There are some common questions around fees that I often hear from women who enquire about private midwifery services. In general, the feeling is that private midwifery is very expensive. Some women want to barter, many want a discount or other reduction, some want to re-pay me after their baby bonus comes in (this payment is now made over 6 months after the baby is born) and many simply do not understand why they need to pay at all.

All of this baffles me.

Do we bartner for other goods and services at this stage of evolution? Can I pay my mortgage with eggs from my farm? Or maybe they’ll accept my car as payment? That ought to knock a few thousand off the mortgage, surely. Sadly, no, our society runs on money.

Do we ask for a discount at the dentist? Maybe the dentist can do only my top teeth and I’ll pay half price?

Midwifery is a kind and caring profession that is unlike any other. We go to family’s homes, often meeting their extended family and close friends. We form strong bonds with our clients that often last way beyond the official 6-week discharge. I have recently attended a birthday party for a very special person who came into this world just over a year ago. Her family is very dear to me, as are many of the families I work with. Midwifery is heart and soul. It’s a passion. If I didn’t need money to live, I would do it for free because there’s no other “job” in this world that brings me and the families I partner with, more pleasure and joy and satisfaction.

But …. I do need to live. And if I was employed, my boss could not expect me to work for free.

It saddens me to have a woman enquire about my service and then exclaim how expensive it is and hang up quickly. It saddens me to read posts on forums from people who are only wanting a student midwife or a trainee doula because they do not value their babies, births and themselves enough to engage a private midwife.

When women say, “It’s too expensive”, I hear, “I don’t prioritise and value myself enough to find the money to pay for this essential service”. We find money for cars, holidays, new computers, clothes, handbags …. but when people find that the going rate for private midwifery care is around $5000, they baulk at that amount. An average of $5000 over 42 weeks of care is $119 per week. That’s what the family pays. What does the midwife commit for this payment?

Well, I think there are two main aspects. One is lifestyle and the other is “business”.

Lifestyle first.
Being on call is a part of midwifery. I take calls from clients any day, any time. I’m ready, at their beck and call whenever they need me. For labour, because they’re concerned about something and need me to check things out, because they’re fearful or anxious, or becuase they’ve had their baby and are having difficulty feeding. It’s also about being on call for births – that’s of course a big part of being a private midwife. Babies come when they’re ready but most come between 37 and 42 weeks. What this means for the midwife is that for that entire 5 week period, she is on call for birth. Bit in reality, from the time she accepts a client’s booking, she commits to being available for that woman’s pregnancy, birth and new parenting time. No holidays, nothing planned that can’t be cancelled at short notice. No other employment. Simply being on call. When a midwife is on call, she lives, sleeps and showers with her phone. It’s always on. It’s on at the movies. It’s on at an expensive restaurant (sans alcohol because you can’t drink if you’re on call). It’s on during your best friend’s wedding. It’s on when you’re tired, it’s on at the supermarket. And it does ring. And when it does, the midwife drops what she is doing and attends her birthing client. Always. No weekends off. You must always have your car with you, packed with your birthing kit and oxygen and suction … because you just never know when the phone’s going to go off. And when you go, you don’t know how long you’re going to be gone for. A few hours? A day? 2 or 3 days? Hmmm. Better pack a change of clothes and toiletries.

Now if it was any other “job”, being on call would be a huge issue. But midwifery is a passion and so the 3am phone calls on a wet and cold winter’s morning are answered excitedly. Besides, it’s wonderful to be at births at sunrise. There’s something so special about welcoming a new baby at the start of a new day.

Now the other side to midwifery is … business.

Private midwives run their own businesses. It is our only source of income and we cannot take unlimited numbers of births each month or we’d miss some. That, of course, is not the aim. Therefore I limit my bookings to an average of 2 births per month. Like any business, there are expenses. These aren’t obvious to clients. But they’re there. The car, consulting rooms and insurance are the biggest expenses. It’s not unusual to do 30,000Km per year. Petrol is filled every week, sometimes twice a week. Then there’s midwifery equipment. There’s not a lot there really, and most items aren’t that expensive. Dopplers are probably the most expensive “tool” and they cost anywhere from $350 – over $1000. But there are other costs such oxygen and suction hire and sterilisation of instruments. Then there are other expenses related to holding a professional license. We are required to participate in at least 40 hours of continuing professional development (ongoing education) each year. We have fees associated with professional memberships, journal subscriptions, registration renewal and so on.

There are costs associated with running an office: stationery, printing, computer, fax machine, marketing aids such as brochures and business cards, exhibiting at expos, advertising and so on. Then there’s things like superannuation, annual leave and sick leave. If we don’t work, no money comes in so we need to plan for some time off for a holiday and also for the inevitable cold or flu that might strike once in a while.

Doctors, Energy Australia, Coles etc do not accept requests for discounts or payment 6-12 months after purchase (some shops do, but you can’t generally do this for fruit and veges and bills). If we can’t afford the services, we either need to make a more affordable choice or find the money to pay for the goods or services. We don’t ask the supplier or provider to compromise their position.

If women don’t pay their midwife, their midwife cannot afford to pay her bills or run her practice. Believe me, midwives do not live rich lives. Most do not drive Porsches, live in fancy houses and have expensive holidays. But we do need to live.

I have had clients who truly don’t have money, find the full fee, make payments on time and never question it. They know the value of their choice. I’d like to share with my readers some of the comments I have heard from my clients about fees:
“We received an exemplary standard of care, unavailable through any other service … we received a top quality service which was incredibly good value for money.”
“I believe this service is superior to any other available and really suited our needs”
“The service is very thorough and “on-call” whenever we needed it.”
“It’s not expensive when you look at the hours that go into it”

What are your views on private midwives requesting payment for their services?

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There is some debate about private midwifery, in particular the desirability – or even the need for – insurance and regulation. It is an interesting debate to follow. One side argues for no Medicare funding – we never had it anyway, no insurance – we haven’t had that for a few years, and no regulation. I would ask – if there was no regulation – are we indeed a profession? Does it matter?

A friend sent me an article recently that has fascinated me: “Why is UK medicine no longer a self-regulating profession? The role of scandals involving “bad apple” doctors.”

It was a very interesting article to read. The article identifies the role played by a series of medical scandals in the UK that basically ended the model of self-regulation of the medical profession that had been in place for 150 years. The original motive for professional self-regulation was “to resolve the principal-agent problem inherent in the doctor-patient relationship. The profession, in return for its self-regulating privileges, undertook to act as a reliable guarantor for the competence and conduct of each of its members”.

This is perhaps what is lacking in midwifery, and perhaps why we are seeing a huge amount of regulation at the moment. Midwifery has never really had a process of self-regulation. Midwives have not held each other to account for preventable outcomes. The collegial model adopted by the medical profession “left it fatally vulnerable to the problem of “bad apples”: those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers”. I wonder if this is what we are seeing in midwifery?

In the UK, it was the convergence of social and political conditions and public anger and shifts in social attitudes that presented an opportunity for imposing standards for accountability. Private midwifery has, until recently, been untouched. I remember leaving hospital employment to move to private practice and being amazed by the lack of processes, accountability, systems, structure … hospitals are full of these things but they were lacking in private practice. If I did these things, it was up to me. If not, it was no problem. I set up many processes and systems and dedicated a lot of resources to ensure that these were robust, practical and worthwhile. I have found he process of eligibility and meeting the requirements of the Quality and Safety Framework to be relatively ok because I already had much of this in place.

However, to those who argue against the need for increased accountability, insurance, regulation – professionalism – that is thrust upon us, I would venture to say that those attitudes are the precise reason why we have been thrust into the position of such intense regulation and accountability. If we did not have these, would we be members of the profession that is midwifery? For those who could care less about professionalism, I would ask why they completed their degree and applied for registration. Anyone can be with a woman in pregnancy and birth, but the title and practice of midwifery is one that we should hold dear and be proud of: it is one that is made stronger by regulation and accountability and one that gives the public an assurance of a certain standard of care.

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