Written by: Jess Kimball
Providing Accessible Care and Getting Paid For It
I think it is really great to make birth and postpartum services accessible to all who desire them, but I also think birthworkers deserve to be paid for what they do. Many birthworkers have a passion and dedication to providing care to underserved communities, but that leads to burnout when you are not adequately compensated. You need to and should collect a paycheck. Your family needs food on the table, shoes on their feet, and a roof over their head. And you need a business model that allows you to pay for a backup so that you can attend holidays and birthdays while still having secure coverage for your clients. You need sustainability to do this work longer than the typical 3-year stint most birthworkers work.
What does an effective accessible care model look like?
Maybe you want to take one pro bono postpartum family a year and three pro bono births. Maybe it’s one pro bono client where you attend their birth and offer postpartum care. Maybe you want to take as many pro bono clients as possible but have funding so that you’re paid for the care you provide. I have seen a few methods for doing this.
- Grant funding to cover your services
- Past clients making a donation to cover future clients’ care
- Families registering for doula services and having the care gifted to them
- If booked hours go unused by a client make them nonrefundable and donate them to a family in need
- Barter and trade! Does a local mechanic need midwifery or doula care? Can you do a dollar-for-dollar write-off for the services that mechanic provides you with for your vehicle? Can you do that for a farmer that provides you with beef and a summer farm share?
Another way you can make care more accessible is through partnerships.
Is there a parent-child center in your town that will pay you to teach classes or lead support groups? Have them pay you your hourly rate using their grant funds so that families can attend for free, but you still get paid. Maybe families cannot directly receive services from you, but they can at least access education and some emotional support.
Another partnership possibility is working with the local hospital or parent-child centers to create a pre-recorded childbirth education or newborn care class. You can get paid to create it, they can share it with patients and community members, and your business ends up being seen by more local families (some of which may hire you).
Do you have a passive income stream such as selling shirts or other merchandise? Can you use the profits made there to create a scholarship fund that allows you to take on pro bono clients?
Ask yourself how you can use other revenue streams, partnerships, and funding to make your care accessible while still paying yourself a salary.
There can be so much guilt and shame in the birth world, usually from other providers. I see it most often with providers trying to guilt people into charging a lower rate.
Please do not fall for this. You deserve to be paid a high rate that allows you to not just break even but actually make a profit on the work you are doing. There are ways to provide accessible care that do not require you to forfeit an income.
Inclusive Payment Options
Employee Benefits
Employers that cover doulas:
- Walmart (state dependent)
- CVS Health
- Microsoft
- Pioneer
Insurance Reimbursement
Sometimes BCBS will reimburse families for birth doula services if the doula is certified with an NPI. Clients should contact BCBS before hiring a doula and get a confirmation in writing.
Have Cigna? They can reimburse/cover CLC and IBCLC appointments if you choose an in-network provider! They have also reimbursed doula services as preventative care if you submit a letter from your provider. Some doulas can accept Medicaid or TriCare.
Medicaid coverage of doulas is specific to the state.
Other Parenthood Related Services Insurance May Cover:
- A Medical Grade Pump Rental
- Breastmilk Storage Bags
- Nipple Shields
- Supplemental Nursing System
- 1 Breast Pump
- Childbirth Education
- Breastfeeding
- Newborn Care
- Infant CPR
- Safety Classes
Sliding Scale
If you choose to offer a sliding scale model I think it is important to state that on your website so that those who need it feel comfortable reaching out for that information.
When operating on a sliding scale some choose to offer two set rates; a normal rate they would charge and a rate for those who request a lower rate. Maybe they usually charge $50 per hour, but on the sliding scale, they offer $35 per hour. This can work well for some, but only if there is a balance between the number of clients paying the full rate and the amount paying a sliding scale. When creating a business plan you should consider a ratio that makes sense. How many full rates to sliding-scale rate clients keep your business afloat?
Maybe that is 4 full rate clients:1 sliding scale rate. Run the calculations and determine this prior to implementing a sliding scale model.
Another sliding scale model is a payment rate based on household income. This puts every client you have on the sliding scale and adjusts the percentage they pay based on their income level.
Payment Plans
Sometimes making care more accessible for a family is as simple as setting up a payment plan option for them. To do this effectively it is best to begin the payment plan as early as possible. Set a range of what downpayment amount you’ll accept. Maybe it is a minimum of $300 down or 25% down at contract signing. Then set the reminder to be divided up over a certain amount of weeks or months. Once the plan is in place and agreed upon I recommend using an automatic billing service such as QuickBooks to lighten up the number of administrative tasks you have, and so you do not forget to bill the client.
If you use a payment plan you don’t have to offer a sliding scale or reduced prices, or you can offer both or even none. The choice is yours! Some find it better to use a payment plan and receive their full rate with no interest charged while some prefer just offering a sliding scale and getting paid sooner. Some birthworkers use a payment plan option but do choose to add a low-interest rate as well. The choice is up to the business owner and what works best for them, their employees, and their own families.
HSA or FSA Funds
What are HSA/FSA funds?
HSAs, HRAs, and FSAs are accounts used to save on taxes and pay for qualified medical, prescription, dental, and vision expenses. Spelled out: HSA is a health savings account. HRA is a health reimbursement account or arrangement. FSA is a flexible spending account or arrangement.
Who can accept these funds? Birth and postpartum services are eligible for reimbursement with flexible spending accounts (FSA), health savings accounts (HSA), and health reimbursement accounts (HRA) with a letter from a medical provider or the birthworker. Birthworkers can also accept these funds directly. One way to accept these funds is through Square or Paypal. Square can accept payment from any of these accounts as long as the business MCC is a licensed healthcare provider or pharmacy. A transaction or transfer fee is typically charged, but for the birthworker, these can be written off on taxes.
There are so many different ways to accept payment that makes care a little easier for people to access and do not leave us feeling unappreciated or burnt out. Doing this makes care inclusive and equitable. It leaves room in our emotional capacity to take on clients who cannot afford our services. Setting your payment options does not have to feel like something that closes you off, it can create spaciousness!
At Global Foundation for Girls (GFG), we are active thought partners, serving global communities of birthing persons in order to advance and support the advocacy movement. Our networks serve Black and brown girls (trans or cis) and gender-diverse youth survivors of sexual violence, retributive (corrective) violence, assault, obstetric violence, birth injustice, discrimination, or disenfranchisement due to their gender, race, sexual orientation, gender expression, faith, ability, or other identity markers. This demographic likely includes youth from low-income neighborhoods and varying language skills and immigration statuses. Our team is made up of birth advocates, many of which are birthworkers, from all over the world.
Jess Kimball, AS, CLC, CD, PCD, PMH-C