What do midwives get paid?

Waikato community midwife Sheryl Wright unpackages some of the myths surrounding midwife pay.

In a discussion about birthing, someone commented to me that midwives "don’t want women to birth in hospitals or have interventions because this will result in them being paid less". As a midwife, I found this quite shocking, not only because it’s completely untrue, but also because of the distressing insinuation that midwives might willingly put the lives of mothers and babies at risk so they could earn more! I wondered how widespread this belief was and sure enough when I did a Google search there were many website forum entries on the topic of what midwives get paid. Unfortunately almost all of the responses were inaccurate. There also seemed to be widespread (and erroneous) belief that midwives 'get paid heaps'. So here it is – the honest truth.

Firstly it’s important to understand the difference between core and community midwives. Core midwives work shifts in a maternity facility (e.g. a hospital or birth centre) and get paid wages based on an hourly rate. They are employees so work set hours and are not on-call. This article focuses on community midwives who are self-employed, on-call and work as LMCs (Lead Maternity Carers).

All LMCs, including community LMC midwives, are contracted to the Ministry of Health and the services they are required to provide and what they will get paid for these services are outlined in a document called the Primary Maternity Services Notice.  www.health.govt.nz/system/files/documents/publications/s88-primary-maternity-services-notice-gazetted-2007.pdf  These services are broken down into care modules and the midwife can claim these fees after she has completed the work. The fees payable are detailed here:  www.maternitycare.co.nz/wp-content/uploads/2012/11/Primary-Maternity-Services-Amendment-Notice-2012.pdf 

These fees are for providing primary care which means all the care that a community midwife would be expected to undertake during a typical uncomplicated pregnancy and birth experience. Unfortunately this is where things seem to get confused as many people seem to believe that community midwives lose money if women need additional care from other healthcare providers. This is untrue as the government funds secondary and tertiary care in a separate budget, so as long as the community midwife provides all the possible primary care then she gets paid. In many cases community midwives will provide some secondary or tertiary care, for example in an emergency situation or until the woman can be transported to a facility where this is available, but there are no financial incentives to not refer a woman to the hospital or to talk her out an epidural! In fact in many cases a midwife would receive the same fee, but for less work, if the woman was transferred to secondary or tertiary care and they took over all or a portion of the care. 

So what exactly do community midwives get paid for the services they provide?    

For antenatal (before birth) care if a woman books in early pregnancy and the midwife provides all the antenatal care she will be paid the first and second trimester fee of $307.50 and the third trimester fee of $297. During this time most women will have on average ten to twelve routine antenatal visits. These fees reduce if the woman books late in pregnancy or if the woman moves away and needs to change to another midwife. There are no additional fees if the woman requires extra visits or has additional needs. 

When women are having their first baby (or a vaginal birth after a previous caesarean) the fee is $1117, for all subsequent births it is $876. This fee does not alter regardless of whether the woman has a 30 minute or 30 hour labour, or if she is a big city hospital or a rural birthing unit. As stated above, if a woman requires additional care (including an emergency caesarean section) then as long as the midwife has provided primary care then she gets paid the full fee. If an elective (planned) caesarean section occurs then no birth fee is paid but the midwife can claim $318 if she attends the caesarean for support. In the case of home births there is an addition payment of $451 however this is used to pay for a second midwife to attend and also allows for the re-stocking of items the midwife will have used during the birth from her own supplies.

For postnatal (after birth) care the standard payment for care from birth till six weeks after is $492 if the woman has an inpatient stay at a maternity facility. If the woman births at home, or goes home within 12 hours of birth, the fee increases to $553.50 as the midwife will be expected to make additional home visits in place of the care that would otherwise have been provided by the maternity facility staff.  Women are entitled to a minimum of seven postnatal visits but around nine visits is average.  Should the woman have additional needs and require more than twelve postnatal visits a further $159 can be claimed.   Travel subsidises are also available for women who live in semi rural ($154), rural ($231) or remote rural ($410) locations, however there is no real profit in these payments as they simply cover the additional fuel and vehicle expenses the midwife will incur when home visiting these rural women.   

So how does this all add up? Using the example of a woman who books at eight weeks with her second baby, labours and births in a maternity facility (with an inpatient postnatal stay) and has nine visits following birth then the total payment is $1972.50 (excluding GST). Over a year based on a recommended caseload of 45 clients, and allowing for ten first time mums this makes a total of $91,172.50.  Sounds good right?  But during the year…

• three women who had planned to have normal vaginal births require an elective (planned not emergency) caesarean section ($ - 2397)
• one women expecting her first baby moves away unexpectedly two weeks before she is due and it’s too late to take another booking  ($ -  1778) 
• three women book with the midwife late in their pregnancy so the first and second trimester fees can not be claimed ($ - 1306.50).

This leaves a total of $ 85,691 from which the midwife must pay all her own expenses. This will include things such as clinic rent, fuel and running costs for her vehicle, telephone expenses, postage, stationery, equipment replacement, insurance, ACC cover, advertising, accountancy fees etc. For most the biggest cost will be vehicle expenses, with an average cost of around $5000 per year (excluding car loan payments). There are also considerable compulsory costs involved in keeping your midwifery registration current such as payments for an annual practising certificate ($400), indemnity insurance ($695), ongoing education ($500), Midwifery Standards Reviews ($150) etc. In total, average expenses come to around $25,000 per year (excluding student loan payments which are not considered business expenses). Once expenses are deducted this leaves $60,691 from which income tax of approximately $11,227 will need to be paid, leaving a net income of $49,464.

For this community midwives are required to be on-call 24/7 for all 365 days of the year. They are not entitled to any holiday pay, long service leave, sick leave or bereavement leave. They will frequently work long hours including nights, weekends and public holidays. With babies often being born at night a typical community midwife will lose around 25 nights sleep a year. In addition to the one-to-one midwifery care provided there are also lots of ‘invisible’ tasks they must do. This includes making and receiving phone calls, writing referrals, arranging and checking test results and the continually growing amount of paperwork that is required.   

To counter these demands it is vital that midwives ensure they take regular time off to prevent burnout, however for this to happen they need to make their own arrangements with another community midwife to provide them with back-up cover. This will mean they either have to pay her for the cover (reducing income further) or by providing her with reciprocal time off. 

Community midwives are not able to charge women for their services so they are dependent on the fees from the Ministry of Health contract. Unfortunately this contract is not regularly reviewed, and a recent increase in 2012 of only 2.5% was the first since 2007. The contract does not include provision for any annual cost of living increases (the only Ministry of Health contract for health professionals that doesn’t!) so the only option midwives have to increase their income to keep up with the escalating cost of living is to increase the number of women they care for.  Unfortunately this is generally not an option because the work is too demanding and can result in midwives having to work long hours and putting their own health and well-being at risk.

Using the above figures and based on a standard 40-hour working week (which most community midwives would consider a dream!) this equates to an hourly rate of $29 (or $23 after tax). Does this seem reasonable for a university degree qualified health professional who provides vital community services and bears considerable responsibility for the safety of women and babies? Certainly it would seem unlikely that a self-employed plumber would be willing to be called out at 3am for this hourly rate! While there would be very few midwives who would list ‘making money’ as the reason they became midwives, surely it’s not unreasonable for midwives to be more fairly reimbursed for the work they do?  

Sheryl Wright is a community midwife with over ten years experience of rural and remote rural midwifery in the North Waikato.