The COVID-19 pandemic has many pregnant people looking into giving birth at home. But what one would think would be less expensive actually turns out to being significantly more for many. Here's what you need to know.

By Amanda Krupa, MSc
May 07, 2020
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While I was on maternity leave a few years ago, I binged on Call the Midwife, the PBS series based on the best-selling memoirs of the late Jennifer Worth that tells tales of midwifery and home births in London's East End throughout the 1950s—a big transitionary decade in prenatal care.

Today in the U.S. only about 1 percent of babies are born at home each year. The reasons as to why this statistic is so low are many, but cost is often listed as a primary barrier. (Pretty ironic considering the midwifes in the PBS series saw women who couldn't afford hospital deliveries back in the '50s).

"There are wonderful midwives and birthing centers that specialize in working with women of color and who have developed practices to encourage home birth as a viable option," says Talitha Phillips, a labor and postpartum doula and CEO of Claris Health, a nonprofit caring for women before, during, and after pregnancy in neighborhoods across Los Angeles. "But, it is more attractive and accessible to the economically privileged, regardless of race or ethnicity."

Considering giving birth at home? Start by taking these steps to determine what the cost would be for your particular situation.

Step 1: Ask your health insurance company about home birth coverage.

"If money is at all a concern, I would definitely call your insurance company yourself to clarify everything—don't rely on secondhand information," says Tyree Bruce, who had a home birth with her youngest child, Jenna, now 16. Bruce saw an obstetrician who used nurse midwives and all her office visits and labs were covered under Blue Cross Blue Shield of Illinois. "I had no clue the actual home birth itself wasn't covered until I received the bill. I thought it would be less expensive, but I paid more than I did for my four older kids who were born at the hospital with Pitocin, forceps, and a vacuum."

Insurance is complicated and overwhelming if you don't know what to ask. Ray Rachlin, founder of Refuge Midwifery in Philadelphia, has a free home birth worksheet to help you when calling to check into your policy. From there, you should have a good idea of where you stand.

As of now, 33 states cover birth center deliveries and only 21 states cover home births in their Medicaid program. "During the pandemic, I've had many clients want to choose a home birth, but sadly they just couldn't afford the cost—especially after many had already contributed or reached their insurance deductibles," says Phillips. The issue is evolving. Last month, Flor Cruz started the Change.org petition, "Home births need to be fully covered by insurance companies during COVID-19 and always."

If you find out your insurance doesn't cover home birth, be prepared for the out-of-pocket costs ranging anywhere from $3,000 to $9,000. This price tag—at a time when 1 in 6 Americans are unemployed—can be stretch. After all, you still have to buy everything else that a baby needs; it adds up quickly! Losing a job, or even reducing hours to part time, can result in a loss of insurance coverage for a woman during pregnancy and postpartum. Phillips said clients at Claris Health are experiencing many challenges right now including unemployment, depression, abuse, addiction, and much more. "They are coming to us with various pressing needs and insurance is often one of them."

Many midwifes across the U.S. are working pro bono or at a reduced rate to help uninsured pregnant women in this time of need, but statistically there really isn't enough to meet the current demand. Which leads me to my next point—and step two. Even if you have the money to invest in a home birth, finding a midwife right now who is taking on new patients might be challenging.

Step 2: Find two certified providers to be with you during labor.

Look for a certified nurse-midwife (CNM), a certified direct-entry midwife (CPM or CM), or an obstetrician with lots of home birth experience. It's OK to shop around until you feel like you've found a good fit—the birth of your baby should not be an impulse purchase! The American Academy of Pediatrics (AAP) recommends that these two providers also practice within a regulated health system (i.e. make sure they are also affiliated with a local hospital near you). They should also have the proper training, skills, and equipment to perform a full resuscitation should your baby need help starting to breath. Ask about education, credentials, and whether each is licensed to practice in your state.

Most midwives charge a flat rate—where that $3,000 to $9,000 range comes in. Some give cash discounts, offer payment plans, and the ability to use FSA/HSA. The flat fee typically covers all prenatal, birth, postpartum, and newborn care; it does not include labs, ultrasounds, or birth supplies. (More on that later).

Your midwife will bring all the medical equipment necessary for monitoring you and your baby's vital signs: a fetal Doppler used to listen to the baby's heartbeat, stethoscope, and blood pressure cuff. They also carry things such as a portable oxygen tank, IV supplies, emergency medications for bleeding, local anesthetic, and suturing supplies.

Step 3: Know your risk. Giving birth at home isn't for everyone.

There are plenty of women who, despite having crossed all of their "T's" and dotted all of their "I's," just aren't good candidates for having a home birth. I am including this point, because, hey, your life and your baby's life could be the biggest cost! Women with low-risk pregnancies are more likely to have a successful home birth. What may start out as a low-risk pregnancy may later become a high-risk pregnancy, and these women should give birth in a hospital. You'll need to be open to the possibility of your birth plan changing outside of your control. (Signal pregnant lady hormones!)

The AAP does not recommend planned home birth, which is associated with a "twofold to threefold increase in infant mortality in the United States." They also warn that planned home births that take place longer than 15 or 20 minutes away from a hospital have also been associated with increased risk. It's therefore vital to take geography into account, as well as the weather and any other possible delays that may impact your ability to get to a hospital quickly if needed.

Here are some examples when your midwife may need to transfer your care to another provider or prepare you for birthing at the hospital:

  • Diabetes, high blood pressure, or heart disease
  • Prior C-section or other uterine surgery
  • Pregnancy complications, such as premature labor, preeclampsia, twins or multiples
  • Baby in breech at 37 weeks
  • Your labor stops progressing
  • Heavy bleeding
  • Your baby shows signs of distress, such as a concerning heart rate
  • You decide you want pain medication (such as an epidural) while laboring at home (Yes, it happens.)

Step 4: Plan for additional expenses.

Prior to the home birth, your midwife will usually give you a checklist of things to do and things to buy. Here's the highly detailed supply list Midwifery Services of South Texas provides to their patients. Most of the items are your standard cleaning supplies, bed sheets, etc. Plenty of toilet paper is also on the list! Here are a few extra expenses to keep in mind as well:

  • Birth kits range in cost, but average between $50 and $90. They contain items like cord clamps, sterile gloves, mesh underwear, plastic-backed pads, and other basic medical supplies.
  • A babysitter for your other children during the home birth. Though kids are usually allowed to be present at home births, most midwives are now limiting the number of people who can be present at the birth—not just for your safety, but for theirs. The exact rules will vary by practice.
  • A postpartum doula, if you hire one, specializes in helping families after the baby's born. They will likely charge by the hour; their rate varies from $25 to $65 an hour depending on your location. The organization DONA International can help you find a postpartum doula through its online doula locator.

Step 5: Find a supportive pediatrician.

Before you deliver, you'll also want to establish a relationship with a pediatrician in your community who'll be able to see your baby a day or two after birth. Your midwife should be able to recommend one who they have worked with before. The AAP also has a Find a Pediatrician tool where you can search by zip code.

Be sure to make an appointment to see your pediatrician within 24 hours after your baby is born and again within 48 hours of that first visit. Even during the pandemic, your baby's newborn visits should not be delayed! Your pediatrician will provide all vaccines for your baby as well as the newborn hearing screening. Midwives can offer a vitamin K shot, which is routinely given in the hospital to prevent rare hemorrhagic disease of the newborn (HDN).

What About Costs for Emergency Unplanned Home Births?

This common TV scenario does happen to about 2 in 1,000 women. "After everything was over, I remember being surprised that the bill was more than I expected—and I had PPO!" says Liz Haberkorn, who had an unplanned home birth with her daughter, Mae, in 2015. (Her husband, Peter, delivered Mae and called 911.) "There was the fee for the ambulance services, the emergency room, the labor and delivery fee to deliver my placenta, and the postnatal unit. In retrospect, I guess it makes sense that we had to pay out-of-pocket more."

As some moms consider going it alone to be the safer alternative, Haberkorn has this message: "It was truly by the grace of God that Mae and I came out of the situation healthy and stable. I can understand hospitals might be a scary place to be right now, but what if something happens and you or the baby needs emergency care. Why risk it?"

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