Homebirth for Servicemembers
This post is a guide to any service member (birthing person) who is interested in a homebirth. I will draw from my personal experience as a service member in the USAF so you may need to alter this guide based on your service component. As stated above, this is a guide, every situation is different and I respect everyone's individual choices, it is not meant as medical advice, it is not meant to represent the USAF.
Great resource for learning more—->Homebirth Overview
1. Budget. $3,000-$5,000. Homebirth costs vary greatly based on provider and location. Some lay midwives even barter or accept payment based on what you can afford. I found myself in this situation with my first midwife in Grand Forks ND. A doula will be an additional cost, if you chose to hire one. If this is your first homebirth, I strongly recommend an experienced doula. A doula is a vital part of the birth team and will be able to assist in many aspects of your labor to include pain management, emotional support, labor support, hiding your partner through labor support, communicating with your midwife, and in some cases delivering baby on close calls! Some doulas will work for free in certain situations, perhaps they are working towards a certification or do so many pro bono clients, it really just depends. Doula services range from $500-$1,000 again depending on the services.
We all have emotional reactions to money, wow....this birth is sounding expensive! I strongly urge you not to try to hire the cheapest care provider you can find, that is not a good criteria for selecting your midwife. It may be helpful to keep the following in mind. Homebirth is "on-call" work for your providers. They will block out their schedule 2 weeks in advance of your due date, and two weeks after. That means having a midwife backup on staff, flexible work hours, childcare, leaving their phone on at all hours, avoiding alcohol, surgeries, travel, vacations, personal commitments....considering much of this is mitigated in a hospital environment as there are shift changes and multiple staff who will show up and have no continuity with the patients but at least there is 24/7 coverage. Whereas a midwife is partnered with you through your care, and in order for them to also show up to your birth event whenever the time comes their time must also align with whenever your birth occurs. They also have to reserve this time for other clients, so it is a significant adjustment for their schedule. Also, they may attend a birth for close to 12 hours or longer, along with multiple pre-natal and post-natal visits, altogether, there are probably at least 24 hours invested in work hours per birth for a doula and well beyond that for a midwife if you are seeing one regularly, so considering what all goes into the support of a doula and midwife the price is reflecting all of those aspects, not just the birth itself. By comparison, if I said you were spending $3,000 on your self care this year....that would seem much different. Try this creative exercise for some perspective, add up all of the expenses you can think of that count as self care. Hair, nail and body treatments, gym memberships, eating out, vacations, etc...and compare that with the estimated cost of a homebirth. Hopefully that helps!
What about TRICARE? As a military member (not a dependent) you are different, here is the reality... as of the writing of this post, military members are not technically "beneficiaries" of Tricare, their care falls under the Military Health Care system and they are only entitled to "standards of care" of the Military Treatment Facility if one is available. If one is not available, the member will be referred to a civilian hospital. This is for all health care, not just OB/GYN which is our focus for this discussion. An example is dental, Tricare's literature specifically authorizes pregnant women to have an additional cleaning, there's medical evidence that pregnancy lowers your immune system and makes pregnant people more susceptible to inflammation and gum infection which can lead to further problems and thereby warranting more preventative care.... however finding a military dental clinic that will honor this Tricare covered service is very challenging. When I raised the issue at my MTF I was given the above explanation, the MTF is only required to adhere to standards of care for readiness...not meet Tricare requirements. This was a huge shock to me as a military member, as I always thought if I fell under Prime I was going to receive Prime benefits....yes and no.
So how does this apply to birth? If there is an MTF with OB/GYN and Labor and Delivery, you will be limited to that location. It is likely that if there are other health needs, that this criteria is different, I am assuming for most birthing persons this is the scenario.
The one exception, is if the MTF will refer you to a Certified Nurse Midwife. In this instance, Tricare benefits would cover some expenses of a homebirth because yes, Tricare does include homebirth in it's covered services. HOWEVER....be prepared for the MTF to deny this request. I don't personally know of anyone who has been successful with this referral process, so my advice about pursuing this option is limited. This is why I recommend budgeting for paying for homebirth out of pocket, as then you are not bound by the MTF/Tricare barriers to your preferred birth.
2. Interview and select your providers. If you are early in your pregnancy this is a great time to start interviewing potential midwifes. Usually you want to select a midwife before the end of your second trimester, this is to afford you enough time to establish a health history, trust and rapport with your provider as well as respect her practice schedule. Some midwives may have fees for late hire, as this is a disruption to their practice. Others may decline to onboard clients past a certain point in the pregnancy for safety reasons, so you will want to ensure you don't delay your search for a midwife. Finally, they tend to limit their clients for the above mentioned reasons about coverage, so the best chances of finding a midwife you are really comfortable with you will want to interview early to ensure you have a spot in their schedule! If you live somewhere more remote/rural, there may be less providers in your travel range, so you will need to check around your area. For example, a midwife may have a personal travel limit of one hour and decide she isn't able to support births outside of that radius. Most midwives and doulas will have some form of social media, but you can also check through other birth support workers such as chiropractors, naturopaths, yoga studios, for referrals. There are many guides and planners you can refer to for how to interview a provider. Don't forget to ask if they have a military discount!
3. Co-care. Co care is when you are seen by both a midwife and continue to attend some or all of your OB/GYN appointments. Since you are paying out of pocket for your midwife, you won't receive a Tricare bill for any MTF/hospital OB/GYN services. This is great for covering your labs, ultrasounds, and routine check ups. Anyone can pursue co-care, you don't have to report this to your provider or Tricare, it's just what you feel most comfortable with. You may feel more comfortable being closely monitored by the hospital, or you may even be really lucky and have a provider you really love who is super supportive of homebirth! This was the case with my first pregnancy! My doctor knew my midwife and gently reminded me that should I desire to transfer to the hospital he would gladly help me deliver. I've even heard of OB/GYNs who attend homebirths....this is obviously very situation dependent, but demonstrates the variety of birth providers and options that do exist. My personal experience with my first provider was so kind and respectful, but it is not always the case. This is also a great option for moms with some borderline health issues, or perhaps those who fall under Maternal Fetal Medicine who want to take advantage of continued monitoring...again, this was helpful in my third pregnancy because I had developed a subchorionic hemorrhage early in the first trimester and was very concerned about it's impact on the pregnancy. MFM monitored me closely, and I still chose to move ahead with a homebirth.
4. Attitudes towards homebirth. Medical bullying is real. Especially in the military health system, there are certain attitudes against homebirth that have ultimately brought me here. Should you find yourself in a situation where your care provider is yelling, cussing, angry, threatening you, your health, the health of your baby, your career, receiving punishment, not being able to homebirth, or accusing you of any labels such as "difficult, impossible, or illegal" then you are being bullied. This is not okay. I strongly recommend that you speak with your Airmen Defense Council/military legal office regarding any questions you have about your care. You can also try the patient advocate, however in my experience these are useless. I don't think they are out to get someone personally for homebirth...its just such a rare choice that it is not yet a normalized "socially accepted" choice. It is still viewed as "risky and unsafe" among many. Even though most people who hold this view might not even know much about homebirth. I recommend that you definitely document every negative encounter. Remember, you have the right to professional care. You don't have to see a provider if they make you uncomfortable, ever. You have the right to a chaperone. You have the right to switch providers. You have the right to stop an appointment or procedure at any time! This includes an exam, a transvaginal ultrasound, or any medical intervention, including vaccinations.
Additional Thoughts. There is another consideration regarding homebirth for military members. Time to start quoting AFIs!
AFI44-102 17 MARCH 2015 41
4.8.3. The AF/SG endorses the policy of ACOG and AAP Guidelines for Perinatal Care, "Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes." Due to the two to three fold increased risk of neonatal death referenced above, the Air Force does not favor home delivery. If an elective home delivery on base is planned nonetheless, the installation Commander, in consultation with the MTF/CC, will first ascertain to his/her satisfaction whether the provider participating in the delivery is properly licensed by the host jurisdiction to perform the procedure and that the welfare of personnel on base is not jeopardized. (T-1)
Let me break this one down-there are endless way babies enter the world. Some babies arrive with minutes to spare others with days of slow progress and everywhere in between. I am not a lawyer by a landslide but I enjoy picking apart the hasty format of this AFI as it attempts to dominate a woman’s choice to birth-which is in fact not determined by ACOG! Also It does not specify that you can’t have an unassisted homebirth….it just assumes that it will be an assisted birth with a licensed provider, there is a lot of grey area in this paragraph. Definitely don’t intentionally violate an AFI, that’s not what I’m advocating. If you do live on base and want a homebirth a midwife with a birth center may be a better option for you. These are more and more popular as many parents like the comfort of a birth center and the proximity to a hospital. I don’t know anyone who’s baby is delivered to them. The appropriate verbiage should read “home birth” ( for what it’s worth I am pointing this out since words matter). And as long as we expect moms, especially first time moms to somehow anticipate the unpredictability of early labor with the precision of determining hospital policies (when to show up to L&D and timing contractions and if your water has broken and multiple other factors…) all during Covid no less, moms will probably struggle to make it to the hospital at the perfect dilated state! So maybe you just labored at home longer than you realized and now it’s time for pushing and too late to transfer….does this happen? Every day. Maybe your laboring at home and try to transfer but the weather causes the roads to shut down or maybe your car has an issue, I’m just saying there are so many reasons you might not make it to the hospital even with a planned hospital birth.
I recall a conversation between my Air Force Lt Col Midwife who was working at my military hospital where I was under co care, I had just completed my GBS strep test and was sharing with her for the first time my birth plan and was excited to have a military midwife as my provider, who at that point had been catching babies for decades, when I shared with her my plans for a second homebirth things took an ugly turn. She balked and threatened me with the above AFI (incorrectly stating it required installation commander approval). I had already read the AFI and corrected her on the spot. I then asked her about transferring to the hospital as my backup plan. Always have a birth plan back up with a planned homebirth! Her response was hugely disappointing as she basically dismissed my medical needs and said she isn’t capable of triaging a homebirth transfer. This response is negligent and incorrect. Because here is the bottom line….every single mother who spontaneously begins labor at her home and walks out her front door with her hospital bag is a homebirth transfer. Let me say that again. The very first medical intervention in your birth whether you realize it or not is the decision to walk out your very own front door.
There’s many ways babies come into the world, what matters most to me as a doula is that moms choices are respected and that they are supported. I share my knowledge of birth here for that very reason. I am not trying to convince anyone to homebirth, nope, I don’t think it’s for everyone actually. I think some women are much safer in a hospital in certain circumstances. That’s not the point, the point is helping out the people who do want to attempt a homebirth navigate the challenges in front of them, because it is an unconventional choice in 2021.
Is it worth it? Only you can answer that question. If the sticker shock of a homebirth is deterring, that is understandable. We have been conditioned to accept that birth is covered under insurance and the thought of paying for it seems perhaps out of reach practically speaking when we could "save" that money. There are so many ways to tackle this. Perhaps for your baby shower you ask for donations for your homebirth in lieu of registry items. (If this is your second/beyond birth, perhaps this is less of an issue for you). Perhaps you look at your finances and make some adjustments, and cut back on some other discretionary areas. Ultimately when we look at our values and what we want most, money seems less and less important in the grand scheme. And even if after going through all the preparations, you decide to give birth in a hospital, that is perfectly okay! Because it will have been your choice :)