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Monday, March 13, 2006

Economics of A Doula's Fees

Question: How do you set your fees?

[Ed. note - This is from a sheet of Frequently Asked Questions provided by a midwife who also offers labor support as a private-duty midwife. Some of the details may not apply to doulas who work strictly in accordance with DONA guidelines.]

[Other people are completely welcome to borrow the text from this page and tailor it to their own needs. Best wishes getting decent compensation for this vital work helping birthing families!]

Answer: The economics of professional labor support work are a mystery to many people; I offer this information so that you'll have a better idea of what you're paying for:

Hours - Couples having a first baby may imagine that I'll only be spending a few hours with them during the labor and birth. In reality, an eight-hour labor would be considered pretty zippy; most first labors last longer than 16 hours; the longest continuous time I've spent providing labor support is 38 hours. Average time spent with a woman for her labor and birth is about 16 hours. I spend another 10 hours in prenatal and postpartum meetings, and another hour or two in phone calls. My fee translates to an hourly rate of about $35/hour, before expenses and self-employment taxes.

Clients per Week - When I make a commitment to be available to attend you in labor, I have to limit the number of clients I put on my calendar so as to avoid birth conflicts and to ensure that I am reasonably rested when you go into labor. The rule of thumb for birth professionals providing in-home services is that one client per week is a full schedule. Since most of my clients are first-time mothers, I find that three clients per month is a full-time workload.

Clients per Year - When I put your due date on my calendar, I commit to being available two weeks beforehand and two weeks after that date. This means that when I schedule a two-week vacation, I have to add another four weeks during which I cannot accept clients. A full calendar is 32 clients per year; in reality, there are some weeks where I have to turn clients away and then there are other weeks where I have no births on the calendar.

Consultant Factor - The rule of thumb is that a self-employed professional's income is only half of what they earn, after deductions for vacation and sick time, self-employment taxes, health insurance, and business expenses. As you may imagine, my communication expenses are high - business phone, pager, cell phone and computer connection; I also have routine professional and office expenses and unusual transportation and supplies expenses. In addition, I bring several thousand dollars worth of equipment to your birth as part of providing midwifery care.

Putting It All Together - The annual income of someone providing labor support services with a responsible client load and a strong commitment to being available for your birth is 1/2 the number of clients per year times their fee per client. This is about 16 times the fee per client, and, yes, that's before taxes, including extra self-employment taxes. Although I am dedicated to this work, being on-call all the time requires a very high level of personal sacrifice, including a willingness to be beeped awake after half an hour of sleep to go attend a labor for the next 40 hours. About 25% of my clients have some kind of early labor which starts and stops, resulting in two trips to their home and being beeped awake twice. This past year, I spent most of my birthday at a labor, I spent Thanksgiving Day in a hospital, and I was beeped away from a big family gathering. I cannot take weekend trips away from the area, and even day trips to Santa Cruz or San Francisco have to be planned around traffic conditions. I never know what I'm going to encounter at a particular labor - I may end up wearing out my body supporting the woman in different birth positions; I may end up holding a vomit bowl for someone vomiting with every contraction during transition; I may end up with blood, meconium or worse on my clothes. Given all this, I'm sure you can understand why I bristled when someone once asked me why I charge "so much".

Bottom Line - Nobody's getting rich doing labor support work. I wish I could offer my services at a rate than everyone can afford, but that would require that I make even greater financial sacrifices than I am already making to do this work. I am a self-supporting professional, and my options are to earn a living wage working with birth or pursue more conventional employment, which would pay much more. There are people offering doula services at significantly reduced prices. They are either offering significantly reduced services, are still in training, or are basically offering charity. If you need charity, I encourage you to get labor support however you can; otherwise, you are doing future birthing women a disservice by making labor support an underpaid profession that cannot attract or keep talented, skilled individuals. If you end up selecting a doula who is undercharging for her services, I strongly encourage you to pay her more than she is asking; otherwise, she may not be around to help you with your next child.

Advocacy Suggestions - My services are covered by many health insurance plans because I'm a licensed provider; however, most non-midwife doula services are not. You can talk with your Human Resources representatives to ask them to lobby to include all doula services as a covered option in your plan. Additionally, you could talk with your midwife or doctor to encourage them to offer universal doula care to their clients. By hiring several doulas to be on-call for their clients, they could substantially reduce the cost per birth, although the doula might be someone you've never met before. You could also advocate for the hospital to provide universal doula care, so that it would be covered in the same way as their in-house lactation consultants are covered.

(text taken from


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