Alternative Birth Options and Health Insurance Coverage

In the early 1900s, nearly all American women gave birth outside a hospital. By the 1940s, less than 50 percent of them delivered their babies at home. And by the late 1960s, just 1 percent did so.

That's pretty much where things stand today. Almost all babies in the U.S. are now delivered in a hospital--in stark contrast to what was commonplace a century or so ago.

No one is likely to argue the tide is racing back toward out-of-hospital births, but it does seem to be leaning in that direction--if only slightly.

According to the Centers for Disease Control and Prevention (aka the CDC), the percentage of out-of-hospital deliveries increased from 1.26 percent of all U.S. births in 2011 to 1.36 percent in 2012.

Most of these "alternative" deliveries occur at home, although a good number take place in freestanding birthing centers. (In 2012, just over 35,000 of the nearly 54,000 out-of-hospital births in the U.S. happened at home. Birthing centers served as the setting for around 15,500 of them.)

Having babies at home or in dedicated centers isn't the only alternative birth option American women are embracing these days. They're also increasingly utilizing doulas, midwives, and night nurses to help them through their pregnancies and deliveries.

The most recently gathered statistics associated with doulas, for instance, suggest about 6 percent of U.S. women use them during childbirth. A little over 8 percent call on midwives while pregnant, according to another study.

That's all well and good, you say, but how much does a doula or a midwife or a birthing center cost? And how do those price tags compare to the ones attached to their more traditional counterparts, like doctors and obstetricians and hospitals? Also, does health insurance usually cover these alternative birth options?

Keep reading for answers to all of these questions and a few more.

By the way, if you're currently uninsured, check out our article about how to choose the best health insurance plan for your pregnancy.

Doulas

Americanpregnancy.org says "doula" is a Greek word that means women’s servant.

Most modern doulas would balk at being called servants. "Helpers" might prompt a nod of agreement, though. Even better options: birth assistants, labor companions, labor support professionals, or labor support specialists.

That's because, as americanpregnancy.org puts it, a doula is a professional trained in childbirth who provides emotional, physical, and educational support to a mother who is expecting, is experiencing labor, or has recently given birth. The doula’s purpose is to help women have a safe, memorable, and empowering birthing experience. (Although some doulas help women through abortions or help people who are dying, too.) Specifically:

• Antepartum doulas assist pregnant women who are put on bed rest to prevent preterm labor.
• Birth or labor doulas provide care during delivery.
• Postpartum doulas support new moms in the first few weeks after they give birth.

Note: doulas aren't medical professionals. They don't actually deliver babies or offer any other kind of medical care. Many doulas are certified, however. To earn their certificate they must complete a training program and pass an exam.

Doulas may not have professional medical training, but many pregnant women swear by them anyway. Why? Because with their assistance you may be able to:

• avoid a Cesarean section (or C-section) delivery
• give birth without needing as many--or any, in some cases--pain medications
• spend less time in labor

Studies also have found that women who work with a doula while pregnant are more likely to describe their deliveries in a positive way.

All of that positive support comes at a cost, of course. How much you pay depends on where you live. If you call a more rural area home, for instance, you may only pay a few hundred dollars. On the other hand, it isn't unusual for pregnant women in urban settings to pay thousands of dollars for a doula.

Also impacting the potential price tag here: how long you employ a doula. In other words, if you only need one for a portion of your pregnancy, you'll pay less than if you need one for the whole nine (or more) months.

As you might expect, health insurance coverage of doula services is all over the map. Some plans help pay the associated costs, while others do not.

The best way to find out how your plan treats doulas: pick up the phone and call your insurer. Or send them an email.

Do the same if you're on Medicaid. A couple of states currently require their Medicaid programs to cover certified doula services and others may cover them even without legislative involvement.

If your plan or coverage won't help in any way, head to Google (or your search engine of choice). You may find doulas willing to volunteer their time and expertise to women who can't afford to pay them. Or you may find some who charge less in such situations.

Midwives

Unlike doulas, midwives are trained medical professionals. Like doulas, however, they can care for women before, during, and after their pregnancies.

You may think of midwives chiefly as pregnancy and birthing assistants--much like doulas. Although they sometimes take on that role, they're just as likely to lead a woman through labor and delivery.

Something that differentiates midwives from physicians or obstetricians is they tend to be proponents of natural childbirth. At the very least, they usually try to minimize unnecessary interventions during a pregnancy.

Something to pay close attention to if you decide to hire a midwife: their level of certification. In particular, you'll probably want to look for a certified nurse-midwife (or CNM). These midwives are registered nurses. And to earn this certification, they have to graduate from an accredited education program and pass a national exam. Certified nurse-midwives can practice in all 50 states and in the District of Columbia.

That's not to suggest you should ignore certified midwives (CMs) or certified professional midwives (CPMs). Not all states permit CMs or CPMs to practice, though, and that may give some women pause.

Regardless of whether you hire a CNM, CPM, or CM, your midwife should be able to help you in a variety of locations--your home, a private office, a birthing center, or even the hospital.

What does "help" mean here? Typically, a midwife can do most of the things a physician or obstetrician can do while caring for a pregnant woman.

Generally, that means they're knowledgeable about prenatal care, labor, and postnatal care. More specifically, it means they often can help with:

• prenatal exams, tests, and screenings
• diet, nutrition, and exercise advice
• medications
• emotional support
• lactation and breastfeeding counseling or education

In addition to leading or assisting with your delivery, of course.

One catch to all of this: most experts recommend using a midwife only if you're at a low risk for complications. As such, if you run into any problems during your pregnancy, you'll probably want your midwife to at least consult with a physician, obstetrician, or other specialist. (On a related note, read our article about unexpected pregnancy costs and how health insurance covers--or doesn't cover--them.)

Although you'll typically pay more for a midwife than you will for a doula, you may not pay too much more. According to pregnancycorner.com, the average cost of a midwife in the U.S. is around $2,000. That means you'll sometimes pay a good deal more than that amount, but it also means you'll sometimes pay less.

Where you end up on that spectrum mostly depends on where you live and what services you need.

In any case, you can expect to pay less for a midwife than you'd pay for traditional obstetrical care in a hospital, the cost of which can go far beyond $5,000 or even $10,000.

Granted, those savings won't mean much if your health plan doesn't cover at least some of your resulting bill. And that's a distinct possibility given how insurance companies currently treat midwives.

Some insurers don't cover midwife services at all. Some cover them if the midwife helps you deliver your baby in a hospital setting or birthing center, but not if you deliver at home.

Because of this, talk with your insurance company before you start looking for a midwife so you know what your plan will cover and what it won't in this regard.

You should have better luck if you're on Medicaid. But even then you'll want to check with your local agency before you shake any hands or sign on any dotted lines.

Night Nurses (or Night Nannies)

Don't be fooled by the name "night nurse." Although many of these women (and men) are registered nurses, many are not.

Some night nurses or night nannies are certified in various ways, while others simply have a lot of experience taking care of newborns.

Regardless, they all help new moms in basically the same ways. Primarily that means spending nights in their homes and feeding and otherwise taking care of their babies while they sleep.

A lot of mothers hire night nurses for the first week or two after they give birth. Others wait a while, such as until they're ready to return to their jobs.

As helpful as night nurses or night nannies can be in these situations, their assistance isn't cheap. Most charge between $25 and $40 per hour, according to various sources. (Once again, what you wind up paying probably will depend on where you live and how much experience a particular nurse or nanny has.) That means you could spend upwards of $200 a night, and more than $1,000 each week, for this specialized sort of care.

Unfortunately, you'll most likely have to pay for a night nurse out of your own pocket should you decide to make use of one. Few, if any, health insurance plans cover them at this point--even though they cover a lot of other forms of postnatal care. (To learn more, see our article: "What Does Health Insurance Cover After Pregnancy?")

That said, if you or your baby come home with any special health needs, it's possible your plan will pick up some of the cost. You'll obviously have to talk with your insurer to find out one way or the other, however.

Birthing Centers

According to CNN, the number of babies born in U.S. birthing centers increased 55 percent from 2007 to 2015.

Medicaid is responsible for some, if not most, of that growth, thanks to the Affordable Care Act (also called the ACA or Obamacare) requiring state Medicaid programs to pay these centers a facility fee. Still, their appealing nature probably played a role as well.

Basically, delivering your baby at a birthing center is more like doing so at home than in a hospital. Birthing centers tend to be cozy and low-tech. Midwives, rather than obstetricians or physicians, typically serve as their primary care providers. And natural childbirth is emphasized over the kinds of medications and medical interventions common in more clinical settings.

One of the main benefits of using a birthing center is the mother's recovery time often is far shorter than it would be if she delivered her baby in a hospital. In fact, many women spend just a few hours in a birthing center after giving birth, while a couple of days isn't unheard of in a hospital.

Another common benefit: birthing centers are almost always cheaper than hospitals. The average cost for a birthing center is around $3,000, while hospitals charge many times that amount.

There are a few downsides to using a birthing center. One is they're not the best places for complicated pregnancies or deliveries.

Also, insurance coverage can be spotty. That said, more U.S. health plans cover birthing centers than in the past. So, if you want to go this route, contact your insurance company and ask how your plan treats this type of care. Talk with the birthing centers you're considering, too; they may be able to help.

And what if you're on Medicaid, as many women are during their pregnancies? You're in luck. As mentioned earlier, Obamacare requires state Medicaid programs to cover the services of licensed birthing centers. For more information, get in touch with your local agency.

Home Births

There's quite a lot of overlap between home births and midwives. Which makes sense, as midwives often run the show, so to speak, during home births.

There's also a good bit of overlap between birthing centers and home births. Which is to say that women who give birth at home often do so for reasons that are similar to why women deliver their babies in birthing centers.

In other words, they usually want to give birth in a comfortable setting. They want to be surrounded by family or friends. They want to avoid all the medications and medical interventions or interruptions that are so common during hospital deliveries. And they typically want to feel more in control of the entire birthing process.

Cost tends to be a concern, too. As in, many pregnant women choose home birth so they can bypass the sky-high bills associated with most hospital births.

So, how much does a home birth usually cost? Around $3,000--or about 60 percent less than you'll pay if you give birth in a hospital.

The thing is, you may have to pay some of all of that amount out of your own pocket whether you have health insurance or not. Although a number of U.S. insurers now cover certain midwife services, many still balk at covering planned home births.

Why? The most common answer is they consider home births to be "not medically appropriate." They also often consider them to be risky.

Speaking of which, here's what one health insurer, Aetna, has to say about the subject:

"According to the policy statement on home delivery of the American College of Obstetricians and Gynecologists, labor and delivery, while a physiological process, clearly presents hazards to both the mother and fetus before and after birth. These hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation."

There are health insurance companies that cover home births, though, so don't give up if that's how you want to deliver your baby. Contact yours to see how--or if--your plan treats this sort of situation.

And even if your health plan covers home births, don't be surprised if it ties some requirements to that coverage. One example: you may have to use a midwife who has been certified by state regulators. Also, you might need to pay for various supplies or pieces of equipment.

Home Births During the Pandemic

The number of women giving birth at home increased by 22% during the first year of the pandemic. Home births remained relatively steady during the first three months of 2020 before rising quickly starting in April.

The rise in home birth is directly attributable to the coronavirus pandemic. We found that concerns over getting COVID-19 at the hospital, hospital lockdowns and fears of family separation all contributed to more mothers choosing to give birth at home.

The nationwide increase in home birth has been particularly pronounced in several states. Home births increased by 68% in South Dakota, 64% in South Carolina and by more than 30% in 11 states. New Hampshire is the only state that saw a decline in home births during 2020.

Water Births

Once again, there's often some overlap between water births, home births, birthing centers, and midwives.

This is because many water births take place at the home of the mom-to-be or at a birthing center. (Though some do take place in hospitals.) And midwives typically oversee these deliveries.

As for what a water birth is, it's usually a birth--and this can mean labor, delivery, or both--that happens while the woman is in a pool or tub filled with warm water.

Some of the benefits associated with water birth are that it can:

• ease pain
• keep the pregnant woman from needing anesthesia or other medications
• speed up labor

How much you pay for a water birth depends on a number of factors. For instance, if your water birth takes place in a hospital, you'll probably pay what you'd pay for a more traditional birth. (The hospital may bill you extra for the tub, however.) The same is true if your water birth is done at a birthing center or at home.

What about insurance? Again, your health plan is most likely to cover water birth if it's done in a hospital or birthing center. If yours takes place at home, you'll face the same insurance challenges any woman who wants to give birth at home faces.

Few, if any, state Medicaid programs currently cover home births, so they're also unlikely to cover home water births. Still, contact your local agency before you decide to pay for one out of your own pocket.

Actually, that's good advice no matter where you get your health coverage. It's never a bad idea to have a conversation with your insurance company about whether or not it covers certain services or situations.

Frequently Asked Questions

Q: Does health insurance cover doula services?

A: Unfortunately, it's hard to answer this question with a simple yes or no. Some U.S. health plans cover doula fees, and some don't. Yours is more likely to do so if you deliver your baby in a hospital, but don't assume that to be true across the board. The only way to be sure about how your plan treats doulas is to contact your insurer before you hire one.

Q: Will my health plan pay for a midwife?

A: Some good news for a change: your health insurance is more likely to pay for, or help you pay for, a midwife than it is to pay for a doula or night nurse. That said, there are plenty of insurers and plans that don't cover midwives, especially if they're attending a home birth. Your best bet to get your health plan to pay for some or all of your midwife bill is to deliver your baby in a birthing center or hospital.

Q: What's the difference between a midwife and a physician or obstetrician?

A: Although obstetricians, physicians, and midwives all are highly educated professionals, they don't go through the same training. That doesn't mean your average midwife--especially if she or he is a CNM--isn't more than capable enough to help you through your pregnancy or deliver your baby. On the contrary. The key is to do your homework before you make a hire. Of course, the same could be said whether you're looking to work with a midwife, obstetrician, or physician.

Q: What's the difference between a doula and a midwife?

A: Doulas usually take a supporting role in a pregnancy and birth. They help mothers-to-be feel comfortable and provide assistance wherever and whenever it's needed. Also, they usually don't have formal medical training.

Midwives, on the other hand, tend to be registered nurses or certified professionals. As such, they can offer women a wide range of health and medical care over the course of their pregnancies. And of course they can deliver babies, too--something doulas aren't trained to do.

Q: Does health insurance cover birthing centers?

A: Although more health plans cover birthing centers now than in the past, it's still not uncommon to come across ones that don't cover them. So, talk with your insurance company--and talk with potential birthing centers, too--about your plans before anything is set in stone. The last thing you want to do is have to pay for this out of your own pocket because you assumed insurance would cover it.

Q: Will my health plan pay for a home birth?

A: Probably not. It's not completely out of the question, though, so contact your insurer about it before you're too far along in your pregnancy (if possible, of course). You never know, they may surprise you and tell you they'll cover every aspect of your planned home birth.

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