How much does home birth cost? Well, like anything else in healthcare, it depends.
Home births totaled 1.6 percent of all U.S. births before the pandemic, through 2017, according to this article in PubMed Central. But experts agree that many more people chose home births after the pandemic began, because of the fear of catching Covid in a medical setting.
Reports of the number of home births in the United States vs. hospital births vary, depending on the source. “Both the number and proportion of U.S. home births were substantially higher in 2020 than in previous years, according to a Pew Research Center analysis of data from the National Center for Health Statistics,” Carolina Aragao wrote for the Pew Research Center in mid-2022, citing 2020 figures. “The number of home births rose from 38,506 in 2019 to 45,646 in 2020, reflecting a 19% increase. Meanwhile, the share of U.S. births that took place at home was about 1.3% in 2020, compared with 1% in 2019.”
While home birth is a preference for a number of women who want to avoid the hospital experience, the pandemic definitely pushed more people to consider home births. One of the women we spoke with told us a friend of hers, the friend’s husband and their newborn all got Covid in the hospital while they were there giving birth.
Lindsay’s story: $4,700 out of pocket
Lindsay, 36, from Long Island, New York, gave birth to her daughter at home in November. (I agreed to use only her first name, as we often do, because health issues are not the first thing people want attached to their internet histories.) Her first child was born in a hospital two years before, in the first year of Covid, in a natural unmedicated birth. For the second baby, she said, she decided she wanted a home birth.
Her husband an engineer, was initially not exactly on board, “because he has been trained by society that home births are scary and crazy,” she said. But he trusted her, and her research, and wanted to support her and the family, she said.
In researching local midwives, she found that one group operating out of the Stony Brook University Medical Center did not do home birth. She knew that she would give birth with whoever showed up if she went back to the hospital, and didn’t want that.
She found her midwife when she was 20 weeks into her pregnancy, after initial care with the first midwife group. Only three midwives in her area do home births, she said. Her midwife has a biller who takes your information and works with you to maximize what insurance will pay.
“The standard home birth fee in my region is about $8,000,” she said. She found that Aetna, her insurer, has a policy against home births. The midwife billed everything under a global code for maternity care, with the midwife as an out-of-network provider. Her insurance would cover 70 percent of out-of-network care, depending on the situation, she said. Ultimately she wound up paying $4,700, and Aetna paid $4,000, she said.
Despite Aetna’s policy, they paid, she said: “They paid for the global maternity care of an out of network provider. It’s none of their business what type of care I’ve received. They don’t know everything. They just know that I received the global maternity care, and I chose an out of network provider, and then they just chose to pay 50% of that bill.”
Hospital birth vs. home birth
In her hospital birth, she said, she had no medical treatment, not even an IV. “The only thing I had was some Advil — one dose, after the birth, and they charged me $70 for that,” she said. “The final bill was $500 for me and a separate bill for my daughter, maybe a couple hundred dollars.”
For the second baby, she said, “I wanted to have a meaningful experience with a care provider I trusted, and so I set up for a natural unmedicated birth — so I wouldn’t run into the cascade of interventions that the system pushes on some women.”
Midwives in Long Island generally have a similar package, she said, around $8,000. First, you pay a retainer fee and then sign a contract. Then, she said, the midwife lays out the costs — that $8,000 includes prenatal care. If you choose home birth, at 34 weeks, you put down another $1,000 retainer fee, and hope you are cleared for home birth.
Lindsay’s midwife has 20 years of experience, she said, and is also licensed to provide care in the hospital in the event that something happens at the last minute and a hospital birth is indicated.
After the prenatal care up to 20 weeks with the initial practice, including a couple of fully covered ultrasounds, Lindsay’s extra costs beyond the $8,000 charge included a $30 copay for three or four tests like blood tests and urinalysis. She also had an ultrasound at 34 weeks, fully covered by insurance, at the midwife group’s’ office, which was in network.
Then the midwife plans to come to the home with either another midwife or a midwife assistant. She will also return a couple of times after birth — being licensed to provide care to the baby for up to 24 days, she said. If there are complications, or if there is a transfer to a hospital, that is not covered by the midwife’s fee — though Lindsay would have gone to Stony Brook, which is in network.
Aetna considers home births not safe, Lindsay said, adding that the Aetna site cites data from the American College of Obstetricians and Gynecologists and other medical sources. They “also have a vested interest, because they are in the business of making money,” she said. “It’s also way cheaper to give birth at home, with less interventions.”
The American College of Obstetrics and Gynecology, discussing the practice, cites “a more than twofold increased risk of perinatal death” on its website.
People make arguments for and against home birth, she said, but “I determined that home birth was a good option for me and my family. And I was a good candidate for it. I’m very happy with my choice — I had an amazing birth. But I’m also a particular person. I’m very determined. I tandem feed my two children. I am very natural, holistic person. Some people may be the complete opposite and feel more safe at hospital. That wasn’t me or my choice.”
Lindsay had an easy first birth in the hospital, she noted, and she and her husband also have good insurance and solid income. Coming up with the full $8,000 out of pocket was not impossible for her and her husband, she said — though it would be out of reach for many.
Frequent claim denials
Lindsay said she had heard from others that claims are frequently denied. Appeals can drag on and on, she said. She is indeed considering appealing her insurer’s payments, she said, noting that they didn’t pay 70 percent of the out-of-network bill, but more like less than 50 percent. She might argue further, she said, but she is just a few months postpartum.
She also said she believes her husband’s insurance policy, because it opposes home birth, could come and ask for the money back if they knew the global maternity care claim went to a home birth.
One more common expenditure, she said, is a doula. Insurers do not pay for a doula, she said — and the doula’s services could run from $600 to $8,000, depending on the package.
“If you have a doula, you are more likely to have a successful vaginal delivery without complications,” she said. But her insurer said it was not an option to pay for a doula, whose work is about providing support and comfort and education, not to make medical decisions. Doulas have to be legally licensed to be present in a hospital, she said, which they did for her first delivery.
She did schedule a doula, but the doula backed out at the last minute, she said. “I didn’t need her anyway,” Lindsay said. “My birth was very fast. I gave birth in less than five hours. My midwife almost didn’t make it — she got there 15 minutes before I birthed the baby.”
She said she had been inspired to want a home birth by reading Ina May Gaskin, who has been described as “the mother of authentic midwifery.” She was a founder of a commune in Tennessee where she and others practiced and taught midwifery. “Her literature is why I was convinced to give my children the start that they needed in life, and to prevent me from having a birth that scarred me or killed me,” Lindsay said. “Our society views home birth as a dangerous thing that only backwoods or uneducated people do, when it’s exactly the complete opposite. Educated, caring, dedicated women choose to have home births because they have done resarch and not taken what society told them, to fear their bodies, and their pain, and that the only thing that will help them is a man who puts drugs into their bodies.
“For me it was a transformative experience,” she said of her home birth.
Lindsay is getting ready to go back to work — she works from home as a project manager. She also creates “positive birth, pregnancy, postpartum and womb art,” displaying and selling online.
Erica’s story: $6,000-plus out of pocket
Erica, now 34, was 33 when she had her first baby, Ashley, by home birth in St. Augustine, Fla., last year. She has worked as a birth doula, a postpartum doula and a childbirth educator since about 2015, and then took some time off because her family moved from New York to Florida and she was preparing to give birth. She also works remotely part-time as an administrative assistant to a board-certified lactation consultant.
Her costs for home birth were $6,000, plus some supplies, she said in a phone interview. “In New York, it’s $8,000 or $9,000,” she said.
The fees were not covered by insurance, she said. “We were told that our insurance plan did not cover home births,” she said. Her husband works from home with a company based in New York, and thus the insurance plan is New York-based, and New York-based insurers tend to be more reluctant to pay for home births than are Florida-based insurers, she said.
Erica started her pregnancy with a different provider, she said, a traditional obstetrician, before moving to Florida. That doctor recommended some genetic testing, “which we did and insurance covered,” she said. then they moved, and the actual birth and the care of the midwife was not covered.
‘Very frustrating’
“It was very frustrating,” she said. “We appealed it twice, but it was not covered.”
Did they give any reason for the denial? “They told me that because our plan was a New-York-based plan, and it did not include home birth coverage, I was denied,” she said. “I submitted a lot of information on why a home birth is safer, especially during Covid.” She pointed to direct quotes on how Florida covers home births, but it didn’t matter, she said.
“I worked with my insurance through my husband’s work,” she said. “They provided a direct contact for an advocate at the insurance company, but she was no help.”
She did expect to get it denied, she said, because that’s not uncommon.
Erica said her sister had her second baby and first home birth in 2020, and fought with the insurance company “and was able to get 100 percent or close to it,” she said. “She just had her second home birth yesterday, and I think she’s getting it covered.”
All of Erica’s prenatal care was covered by the fee that she paid her midwife, she said. Insurance covered routine bloodwork, but she was responsible for copays on a couple of ultrasounds.
Additional spending for supplies
Erica’s midwife also asked her to buy a birth kit with home birth supplies: Chux pads, postpartum supplies and so on. The midwife gave a link to a company where you can buy either the kit or supplies.
“My midwife had a birthing center, and she had supplies left over,” Erica said. But there were some things she had to order — a birth pool liner, a hose and connector, for example. Other things in the birth kit: towels, washcloths and hydrogen peroxide, she said “typically a couple hundred dollars, no more than $300.”
Because she had worked in the New York area in the field of home births, she said she knew that she wanted a home birth, and also knew that many people battle to get insurance coverage.
“it is more of a rarity to get full coverage,” she said. “Some midwives have a biller that helps work with the insurance compeny. Unfortunately mine didn’t.
“I really wanted to work with this midwife,” she added. “I wish it was easier to navigate.”
Why isn’t it? “Insurance companies in general are very old-school,” she said. “Birth happens in the hospital.”
While the American College of Obstetricians and Gynecologists supports hospital births, organizations supporting home births are less robust. HomeBirthForAll.org seems to be on hiatus, saying that the site is “under construction,” but it does encourage donations, noting that $5,000 can cover one home birth, or $200 can cover the rental of a birth tub. The focus seems to be Massachusetts, at least for now.
Erica pointed out that coverage for lactation consultants is also hard to get from insurance companies, as she knows from her administrative part-time job. “We get the runaround all the time,” she said.
Home birth less expensive
Sometimes the system of home birth coverage mimics the institutional system of health insurance coverage, she says — midwives will bill for $10,000 and expect to get $6,000, as is true with hospitals inflating the sticker price for a procedure and expecting a lower payment from an insurer. “They’re trying to fool the system, by billing for $10.000, when you know you’re only paying $6,000,” she said.
She called the insurer to find out hospital-based coverage for both a vaginal delivery or a Cesarean section, she said. “The amount my insurance company would pay was right around the same amount as a home birth, or actually more,” she said. “It would be less expensive for my insurance company to pay for a home birth than a hospital birth.”
She said she and her husband felt comfortable having their baby at home, and “we are in a place financially where we can do it out of pocket.”
“I feel very grateful that we were able to do this, but should we have had to do that?” she asked. “Particularly with Covid. I have a friend who had her baby at the hospital a month before my son was born. She and her husband and her newborn got Covid from the hospital. this is what I was trying to avoid. And I am high-risk.
“It’s baffling that this was not taken into consideration,” she added. “Covid costs to your insurer are several times higher than a home birth.”
Midwives explain the landscape
To get the midwife perspective, I talked to Dr. Heather Findletar Hines of Onelovemidwifery, in Yaphank, N.Y., who has 20 years of experience as a midwife, and is an associate professor at Stony Brook University and midwifery education program director; and Michele Liot, of East End Midwifery, in Southampton, N.Y., who has degrees in nursing and midwifery, and is a certified lactation counselor and certified childbirth educator.
They said the cost of a home birth depends on several things: Geography, insurance coverage and other factors.
Liot explained that prices follow general cost-of-living trends: New York State is more expensive than Florida. New York City is more expensive than Long Island, where Liot and Hines practice. Western and northern New York state are much less expensive than the metropolitan area.
In New York State, Liot said, the range of prices is “probably $6,000 to $15,000-plus.”
Price also depends on the type of midwife. There are four, Liot said:
1. A certified nurse midwife, who is recognized in all 50 states as a credentialed, licensed practitioner.
2. A certified midwife recognized in “seven, or maybe nine” states for full scope midwifery care.
3. Certified professional midwives, who are licensed in “I believe 40 states plus or minus,” but not in New York State.
4. Traditional midwives, apprenticeship-trained midwives — indigenous midwives, for example, who are not licensed anywhere.
The first two are the only credentials recognized by insurance companies, she said. A few certified professional midwives serve communities in northern New York, mainly Mennonite or Amish communities, she said. They do not submit claims to insurance, because those communities typically do not have insurance. Traditional midwives are not covered by insurance.
Will insurance cover the costs? That all depends, Liot said. If a state recognizes the credentials, then the insurance company may cover it. Is there a nationwide reference on what states recognize which credentials? No, she said.
In New York, home birth services are eligible for coverage by law. People are eligible to give birth wherever they desire. There are no midwives in New York who are in network, she said, which means that insurers will say “you are out of network” and refuse to cover. But, she said, there can be an “out-of-network exception,” a “single-payer agreement” or a “gap exception.”
The gap exception, she said, takes place when a person giving birth has, for example, an Affordable Care Act policy that covers obstetrical services — and that person decides to have a home birth. If there are no in-network providers, then the gap in coverage means that the insurer will be obliged to cover the home birth. Liot said the payments in these circumstances are often low, meaning that the midwife will ask for further payment to reach her full fee.
Such negotiations take place well in advance, she said.
Typically what happens, Hines explained: A client comes to her and pays a retainer, often two $1,000 fees to cover all prenatal care, both paid before 36 weeks of gestation. The retainer is part of a contractual agreement “allowing the patient to be on the calendar,” to have bloods drawn, childbirth education, on-call availability and other prenatal care — “someone who’s fully engaging in providing all aspects of care for you.”
When the person comes into a midwifery practice, Hines and Liot said, money inevitably is one of the first topics that comes up. Both use a billing specialist, clearbill.net, who is versed in home-birth charges and insurance company practices. That billing specialist explains to the person how to get the best reimbursement from the insurance company, what questions to ask and how to frame the conversation with the insurer — with the expectation being that the insurer will refuse to pay if at all possible. In the initial conversation, the expectations are set that if the charge is, say, $8,000 for a birth and the insurer pays nothing, or only $2,000, the patient is responsible for the rest.
The billing specialist, they said, is very well versed in things like which insurance companies need every single thing itemized, and which need global billing. If you send the wrong kind of bill, Liot said, you have slowed the process. The billing specialist will also look at insurance coverage and help figure out if this is a gap exception or if the person has private insurance with a low deductible.
Patients need to be the ones arguing with the insurance company, Hines said, because “patients are the best advocates.”
Insurance companies differ, and so do states
State regulations affect what is reimbursed, they said, but more so where your insurance company is based.
Florida-based insurance companies tend to argue less about midwifery care,” Liot said. “Midwifery is very legal and affordable. Birth centers are legal, and midwifery is much more common.”
But New York-based insurers “are much more likely to say, ‘nope, you’re not doing it,'” she said.
“Aetna just put out a thing about home birth that says they don’t support it because the American College of Obstetricians and Gynecologists doesn’t support it,” she said. But the New York “gap exception” means that Aetna has to pay, she said — she just got a reimbursement via Aetna.
By contrast, Liot said, Blue Cross tends to be good about paying for home births. But it still all turns on patients advocating for themselves, she said.
“I just had a client really go after her insurance company aggressively and she got them to reimburse completely,” Liot said. “Like way above and beyond what my desired amount was. She went to bat and literally, we wrote letters with appeals about health care in this country. It got heavy. She was on a crusade for coverage. And she got it.”
Hines and Liot agreed that the insurers will respond more to the consumer than to the provider.
“With a little bit of advocacy, they end up covering, because really, at the end of the day, they are still paying less than if you went to the hospital for your birth,” Liot said. “In the hospital; setting, the insurance companies are paying a facility fee and anesthesia fee and all these other things.”
So how much does a home birth cost?
Hines and Liot said they do not post prices on their websites, and both declined to say specifically for this article how much they charge. They did say that in that New York range they mentioned — $6,000 to $15,000 — they fall roughly in the middle.
Liot said she used to post a price, but then she learned that insurance companies were citing her price to beat down their reimbursements to New York City midwives, and she stopped posting the fee. “My published number affected other people’s bottom lines,” she said.
Both women said that they sometimes need to be able to negotiate, to offer lower prices — Hines in particular said she will lower prices for BIPOC people.
Liot detailed the costs of her home births — she had two, in 2014 and 2016, on Long Island.
“I paid a retainer of $1,500 to my midwife, and the global bill we submitted was $6,500,” she said. “Her total fee is $8,000. Essentially she said ‘we will submit to insurance, but whatever the difference is, you are responsible.'” Eventually the insurer paid Liot $6,500, and she paid her midwife the $6,500 and the $1,500 difference.
Liot also had a doula, which is out of pocket; hers was $2,500 for a combination of childbirth education and doula services.
She borrowed a tub from a friend, so that was free, but she paid $85 for a liner.
Also she bought supplies: Chux pads, postpartum pads, bendy straws and light snacks, per her midwife’s supply list, running around $45-$60, she said. “And then I got vitamin K drops — I didn’t want to opt into the medication.” That was $60.
Beyond that, she said, she tipped the doula and gave her flowers and champagne, and got her midwife a present. “That was probably $300 between tips and presents,” she said.
People of color and home births
For people of color, the picture for home births is very different. Study after study has shown that Black mothers and babies have much worse outcomes in the United Staes overall than do than white women, as this New York Times article documents. People of color fare poorly over the entire U.S. health system, but at childbirth the situation is particularly bad, Hines noted. She is the chair of the Suffolk County Legislative Task Force on Maternal Morbidity and Mortality for BIPOC Women, and her website says One Love Midwifery was “founded expressly to address the racism in healthcare and maternal mortality statistics in the U.S.”
“BIPOC women — Black, indigenous and people of color — should definitely be looking for concierge care,” Hines said. “They should be with the midwife because the health care that they’re getting is filled with disparities. It’s filled with racism. It’s filled with experimentation. It’s filled with bias.
“And because of that, they’re not being seen as patients — their health needs and cries for being seen are not being seen and they’re dying for it.
“Let’s take Serena Williams. She has she knew she had a clotting disorder. She went out telling the nurse that she felt like she was having a clot and they remarked, ‘are you the doctor?’
“Brown and Black people for years have not been seen by healthcare providers — by nurses, doctors. They’re not being taken care of. So they need to have a midwife. They need to have someone who they’re paying to keep them on their schedule and see them and take care of them individually. It’s individual care for one.”
She added, “Latinx patients need Latinx providers. We need people who see their patients and communicate with them and do really good risk assessment. We need midwives providing equitable healthcare to decrease the deaths of moms and babies.
“We need midwives of every color. That’s why I’m an educator. We need midwives in every part of New York State, every part of this country, in their communities, providing equitable health care to decrease deaths for moms and babies.”
So, is home birth covered by insurance?
So how much does it cost? Gothamist, the New York City online news site, said, “Home births run $8,500 to $11,000 — a fee that must be covered by private insurers, according to state law.” But Erica’s husband’s insurance, being New York-based, did not cover it, she said.
NYHomeBirth.com says: “Each midwife practice approaches billing and insurance coverage a bit differently. In general, most homebirth midwives are out-of-network providers. However, we find that certain insurances will cover partially and others will cover the midwife’s fee completely. Even some Medicaid plans cover homebirth. Ask the midwife you are interested in working with to help you understand more about the billing process.”
Time magazine wrote: “‘Most Aetna benefit plans do not cover planned home births (except as required by state regulations) based on the guidance of medical professional societies that evaluate the safety and effectiveness of planned home births,’ Aetna said in a statement to Time. ‘Our plans include coverage for home births,’ UnitedHealthcare said in a statement, though they did not elaborate on what services are covered.”
Paying for home birth: What you can do
Here are some things you can do about the finances of home birth.
When you are interviewing midwives, think not only about whether she’s right for you but also ask about finances, so everything is perfectly clear.
Ask your midwife if she has a billing service, so you can start the financial conversation with an expert. Of course it can be an emotionally charged conversation, but it’s worth remembering that midwifery is a business. She’s going to be taking care of you — and of course you want to take care of her.
Hines and Liot use the same billing service, clearbill.net. Liot’s patients receive a questionnaire to fill out after a conversation with their insurer. (See screenshots.)
Start saving for a home birth as you might save for some other hefty expenditure — buying a house, starting graduate school.
Hines and Liot said some families register to crowdfund a home birth at BeHerVillage, a registry service for things like doula care and lactation support, or the better-known GoFundMe.
Resources: NYHomeBirth.com has lists of midwives in New York City and New York State locales. The Iowa Midwives Association has resources for Iowans. The California Association of Licensed Midwives and the California Nurse-Midwives Association have California resources. You might want to search in your own state because these issues can be state-specific.
Choices In Childbirth has resources for planning.
Childbirth Connection, from the National Partnership for Women and Families, also has resources.
