-nurse midwives being mischaracterized as lazy, greedy, unprofessional, untrained, unskilled, ignorant, or negligent. That is simply not the truth when it comes to the vast majority of home birth midwives I have known. My midwives strive to provide quality health care to low-risk women, to facilitate natural birth, to deal with unexpected complications, to recognize the li its of their scope of practice, and to transfer or transport, when necessary. They recognize that a small fraction of births require a more medicalized approach in the hospital. My midwives have recently (and successfully) managed shoulder dystocia and a surprise breech at home, as well as appropriately transferred care of a woman who needed an induction and cesarean. And that is what we hire them to do.

  8. Awakeman- maybe YOU should rewrite this blog post! LOL! So well said!!!