From Big Belly Services, adapted from Gentle Birth
How a doula sets her fees is a mystery to many people; I offer this information so that you have a better idea of what you're paying for.
Hours - Couples having a first baby may imagine that their doula will only be spending a few hours with them during the labor and birth. In reality, an eight-hour labor would be considered pretty fast; most first labors last at least 24 hours; the longest continuous time I've spent providing labor support is 41 hours. The average time I have spent with a woman for her labor and birth is about 13 hours. I spend another 10 hours in prenatal and postpartum visits, another hour or two in phone calls or email, and up to six hours travel time. Using those averages, my fee translates to an hourly rate of about $25/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 (compared to someone working a shift in a hospital or sharing call with another provider) is that one client per week is a full schedule. Because I also do a lot of teaching, I find that two to 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 vacation, or attend a conference, or have a commitment that I cannot miss, I have to add another four weeks during which I cannot accept clients. Occasionally, my clients hire me with my backup on-call during times that I may be unavailable. I have averaged about 25 clients a year the past few years.
Being Self-Employed - 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, insurance, and business expenses. As you may imagine, my communication expenses are high - business phone, cell phone and computer connection. I also have typical professional and office expenses, continuing education expenses, and unusually high transportation expenses since I primarily travel to people’s homes.
Putting It All Together - 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 awoken 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 multiple phone calls – often in the middle of the night. In past years, I have spent my birthday at a labor, my family spent Christmas day without me, I’ve had to cancel (and then reschedule) numerous classes and appointments, and find middle-of-the-night childcare when my husband was away on business. A few years ago, I was called to a birth Christmas Eve day and got home at 4:30am Christmas morning, just in time to wrap a few presents and get a few hours sleep before my 5-year-old son woke up. I cooked Christmas dinner and went to bed early, only to be called at 11pm Christmas night for another birth. I considered myself lucky to have had the great timing to be home with my family that day! I cannot take weekend trips away from the area, and even day trips to the spa or the mountains have to be judiciously chosen. 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 take catnaps sitting in a chair; I may eat nothing but crackers and dried fruit; 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. Thank goodness I LOVE my work! But the financial reward for this? The annual income of someone providing labor support services with a responsible client load and a strong commitment to being available for birth is 1/2 the number of clients per year times their fee per client.
Experience Factor – When I step into a birth, I bring not only my heart and hands and training, but my experience from over one hundred fifty births and continual research on subjects relating to birth. As a doula and educator, I must keep up-to-date on the latest studies, procedures, protocols, and policies surrounding birth and area hospitals and providers. Did you know that doctors, midwives, and nurses usually only know their way of doing things? As a doula I see the variations from hospital to hospital, between care providers, and over time. Being able to work with many different care providers, I learn all their different approaches and tricks, which I think is unique to the doula profession. And considering that every birth and every family teaches me something new, I have a wealth of knowledge and skills to bring to birth.
Bottom Line - Nobody's getting rich doing doula work. But every doula should be able to make a decent living as a doula without making her life unbearable. 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 to have a more conventional job, which would pay much more (I used to do that!). There are people offering doula services at significantly reduced prices. They are either offering less time and services, are still in training, or are in a financial position to offer free services. If you need free doula services, there are many ways I can help you find a free doula; 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. The most common cause of doula burnout is feeling overwhelmed by the commitment and uncompensated for one’s time and dedication.
Advocacy Suggestions – Doula services are rarely covered by medical insurance plans, even though the statistics prove that doulas can save insurance companies lots of money by reducing the use of medications, interventions, time in the hospital, and surgical (Cesarean) births. 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. Also lobby your State legislature to include doula services in state-funded healthcare so that low-income women have access to experienced doula support and doulas don’t have to further their financial burden by attending these births for free (that is what we do now). 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 (and make their job easier) - although in this model 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. By all means, tell everyone you meet about the support you received from a doula – spread the word about doula care so that more doulas are needed and are well-paid and can continue their work for generations to come.