New York City is often thought of as a progressive city. From my experience, this progressiveness is limited and does not extended to rules and regulations within healthcare. Behind all this lies a conservative lens that reminds me I still live in a capitalist and patriarchal society. In this particular case, I most experience that as a doula and lay midwife. I am writing this article to be able to educate and also clarify what is happening in New York City to the best of my knowledge. If you see anything that I have left out or depicted incorrectly, please let me know.

When I first came back to NYC after being in Texas studying midwifery about 3 years ago, I knew I wasn’t going to be able to be licensed but figured I’d look to be an assistant to a New York State licensed midwife so that I would keep my skills fresh. After reaching out to a few midwives, I finally was able to work with a fellow midwife of color. I was stunned when they told me about the struggles they were facing in their practice. Over the years, some homebirth midwives who were accessible to NYC birthing folks were used to having caseloads of 40 – 60 women in a year saw their practices declining. The midwife I assisted was used to about 40 or so births in a year; I attended four births with her in the year I worked with her. Though insurance reimbursement had seldom been easy for midwives, their out-of-network status has increasingly made it difficult for birthing folks to afford homebirths.

When you use out-of-network benefits, a conversation with the insurance company usually ensues between the midwife’s insurance biller and the insurance company representative. There is a request made with the appropriate procedure codes so that the claim reflects the midwife’s fee. The thing is, sometimes the out-of-network benefit has a maximum amount that it will pay out. So, for example, the midwife’s fee that includes prenatal visits, labor and birth as well as postpartum visits will probably cost a birthing individual about $8000 (ballpark/example figure). The insurance company tells the potential homebirth client (or they already have prior knowledge) that they can cover out-of-network providers for about $2500. This then leaves the potential birth client with a bill of $5500 to pay out of pocket (again this is one example and not the exact way it plays out). There are midwives who are flexible and committed to working with clients regardless of their financial restraints, so it is worth doing the research and not letting this possibility deter someone. In addition, there are instances where the insurance companies will reimburse the client for what they paid out of pocket. Please, if you know more about this than I do, respectfully correct me.

From my knowledge, the managed Medicaid plan (such as MetroPlus, Healthfirst, Fidelis, etc) that pays equitably or will be the easiest to get paid services through varies. This particular midwifery practice lays out specific instructions on insurance; “in New York State, midwifery services for home birth must be covered by law. The extent of coverage is determined by each individual plan.” It is important to highlight that the extent of how much of the maternity services are covered is up to the discretion of each insurance plan. This means that there is no true regulation of how much is required to be covered for the home birth option. Of note, and this speaks to the point about out of pocket expenses I mentioned above, “most plans pay the Medicaid rate for comprehensive maternity care, which at this time is $1720 for all prenatal care, labor/birth and postnatal care. Some will also pay $123 for a newborn exam. The remainder of the midwives’ fee is the family’s responsibility and must be paid in advance of the birth.”

It is also worth mentioning that HBAC (homebirth after cesarean) are not covered or “approved” by some insurance companies, and some midwives have opted out of doing them for many reasons. This then means that a person who has had a cesarean section in their first birth and has realized they want different care is then put in a position to either be at risk for another cesarean section, finding a hospital-based provider who will support a VBAC client, or try to find a homebirth midwife willing to take them on as a client. The thing is, people who are not knowledgeable or aware that they can have a homebirth while having a managed Medicaid plan may not even consider it. Because homebirth is still viewed by some folks as dangerous and antiquated, thanks to poverty shaming, colonialism, and the smear campaign the medical profession executed in the 1900s, and hospital birth is considered superior, pregnant people often do not find out the potential harm and risks they can encounter in a hospital, particularly a public hospital. There are many qualified and well-trained home birth midwives in New York City with years of experience to serve pregnant folks who still want to pursue this option because they know of the anti-homebirth propaganda that has been pushed for decades. Folks that come recommended are Umaimah Mahmud-Thiam, Nya Memaniye Cinque and her practice Dyekora Sumda Midwifery & Nutrition ServicesTakiya Sakina Ballard, JJB Midwifery, Tioma Allison, and more can be found at Homebirth Midwives of New York.

For the person who does want a hospital birth, they have the option of potentially working with a hospital-based midwife that can do their care and delivery. This comes with the stipulation that a potential client should be aware of whether or not they will work with the same midwife for their entire pregnancy and birth. Hospital-based midwives from my experience provide wonderful care. I have heard from other doulas that there are midwifery practices holding it down in the hospitals and doing the best they can to give birthing individuals the care they deserve; some practices in New York City in public hospital for folks who have Medicaid or Medicaid-managed care plans are North Central Bronx Hospital Midwives, Lenox Hill Midwives and Metropolitan Hospital Midwives. However, hospital midwives do their work within the constraints of hospitals that may place restrictions on them that are not necessarily in line with how they would like to practice. There are instances that these midwives still need to interact with an attending physician that may either be cooperative or restrictive. As previously mentioned, some people are not even aware that there is the option to work with a midwife within a hospital setting.

What ends up happening is that these options, as described above, are available but are only coming into the consciousness of folks in recent years. Depending also on a person’s education level, the hospital they have access to and possibly their insurance, they may go and see an obstetrician/gynecologist and not get the care they want or didn’t even know they wanted. I personally am not a huge fan of ob/gyns when it comes to childbirth, and I also understand that 1) they are working within a system that may force their hands to do things they in good faith would not do, and 2) ob/gyns are seldom trained in natural birth. Let me say that again. Ob/gyns are seldom trained in natural birth. What this means is that they are normally taught to manage a birth as a pathological emergency and don’t necessarily have the training to attend a birth by holding space for the birth to unfold on its own. There are ob/gyns who are incredibly compassionate and low-intervention but when it comes to a public hospital setting, which is where the demographic I tend to support births at, it can be hard to find a provider like this. Racism, classism, and sexism are deeply embedded in the medical system here in NYC and nationally, which changes the experiences of pregnant people on an individual and collective basis.

Doulas are also becoming much more popular as more people learn about them and what they do. Unfortunately, some still see doulas as a luxury rather than a necessity. In my experience with working with low-income Black and Latino pregnant folks, it can be the difference between a traumatic birth and a birth where the trauma is minimized from the presence of a strong advocate. In New York City, there are many doulas. However, there are not always doulas who are willing to do low-cost and free doula work because it is their bread and butter, so to speak. There is nothing wrong with this. I am of the personal belief that my doula and birthwork is an act of resistance, so I have a commitment to still charge my normal fee of $1500 but make it explicilty clear to people that want to work with me that I am more interested in providing much need support than anything else. I don’t expect that to be every doula’s reality or capability. There are some options for low-income individuals seeking doulas who work to be able to fit various income brackets: Uptown Village Cooperative, Ancient Song Doula Services, By My Side Birth Support Program, and NYC Doula Collective (Tier 1 Doulas).

All this to say, that there are some options available in New York City for a birthing person that are dependent on their insurance and financial situation. The maternity healthcare provider that is available to someone expecting a child can make a huge difference in their pregnancy experience and birth outcome. The better the care, the higher the chances that the pregnant individual will follow their prenatal appointment schedule and feel safe when they are in labor. This is why the midwifery model of care is important to have available for more families and individuals; obstetrics and gynecology are not always the best option, especially if it is a relatively healthy pregnancy with no complications or pre-existing conditions. Home birth is a great option but the truth is, it is not easily accessible to everyone, which leaves no option but to give birth in a hospital. In a hospital setting, the option then becomes having their prenatal care managed by a midwife or an ob/gyn. Even with these options, it is dependent on the culture of the hospital and their relationship to the midwives. I hope this was able to shed a little light on what to expect when expecting in New York City.

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