Money is always a tricky subject, especially when working within a profession in the "healing arts." For many birth workers, this profession is seen as a "calling" as much as it is a job. Add to that the fact of these caretaker roles being traditionally held by women, being seen as "fringe" or outdated, and still sometimes viewed as a luxury item despite mounting evidence otherwise, and with no set national standardization for the profession a leaving a host of intricate and competing economic influences driving the fees for these services in every direction.
When I first started out as a doula, I was living in a community where bartering was the norm. In many ways, I really enjoyed that concept. There was always communal food, carpooling, couchsurfing, skill sharing, etc., and I learned a lot in my nine months there. On the other hand, I was making about $500 a month for a job I was way over qualified for and could barely pay my bills.
I was twenty-two, fairly fresh out of college staring at a five-figure student loan debt and trying, desperately, to grow my doula business. I spent hours upon hours learning how the internet worked (funny, as I almost failed my web building class in college), calling every doula and “alternative” practitioner in town, forming study groups, forming community groups, volunteering at childbirth ed classes, and scrounging for clients, all with zero pay.
I was burnt out and exhausted before I even had my first client. I moved out of that community after less than a year because I could not hack it on little to nothing. I traveled (by bike) south to San Francisco with the woman who was becoming my doula business partner, Jasmiene. We figured that if we could split the cost of owning a small business (and doulas are small business owners), and the time trying to acquire new clients, that we’d have a better chance of turning a profit and not getting burnt out.
Postpartum work in Olympia at that time was almost non-existent. When it did happen, it was often birth doulas and midwives who recognized that their clients needed more support and came over more often out of their own pockets. In the few instances where they were paid, the going rate was somewhere around $15 an hour.
In San Francisco and the surrounding area at the time I moved here and wrote an original post on the costs of being a doula (around 2010) postpartum rates were around $25/hr. Even with the increase in the cost of living (my rent was $850 a month back then), the rate at which doulas were being hired, how organized they were as a group, and how many opportunities there were to continue our education for a smaller fee made this move seem like a wise decision. My birth partner and I tenuously increased our birth rates to $800, but after just two births, we realized we were grossly underselling ourselves…plus we could barely pay rent on one birth a month. Eventually, we were up to $1,000 per birth and $25/hr postpartum ($30/hr for overnight care).
Currently, $35-45/hr is a pretty standard national rate for daytime postpartum care. In major cities, the rate varies from $35/hr for a doula-in-training to $75/hr for a more experienced doula, overnight doula, and / or a doula with advanced lactation support training.
Now, $45 an hour for a doula might seem totally ludicrous to some (and currently, it’s on the low end of the fee spectrum for doulas in the Bay Area), especially when folks still often don’t understand that we’re more than just glorified babysitters, but I want to break it down into what the doula is putting into her services and what you are getting out of it:
Doulas are business owners:
In most cases, doulas are interviewing for new clients constantly. That means they are driving to you, either to your home or to a cafe, and spending money (on drinks and food and gas) and time to get about 1 out of 3-4 interviews ending in a hire. At one point in my career, Jasmiene and I were going to 2 or more interviews every week and shared no more than 6 clients in our practice at any time. More commonly, we had half that. And parents should want to work with doulas with a low-client base and with the ability to rest and take days off to ensure reliability and presence of mind during appointments. That means that they have to pay for that accommodation so we can subsist on this work.
Advertising alone is an incredible financial burden and it’s often hit or miss. Printing business cards, pamphlets, flyers, advertising online, in newspapers, and keeping up a personal website really adds up. In the Bay Area, we were spending about 15% of each fee for these costs alone. If we took a hit one month or couldn’t take on more clients for some reason, those costs still existed. IT IS A BUSINESS.
Printing other materials is just as expensive. We always came to our prenatal visits with a wealth of information as well as necessary documents to fill out so we could be the best support persons possible. Contracts, hand outs, sleep plans, feeding advice, favorite articles, readings specific to each family situation, etc. We weren’t employees of an office with a big, efficient printer, either. Every other month, we would go to the office supply store and buy several hundred dollars worth of printing materials ourselves. We also regularly had to go to a print shop to get things done more professionally and that cost really added up, despite having to do that maybe once every three months.
Despite having the same needs as many other small business owners and freelancers, since doulas are still considered to be working in a "fringe" field, it is rare that we would qualify for small business loans, adjustment programs, grants or scholarships for continuing education, and other perks offered to small businesses in this country. However, we’re still taxed at 40%. It’s rare that we qualify for tax write-offs other businesses might have— like an “approved” home office — since we are in-home support. In-home provider tax credits max out at just under $5,000, by the way.
Parents increasingly want us to be able to process payments electronically, which is more convenient for them, but we are still charged the 1% transfer fees or the up to 10% credit card processing fees, which we are unable to make up down the road in volume, the way other high transaction small businesses often can. Other electronic business tools range from costing $15-65 a month, which adds up quickly in a solo practice, but are becoming necessities in some markets to stay competitive and keep doulas from burning out on non-billable hour work.
Office insurance plans, paid time off, sick leave, paid vacation, family leave…none of those things exist for doulas. If we miss a client visit, we miss upwards of $500. This is why I stress to the doulas I work with on contract writing having some system of rescheduling and illness clauses that don’t leave them super vulnerable. The reality is, though, a few times a year there will be a situation that arises that takes money out of the pocket of the doula that can’t be made up. Keeping doula rates to a livable amount ensures this work can remain as an available and accessible option at all. And it can be seen as a two-way street where the high rates can keep a doula accountable to their clients out of respect for the transactional nature of this beautiful and important work.
Doulas require continuing education:
Most parents are concerned about our credentials. Not only is it expensive to get and keep up with our certifications, most families are looking for doulas who are constantly continuing their business education. These classes aren’t cheap. There are workshops starting at around $35 for a one-day session and they go up to $5,000 for courses offering a specific credential. This can often cause a catch-22 situation where it’s not always the “best” doulas (or the “best” doula FOR YOU) who is able to advance herself and her business, but rather the ones that can afford it and will thus generate more business and be able to get more clients.
Doulas often gather in collectives to help learn from one another and support one another. This takes up an extraordinary amount of time. Like it or not, time is money. We’re not paid hourly for the work we do outside of our interactions with clients and we’re not on a salary. Same for the amount of time we spend reading research articles, books, blogs, and discussing / debating this information with one another. If our collectives don't put money aside for subscriptions to various journals (and most can't afford to do it), those become out of pocket expenses, too.
What are parents getting out off all those behind-the-scenes expenses anyway:
Doulas make themselves available for parents in a way most other traditional care providers can or will not do. They cater their business to their birth / postpartum experience. They are often the only ones there specifically for these families and not for some outside agenda of profit, public health number, political pressures, hubris, generational opinions, etc.
Too few parents understand how alone they will be in the postpartum period. There is an increased awareness about postpartum depression (luckily), but there is very little education and support around the non-pathological changes in the early parenting period. Ditto to the manifestations of postpartum depression that don’t look like sadness — like the prevalence of postpartum OCD and anxiety that is often culturally dismissed as being “thoughtful” parents. Postpartum doulas are trained to recognize and support these mood fluctuations from the normal to the severe and to help families get the support they need. Doulas can then adapt and adjust care according to these changes unlike the many apps and gadgets meant to replace human guidance and interaction in health and parenting.
All that education and community building is what makes doulas the gurus in pregnancy and beyond. Attendance at childbirth education and parenting classes is steadily declining, unfortunately. It’s been shown that most parents are getting the bulk of their information on pregnancy, birth, and postpartum from books and increasingly from websites and social media. Where that might not seem terrible at the outset, but isolating that information doesn’t leave much room for personalization or nuance. Or conversely, there is often too much chatter in the comment sections without any particular vetting or emphasis on sourcing. Parenting books and websites are known hellscapes of opinion and bias, and often have less to do with research driven support than cultural trends and efforts to create a broad network of further brandable items. That’s in no way impossible to avoid in working with a postpartum doula, but there are ways of thoughtfully combatting the shallow and judgmental nature of those sources in working one-on-one with a doula who doesn’t have any incentive to push a particular system upon a family. That level of connection and trust takes time and effort to build, which can happen with a doula contract, but not with a book or blog.
Postpartum doulas come directly to parents, which has well researched and long lasting health benefits and offers a great deal more than a 15-min office appointment with a pediatric care provider. It’s also very draining on our end. There is a great deal of physical and emotional trauma present in birthing in the United States. Sometimes that comes from situations beyond anyone’s control, often, though, it is a symptom of our failing healthcare system. Many new parents fall through the cracks of our assembly-line style of care and it is not uncommon for parents to feel hurt and alone after birth, on top of the normal amount of healing, joy, and exhaustion. Postpartum doulas are there to listen, validate, and counsel parents in this position. It is a calling, and most doulas are happy to do it, but that does not mean that it doesn’t take away from our emotional and physical reserves. So $45 is a bargain compared to the cost of the psychologist couch we’re often keeping families from having to jump into or the expensive and overused treatments like surgical tongue snipping, pushing medications on infants for normal gastrointestinal changes, or unresearched supplements or dietary suggestions. There is a great deal of value in preventative and patient emotional care in this vulnerable time period.
Doulas are there for families soon after baby comes home / the midwife team leaves. They know us. They trust us. That helps when it comes down to figuring out the myriad of details of being a new parent. Doulas may be the only ones that notice marked changes in mood and can stave off worsening postpartum mood disorders. Doulas may be the only ones supporting the choices for feeding, sleeping, pacifiering, diapering, etc. in these families. The community resources doulas work exhaustingly to gather extend into the postpartum support community as well. Doulas are often experts on breastfeeding and infant massage in addition to doing laundry, holding baby so they can shower or go for a walk. They talk families out of late night deep dives down the black holes of mommy blogs and their false alarms. They can be crucial lynchpins against the rising anxieties often falsely pushed upon new parents.
Studies show that this support reduces the need for all sorts of interventions, items, and gadgets, which in the end not only makes the experience more enjoyable and empowering for most folks, but actually saves time and money. Plus, added perk — better for the environment!
The sad truth is that our obstetrical care system does not fully support pregnant people and their families. The US has rising rates of maternal and infant mortalities it is slow to properly acknowledge let alone address. Making the investment of hiring a doula does not form a magical protective shield around you in birth or postpartum, but the studies point to numerous benefits to having this continuous support in pregnancy and early parenting. It is worth the investment in time and money to consider hiring a doula that suits your needs.
Here are some ways you can afford to hire a doula:
Ask for part of the fee covered through baby shower gifts. Truthfully, you DO NOT NEED THAT MUCH BABY STUFF! If someone was going to spend $50 on baby clothes, that could easily go toward your doula fund instead.
Ask your doula if they accept payment plans or work on a sliding scale but please keep in mind everything that she is putting in in order to be a great advocate for you and your baby.
See if there are programs at your hospital, birth center, midwife practice, or community center that can help either connect you to a doula who works on a reduced budget, or one who’s fees are covered by a program or foundation. There are programs for young parents, homeless folks, recent immigrants, veterans, those without insurance, those with lower insurance coverage, high risk parents, and more in many communities, but it takes a bit of effort to find sometimes. Some church programs might have connections to these centering and doula groups, too.
Consider hiring a newer doula. The studies show that working with any person who is there just for you, providing continuous support and encouragement in labor increases safety and satisfaction in the birth process. There are many benefits to working with a doula who has been practicing for a long time, but if they are out of your price range, you could potentially still get a lot out of hiring a recently trained doula for a fraction of the fee.
Call your insurance agency and see if they will cover your postpartum doula costs. This may take calling and asking for several people at different times. It’s all about finding the person with the magic code, asking for specific details for what information you need to have laid out on your claim, and following through. Some doulas are well versed in how to write up their invoices to maximize coverage. If you have Medicaid in some states/cities, there is now growing insurance coverage, so it’s worth asking.
Some midwives and birth centers offer discounts for working with doulas. Every so often, a doula will match that discount (I do!). That can save you upwards of $1000.
Start putting aside money early in pregnancy for support like doulas, lactation consultants, acupuncturists, postpartum care, etc. Resist the urge to spend that money on needless things from Amazon Prime and think about the investment you are making into a smoother transition into new parenting.
I hope you found this rundown helpful in explaining the costs and benefits of working with a doula.