Quick Hit: The Cost of Being Born at Home

File this one under Shameless Self-Promotion.
I have a new piece up at RH Reality Check about homebirth and low-income women.

One mother laboring with her midwife on the roof of her Cobble Hill penthouse, gorgeous Manhattan skyline in the background. Another holding her newborn on her living room couch, exposed brick and high ceilings behind her. These are just two of the scenes from the November New York Times article and slideshow about the growing interest among New York City women in birthing at home. These images paint a very specific picture of homebirth–all the women were pictured in spacious, nicely decorated apartments and, with the exception of one African-American woman, all were white. Watch the popular Ricki Lake documentary The Business of Being Born, released last year, and you get a similar story: Lake and her interviewees were all financially well off and could afford to choose to birth at home. Neither the Times article nor Lake’s film touched on one thing that all these women seemed to have in common–money.

Read the rest here.

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31 Comments

  1. Ismone
    Posted March 20, 2009 at 5:11 pm | Permalink

    Fabulous article, Miriam. My younger sister wrote a piece a while back decrying how people were being stripped of their citizenship, particularly Latinos/as who were born at home to midwives.
    I am considering home birth, but of course, I can afford it. My sister had two, and my mother had six hospital births, the first two of which were dreadful, the last four of which were great, because the doc. who handled the last four really LISTENED TO HER. Unfortunately, he retired. :(

  2. rose0red
    Posted March 20, 2009 at 5:25 pm | Permalink

    For some reason I’m having trouble opening the article. Anybody else having problems?
    I’m really interested to read this. A couple close to my family chose to have their baby at home,even though they knew their insurance wouldn’t cover it. Unfortunately there were complications with the baby that the midwife (a capable professional) couldn’t handle in the home. The baby ended up having to be transported to a hospital and treated at great cost. And of course the insurance wouldn’t cover any of those bills because the ‘problems originated from an unapproved homebirth,’ or some such.
    More evidence that health care needs reform.

  3. rose0red
    Posted March 20, 2009 at 5:26 pm | Permalink

    For some reason I’m having trouble opening the article. Anybody else having problems?
    I’m really interested to read this. A couple close to my family chose to have their baby at home,even though they knew their insurance wouldn’t cover it. Unfortunately there were complications with the baby that the midwife (a capable professional) couldn’t handle in the home. The baby ended up having to be transported to a hospital and treated at great cost. And of course the insurance wouldn’t cover any of those bills because the ‘problems originated from an unapproved homebirth,’ or some such.
    More evidence that health care needs reform.

  4. rose0red
    Posted March 20, 2009 at 5:26 pm | Permalink

    sorry for the double post

  5. baddesignhurts
    Posted March 20, 2009 at 5:48 pm | Permalink

    i have some questions, the first one being: is it equally safe for women without full prenatal care to have homebirths as for those that *did* receive that prenatal care? b/c the lack of even standard prenatal care for low-income women is also horrifying. are there any statistics available on this issue? it would seem unethical to me to support/publicize homebirth for low-income women if they aren’t getting enough medical care in the first place, because it would seem like more could go wrong with a homebirth than with a woman who *did* have complete prenatal care. (i’ve heard that for some very low-income women, it’s not until they actually head to the hospital to deliver that they ever see a doctor during their pregnancy AT ALL.) but i’d like to know more before formulating an opinion.

  6. rose0red
    Posted March 20, 2009 at 5:57 pm | Permalink

    I’m not an expert, but I doubt licensed midwife would consent to delivering a baby at home unless either a) she had been performing pre-natal evaluations for the woman all along, or b) knew the woman had pre-natal exams and had thoroughly reviewed the records. Otherwise, the midwife would open herself up to malpractice charges.
    I imagine many cases of extremely low-income women not having pre-natal care and giving birth at home involve non-certified practitioners or family members delivering babies. Probably not the safest thing.
    But a certified nurse midwives are thoroughly trained and able to handle a large range of problems, in the hospital or in the home. Its just that home births aren’t typically covered by insurance, making them a luxury of the well-off.

  7. Ismone
    Posted March 20, 2009 at 6:05 pm | Permalink

    As far as I know, all midwives perform prenatal care as well. Home-birth is safe for low-risk pregnancies, and determining whether a pregnancy is low-risk or not requires some degree of medical care.

  8. penny rose
    Posted March 20, 2009 at 6:36 pm | Permalink

    It must be nice to be able to afford to HAVE a choice whether to give birth at a a hospital or at home. That choice should be afforded to all women.
    That being said, I do not understand why ANY woman would want to have a baby at home! Sorry,but having a baby is pretty dirty business. After having a baby a room could look like a crime scene straight out of CSI. You have the mucus plug to deal with plus the constant changing of the sheets because of the ambiotic fluid and urine. Let’s not forget about the blood and the possible defecation that happens ( at times) when pushing. I only have a few nice sheets and one mattress and cannot afford to replace them.
    I almost forgot about the grunting, yelling and profanity ,so I guess I can see where having enough money to have a big enough home instead of an apartment(where the neighbors can call the police!) just might come in handy.

  9. penny rose
    Posted March 20, 2009 at 6:36 pm | Permalink

    It must be nice to be able to afford to HAVE a choice whether to give birth at a a hospital or at home. That choice should be afforded to all women.
    That being said, I do not understand why ANY woman would want to have a baby at home! Sorry,but having a baby is pretty dirty business. After having a baby a room could look like a crime scene straight out of CSI. You have the mucus plug to deal with plus the constant changing of the sheets because of the ambiotic fluid and urine. Let’s not forget about the blood and the possible defecation that happens ( at times) when pushing. I only have a few nice sheets and one mattress and cannot afford to replace them.
    I almost forgot about the grunting, yelling and profanity ,so I guess I can see where having enough money to have a big enough home instead of an apartment(where the neighbors can call the police!) just might come in handy.

  10. bifemmefatale
    Posted March 20, 2009 at 6:36 pm | Permalink

    I had both my children at home with midwives, and although I was very much a crunchy hippie doctor-avoiding gal anyway, the cheapness of homebirth compared to hospital birth was a big incentive for us too. We were working poor without Medicaid or private insurance, and my midwife charged us $1200 total for all prenatal care and delivery, (this was in ’93 and ’95) plus I had to go out and buy all the birth supplies. Far cheaper than the hospital would have been.
    My midwife no longer does homebirths because she was prosecuted for a stillbirth that the parents did *not* want her prosecuted for. The Illinois doctors’ lobbies have put a great deal of pressure on prosecutors to stamp out homebirth.
    I firmly believe that for both better maternal and child outcomes and to combat the cost of healthcare, this country (US) needs to stop persecuting midwives and start encouraging birth alternatives. We are so far behind most of Europe in this respect that it isn’t even funny.

  11. Miriam
    Posted March 20, 2009 at 6:37 pm | Permalink

    What I found, which was interesting, is that there were quite a few low income women getting their prenatal care with midwives, or in birthing centers, but then the majority of them were going to the hospital to give birth.
    This was JayVon’s experience, who is a Certified Professional Midwife.
    Access to prenatal care is a whole other issue, and obviously if a woman is not getting prenatal care then she’s not going to be able to choose a midwife for her birth.

  12. Fabiola
    Posted March 20, 2009 at 6:45 pm | Permalink

    I wanted to have a home birth, and it was going to cost my family $3,500. My insurance didn’t cover that…instead I had a hospital birth b/c my little one was breech ended up having a c-section.
    Home births are a privilege if you ask me…I don’t know many women of color that have that choice.

  13. MissKittyFantastico
    Posted March 20, 2009 at 6:53 pm | Permalink

    I was wondering about that too. I think I’d like to come back to a nice clean house afterwords, not have to spend the next few days cleaning up all the bodily fluids. Also, I’d want to be near a hospital in case something did go wrong and they needed to operate. Ideally, I’d like to be in some sort of birthing room setup attached to a hospital, like you see on some TV shows, but I don’t know if those are real.

  14. penny rose
    Posted March 20, 2009 at 7:14 pm | Permalink

    Birthing rooms exist,but you have to pay for those as well. When I had my first child the special birthing room was right next to mine.It looks like a regular bedroom with a kitchen attached and everything. The best part of the room was that it had a rocking chair. I sat my fat,ambiotic,blood and urine dripping ass RIGHT in that chair!( the rocking REALLY helped with the contractions).I was in that room for HOURS.
    Not hell or high water was going to separate me from that chair, so the nurse finally put it in my room.

  15. baddesignhurts
    Posted March 20, 2009 at 7:45 pm | Permalink

    i really wanted to do a waterbirth, because i knew that warm water always helped relieve my menstrual cramps, so i thought that the big tub with warm water would help abate some of the pain. then i found out that only one hospital in the city was equipped, and then i ended up needing an induction anyway. (with an induction, you have to wear a fetal monitor, so you’re on your back. i have pretty much constant back pain from injuring myself rollerblading when i was 16, so it was agony. i ended up going with lotsa drugs.)
    i would have elected for the hospital anyway because i’m concerned about the number of things that could potentially go wrong, but it would sure be wonderful if there were at least some more options so as to minimize the stress, no matter which scenario a woman chooses, both within a hospital and without.

  16. Brandi
    Posted March 20, 2009 at 7:55 pm | Permalink

    The rates of maternal and infant death are roughly the same for homebirths and hospital births.
    Many midwives where I am will do at-home prenatal care as well, which is great for women who don’t like the medicalization of pregnancy either.
    In my personal experience, the midwife needs to deem you low- to moderate- risk birth. Because I went into trauma with my first delivery & my son wasn’t breathing when he was born, no midwife would take me as a homebirth patient. In fact finding anyone who would be willing to allow a VBAC was tough.
    I’ve known of a couple of women who had homebirths who didn’t have prenatal care, but to be honest I don’t think they had midwives there either. Homebirths in most places aren’t illegal for the patient, just the midwife. In the cases you mention (women not seeing any medical professional during pg), I think it’d be hard to find a midwife willing to assist. She would have to at least know the woman before the delivery, and how could she if the mother hadn’t sought out any medical care? I mean, it’s not like you just call up and order a midwife when you go into labor. It has to be a preplanned thing.

  17. Brandi
    Posted March 20, 2009 at 8:02 pm | Permalink

    Most of the mamas I know have had homebirths, and all have had significant help from friends who did lots of the cleaning up for them. Almost everyone who comes to mind used a small inflatable pool to be in until much of the time during labor.
    The initial clean-up can get messy, but it’s not that bad after the delivery. I mean, yeah there’s the placenta to deal with, but many parents make a ritual out of planting it in their yard, so they’re not grossed out by it.

  18. penny rose
    Posted March 20, 2009 at 8:23 pm | Permalink

    I watched a birthing show on tv and the woman was giving birth at home and she used one of those inflatable pools. Question, do they keep changing the water in the pool?
    I guess, what amazed me the most about having a baby was all the … fluids.I expected a mess but was surprised to learn that even during a long labor the amniotic fluid is constantly produced and it can replenish itself. Needless to say,after 24 hours in labor that adds up to a lot of sheets! :)

  19. MiriamCT
    Posted March 20, 2009 at 9:32 pm | Permalink

    no worries about mess, the midwives clean it up. before you have a homebirth you get a homebirth kit that includes lots of the same super aborbant big sheet/pad things that they use in the hospital.

  20. LucyBell
    Posted March 20, 2009 at 10:09 pm | Permalink

    At 26 weeks now, I’ve spent MUCH more time with my midwife than I have in the “clinic” with either the nurse practitioner or the OB; my midwife has provided superior prenatal care, catching things in my blood work for instance, that was overlooked by the doctor.
    And yes, it is currently a very large privilege to “choose” a homebirth…though I’m personally baffled by the system that has created this fact. This seems to be the one instance where having less, doing less and spending less (for homebirth) is the privilege; as opposed to doing more, with more technology, and spending FAR more dollars in the hospital is the default. Birth should NOT be the billion dollar business that it is..women are losing because of it.

  21. MiriamCT
    Posted March 20, 2009 at 10:30 pm | Permalink

    Miriam-
    This was a super powerful article and I think you hit it just right. The part about low income women not having choices and being subjected to more medically invasive births in hospitals is so right.
    When I got pregnant with my son in 2004, my husband and I did not have insurance and only part time jobs. We got on the state health insurance plan for low-income pregnant women and children. I had all my prenatal care at the clinic at the hospital where I was going to deliver. When it was time to have my son, I went into the hospital and was immediately subjected to medical interventions that I did not want or need. Despite my white-middle-class background, I was still just a clinic patient and I was treated like learning meat for all the new residents. I’m sure that women who were clinic patients without my background were treated worse. At least no one tried to give me a Depo-Provera shot when I was released.
    I am expecting now and we are financially in a much better place and are planning a homebirth. It is expensive, and since our insurance won’t cover it, we have to pay out of pocket. But my family is helping pay for it and we can afford it. I feel super lucky to be able to have this choice and I don’t take it for granted at all that it is a financial privilege.

  22. MimiX
    Posted March 20, 2009 at 10:54 pm | Permalink

    Here’s a Washington Post article about one woman who is fighting the good fight re this issue:
    A Labor Without End
    By Phuong Ly
    http://www.washingtonpost.com/wp-dyn/content/article/2007/05/23/AR2007052301294.html

  23. KMS
    Posted March 21, 2009 at 12:15 am | Permalink

    I work as a HB assistant and the majority of our clients *have been* on medicaid. Its not just for the rich. Home birth is WAY cheaper than hospital birth. The problem is, CPM’s are illegal in 25 states, severely limiting access to poorer women.

  24. juliestevenson23
    Posted March 21, 2009 at 4:16 am | Permalink

    Wow, awesome article, Miriam. I’m really surprised that more insurance plans don’t have support for home births. There should be a larger allotted sum, do to all of the point made within the article.
    - Julie, consultant for Credit Report Consultant

  25. Jessica F.
    Posted March 21, 2009 at 5:34 am | Permalink

    My SIL was a practicing midwife for many years and she has told me that a good proportion of her clients chose midwife-assisted homebirth because she charged way less money than even the least-invasive hospital birth.
    @ baddesignhurts: a midwife who assists birth at people’s homes is not like a hospital, available 24 hours a day to anyone who calls her/him. If a person hasn’t been receiving prenatal care (incidentally, when you see a midwife’s price quote, it is the cost for prenatal care and delivery, as opposed to the many thousands of dollars hospital delivery alone can run–we increase the risk of poor birth outcomes when we financially force women out of prenatal care), a midwife isn’t just going to show up at her house to deliver her baby.
    As to the mess: a midwife, like a nurse in a hospital, will bring sheets and/or chucks and will clean up any mess afterwards. They won’t just leave you in a “CSI crime scene”.
    It’s been proven time and time again that for low-risk pregnancies, home birth is just as safe as hospital birth. Yet we continue to prosecute and limit access to midwife-assisted home birth. And those limitations simply serve to restrict women’s choices in birth and to strip women of access to a safe, reasonable alternative to birthing in a hospital.

  26. johanna in dairyland
    Posted March 21, 2009 at 12:14 pm | Permalink

    I’m continually surprised by this too … in WI, where we have licensed midwives and home birth is covered by medicaid, NONE of the big HMOs pay for home births. I’m baffled as to why my HMO will pay 100% of a hospital birth, even if it ends in the more expensive (and more days of hospital stay!) c-section, but won’t cover the fractional cost and potentially better outcome of a home or birth center birth with a licensed practitioner. It seems illogical to me.

  27. saintcatherine
    Posted March 21, 2009 at 4:46 pm | Permalink

    At my first homebirth experience(I was just there to help my laboring friend), the midwife did all the laundry after!
    At my own hb, with my third child, I had already purchased or been given spare sheets for my bed and shower curtains. We made the bed thusly: sheets I like, then shower curtains to cover, then cheap sheet, shower curtain, cheap sheet, shower curtain….you get the idea. I ended up realizing during labor that I was NOT interested in getting into bed…so I got my husband to put down some newpapers and a tarp, which I covered with some more of the sheets. I delivered the head standing up (soooo easy) then turned and squatted for the rest of the delivery.
    The midwives (and hubby helped) cleaned up the floor after putting me to bed and checking us out. They even made me dinner!

  28. saintcatherine
    Posted March 21, 2009 at 4:49 pm | Permalink

    Oh– and I got the shower curtains & sheets at the dollar store, or yard sales. Very cheap. We did the sae thing for washcloths and used our own crock pot to warm the cloths and our own mixing bowl to put the placenta in. So much easier than you think it is going to be!

  29. virago
    Posted March 22, 2009 at 11:40 pm | Permalink

    It’s funny that homebirth is considered a choice for only women who could afford it. My niece had a home delivery because her husband lost his job, and they didn’t have any insurance. She found out that homebirth was a lot cheaper. I guess it is where you live. OTOH, I’ve heard of hospitals who shove women and their babies out the door after only 24 hours, and the mothers ended up bringing their babies back to the hospital because they had jaundice that wasn’t discovered in the first 24 hours. There was a big thing about women and their babies being forced out of the hospital too soon when a regualr three day stay would have been better for mother and infant health. I think that I would rather be in a hospital.

  30. Emily
    Posted March 22, 2009 at 11:49 pm | Permalink

    wow! That sounds like a lot of work for the woman’s body. I wonder if dehydration is a problem during labor or if mothers feel extremely thirsty after birth?

  31. marie-jean84
    Posted March 23, 2009 at 10:25 am | Permalink

    I’ve always thought that if I ever decide to have a child, that I’d prefer to have it at home because then, at least, I can control who’s there and who’s checking me out, so to speak. It seems really like a trival worry in the grand sceme of things, but I’ve always thought of that as a reason to avoid pregnancy altogether.

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