Birthing With Midwives - How Much Do Midwives Make?

My wife (Beth) has been asked this question, and on more than one occasion. Of course, she is asked this question because she is a midwife. However, while it is easy to establish why Beth in particular is asked this question, it is not so easy to determine the motivation behind the question.

Quite frankly, it’s a question that’s difficult for Beth to answer. Does this surprise you? Beth is a Texas Licensed Midwife and Certified Professional Midwife, has been in practice for nine years and twice served as the president of a statewide association of midwives. So she should have no problem answering this question…right?

Not necessarily. There are several reasons why this question is problematic. Look with me at this question a little more carefully, and I think you’ll see what I mean.

My first observation tracks with Beth’s initial reaction to hearing the question. The question is, to some degree at least, a tactless one. In many cases, the person inquiring about income is not meaning to be insensitive. They just aren’t thinking the question through before they speak it out.

Think of it this way: would you ask an OB/GYN, “Just what do OB/GYNs make, anyway?” I rather suspect that most of you reading this would not ask that question of an OB/GYN. Nor would you think to ask members of other professions (surgeons, anesthetists, psychiatrists, etc.) this question. Most people would be sufficiently aware, culturally speaking, that such a question could be embarrassing to someone.

Our system of free enterprise in this country stimulates the competitor in most of us. So a midwife might feel embarrassed if she thinks that she is not earning as much as, say, another woman is making as a school teacher. Furthermore, a midwife may feel embarrassed if she thinks she might be making substantially more than the person asking the question. And because of these possibilities, the question creates tension whenever Beth fields it.

The very fact of the insensitivity/awkwardness of this question gives rise to another question. Why would someone who is otherwise culturally sensitive, who knows not to ask such a question of other professionals, commit such a faux pas? The answer to that question goes to the motivation of the questioner, which leads me to my next point.

There are a number of possible motivations for someone asking this question. For the most part, these various motivations are innocent, that is, the intentions of the questioner are not duplicitous or insidious. However, there are those who inquire about a midwife’s income with something less than wide-eyed innocence. The question can be motivated out of skepticism, asked for the purpose of judging the person and/or the profession. Here, in my view, are the motivations that could drive a person to ask this question.

Curiosity. In some cases, it is simple curiosity that prompts the question. Such persons are often fairly ignorant of modern midwifery practice. They did not know that midwives have practiced continually down through the ages, and that medical doctors delivering babies are the real newcomers to the field of childbirth. Therefore persons asking about a midwife’s income thought of midwifery practice as antiquated and obsolete, and did not think of it in terms of a profession. Accordingly, they in all innocence asked the awkward question. In fact, Beth has even been asked if she gets paid for her services.

Assessing midwifery as a possible career. Others may ask the question because they are actually trying to determine whether or not midwifery is a profitable career move. Some ask this for themselves, while others ask for the sake of some loved one, usually a daughter. It is more common for people asking from this motivation to be more culturally sensitive in asking the question (e.g., “If you don’t mind my asking…?”).

Judging professionalism. Still others ask the question so as to get a sense of the professionalism of the midwife, or the respectability of the profession itself. This motivation is closely related to the previous one, but is generally more judgmental. The thinking is that knowing how much a midwife makes tells them how valid or respectable the profession is. In other words, the one asking from this motivation is treating money as the yardstick, and in asking this question is either taking the midwife’s measure or sizing up the midwifery profession as a whole.

Free/Private enterprise is another reason the question is difficult to answer. In this nation, we have the freedom to choose our profession and to prosper in it according to our own determination and diligence. It is not written anywhere that a midwife can only make so much money. Therefore, a midwife’s income depends on the fees she charges, and the number of clients she serves. And this combination of factors translates into quite a bit of diversity of incomes in the midwifery community.

There is another factor to be considered, one that effectively limits income. While it is not mandated on some state level that a midwife is limited on how much she can make, a midwife’s fees are determined in no small part by what the market will bear. And even within the state, not all markets are created equal. Standards of living vary widely. For example, judging by median household income and median house values, the standard of living in Dallas is about double what it is in Donna.[1] So a midwife’s location has a significant impact on her income, yet another reason why the whole question is difficult to answer.

So, answering this question is, as I said before, problematic, to say the least. And yet the question is not going away (Beth heard another example of it, just today). What is a midwife to do, or, more to the point, say? How should you answer the question, “How much do midwives make?”

Given the fact of differing motivations, there should most likely be more than one answer to this irksome question. If I were a midwife, some or all of the comments I’ve made in this article would serve as my answer. But since I am not a midwife, I will commend to you the answer given by a midwife that I know (in every sense of that word, including the “Biblical” sense).

Beth’s answer to this question of a midwife’s income may be summed up in four words: “usual, customary and reasonable.” This is a standard phrase in insurance jargon, and is used to refer to “the commonly charged or prevailing fees for health services within a geographic area.”[2] Beth has dealt with insurance companies, and has been paid by those companies according to this “usual and customary” criterion. As she puts it,

“When insurance companies pay for midwifery services (which they do), they will pay according to what is usual, customary and reasonable for those services in the midwife’s geographical area. This means that most insurance companies will usually pay as much to a midwife as they will pay to a physician, as long as the services provided are the same.”

So in very broad terms, when a midwife submits a claim to an insurance company, she can (and should) be paid what an OB/GYN gets for comparable prenatal care and delivery.

Of course, this information doesn’t completely answer the question of how much a midwife makes; it is only an indicator. OB/GYNs see more clients (or “patients,” in medical terminology) as a result of the impersonal, almost assembly-line style of the typical obstetrical practice. They routinely perform a number of medical procedures, and a high percentage of their “patients” wind up (unnecessarily, in many cases) with C-sections. Due to these factors and others, then, the annual income of an OB/GYN is typically significantly higher than that of a midwife.

So, in answering this question, Beth gives a basic indicator to people that helps them to see the income potential (as well as the worth) of midwifery care. She then clarifies her position, and I will conclude this article by letting her put it in her own words.

“Your question was ‘How much do midwives make?’ Well, what a midwife makes will vary based upon a number of factors: where the midwife lives, what her fees are, how many clients she sees, and so forth. Those of us who work full time make a decent living.

“Many clients have told me that I don’t make near enough money for what I do. And sometimes after a particularly long and difficult birth, I might even be tempted to agree with them. But as most midwives will tell you, I didn’t become a midwife in order to make money. My biggest rewards cannot be measured in dollars and cents. I have had many clients tell me that my care made all the difference in the world. And that expression of gratitude is one of my biggest rewards for being a midwife.”

Endnotes

[1] Source: http://www.city-data.com/ (7 April, 2005). The median household income in Donna, Texas (Hidalgo County) in the year 2000 was $22,800. The median house value in Donna at the same time was $43,000 (http://www.city-data.com/city/Donna-Texas.html). The median household income in Dallas at that same time was $37,628, and the median house value was $89,800 (http://www.city-data.com/city/Dallas-Texas.html).