The Cost of Being Born At Home

Miriam Pérez

Upwardly-mobile moms may finally be catching on to the benefits of midwifery and homebirth, but low-income women are still firmly planted in the hospital, most often with medicalized births overseen by doctors.

Yesterday
in New York City,
Julie Finefrock
appeared before the health fund subcommittee of the Service Employees
International Union (SEIU) as part of her appeal of their denial of
her homebirth coverage. Ms. Finefrock, who is six months pregnant, is
married to an SEIU employee. Their insurance plan excludes homebirth
coverage, despite New York State regulations that require that private insurance cover out-of-hospital
birth with a licensed practitioner.
Ms. Finefrock’s situation is just one example of a larger fight to
increase access to homebirth nationally, and it’s a fight that has
ramped up due to new media attention to the issue.

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.   

Despite The Business of Being
Born
‘s
relative
popularity, the film only reaches and speaks to a limited audience.
"The Business of Being Born is fabulous, but low-income women
are not seeing it," says JayVon Muhammad, an African American Certified
Professional Midwife (CPM) in Sacramento  "The midwives that
are promoting it don’t typically have low-income women in their client
base…[Even when low income women see the film, they] don’t see women
that look like them, economically and ethnically, they can’t see themselves. 
They think that only ‘those’ women do that." 

Upwardly-mobile
moms in New York City may finally be catching on to the benefits of midwifery
and homebirth, but low-income women are still firmly planted in the
hospital most often with medicalized births overseen by doctors. Current
efforts to transform birth – offering women more options and preserving
their decision-making – are not reaching low-income women. Birth activism
draws attention to the ubiquitous media portrayal of highly interventionist
births, the normalization of c-sections, and the lack of choice afforded to women by their doctors, whose hands, in turn, are tied by hospital
policy and malpractice fears. The criticisms made by birth activists
are accurate yet incomplete. Missing from these conversations is how
low-income women – who suffer the worst outcomes for their babies,
including lower
birth weights and higher infant mortality rates

– are making decisions about where and how to give birth.  

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The
maternity reform movement’s frame of consumer choice
(exemplified by the name of one of the primary advocacy organizations, Choices in Childbirth) may be at least partially to blame. This
frame neglects the reality that many women can’t make a choice at
all. "I work in a (very) low-income Medicaid clinic in Sacramento,
and the women all have Medicaid or Family Pact as insurance," Muhammad
explains. "Medicaid doesn’t cover homebirth, so even if women choose
to have homebirth, they are not covered, leaving no choice at all.
As a result, when women show an interest, and very few do, they don’t
have a choice. They are forced (due to lack of money, and insurance)
to deliver in the hospital."

There
are a number of barriers to low-income women giving birth out of hospital.
As Muhammad highlighted, Medicaid is the first. Medicaid and other state
health insurance programs generally do not cover out-of-hospital births.
According to Steff Hedenkamp, Communications Coordinator at The
Big Push for Midwives
,
only in nine states can CPMs (who account for the majority of homebirth
practitioners) register as Medicaid providers. Even in those states,
very few CPMs go through the process because of bureaucratic red tape.
Yet even if a woman has private insurance, she often faces similar barriers
when trying to choose out-of-hospital birth. The estimated $4000 that
a homebirth costs without insurance coverage might not be an impossible
hurdle to cross for a middle class family, but is a near impossibility
for low-income women.  

Medicaid
policy may be the most significant logistical barrier, but it isn’t
the only one standing in the way of low-income women delivering outside
the hospital. Doulas and midwives who work in low-income communities
of color see the barriers as being social in addition to financial. Muhammad explains: "In low-income black communities, which I am a product
of, we don’t learn about natural birth, or birthing choices." 

Claudia
Booker, an African American doula in Washington, DC, agrees. She explains
that women in low-income communities of color stopped giving birth outside
of hospitals at least three generations ago. There is also a sense,
she noted, that giving birth at home is "what poor people do and [that
homebirth] was something we did because we had no option." This history
reflects a larger transition among US women giving birth at home to
hospital birth, which happened in the 1920s. Low-income communities,
and particularly African American ones, took longer to make this transition
because of poverty, racism and lack of access to hospitals. Now the
paradigm has shifted and hospitals are where low-income people get most
of their health care.  

Another
barrier to home birth for low-income women is concern over birth certificates
for their babies. In recent years, particularly since 9/11, obtaining
passports and other citizenship documentation has become increasingly
difficult. The crackdown has focused on people born to midwives at home.
Immigration authorities have begun questioning
the validity of documents

from these midwives and holding those individuals to a much higher burden
of proof. This has had a disproportionate
impact on Latinos
and other
immigrants, requiring them to go to great lengths to obtain passports
and other documentation. Claudia Booker thinks this fear of citizenship
being questioned may keep low-income people from leaving the hospital
to give birth.  

The
media depictions of home birth moms are not far off from the demographics
of those at the helm of the maternity reform movement. This small collection
of organizations and individuals, primarily made up of midwives, doulas
and mothers, is predominantly white and middle class.  Steff Hedenkamp
from the Big
Push for Midwives
readily
admits these shortcomings. "You could say we’re not doing enough
to reach out and engage with lower income women, and it’s probably
true. We’re not doing enough on every level." It’s difficult to
say whether it’s merely a demographic issue, or reflective of something
larger, but it’s clear that the demands of the maternity reform movement
are not promoting the needs of low-income women. Even if the Medicaid
barrier were to be eliminated, the education provided by films like
The Business of Being Born
need to be geared specifically toward
low-income women or they aren’t going to leave the hospitals anytime
soon. "My clients don’t know a thing about homebirth, nor do they
understand why they would even consider such a thing," explains Muhammad. "They
are not educated about the benefits of birthing out of the hospital
or birthing without interventions.  Many of them think the elective c-sections
are okay, and can’t wait to schedule theirs, as they have friends that
have." 

One
thing that all these advocates can agree on is that the current health
care crisis may provide an opportunity for real maternity reform. During
such shaky economic times for the health care industry, cost cutting
is a definite priority. Steff thinks birth might be the perfect target
for savings, as midwives cost less than obstetricians, and vaginal birth less than a c-section. "If anyone is doing real healthcare reform, they have
to look at the cost of maternity care. A thirty-percent c-section rate
and rising? It’s not sustainable. No way." These reforms may have
a chance of reaching low-income women, particularly if lower cost birth
options, like midwives, homebirth and birthing centers become part of
a universal health care package.

Muhammad put it plainly: "If Medicaid
doesn’t start covering homebirth, any positive changes toward homebirth
will not benefit poor women.  They will have to choose between
homebirth and food, and food will win every time."

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