I draw on my knowledge and experience to provide emotional support, physical comfort, and, as needed, communication with hospital staff to make sure that you have the information you need to make informed decisions in labor. I can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, massage, position changes and other techniques for comfort. I am independent and self-employed. As your personal labor support professional, I am working for you, not your caregiver or hospital.
My standard services include one prenatal visit in my office, one prenatal visit in your home, support at your labor and birth, and a postpartum office visit or extended phone call. In addition, I am available for phone consultation to answer questions or provide information about your pregnancy and recommended tests and procedures.
Detailed Discussion of Your Birth Plans - We review and discuss your birth plans and your preferences regarding the nature of my labor support and advocacy.
Assessment of your baby’s position to prevent a posterior position and painful back labor and to detect and correct cord entanglement that might affect your labor.
Review of the process of labor and birth - I am trained as a midwife and labor coach rather than a childbirth educator, so I take a pragmatic approach to this review. I bring my diagrams and 3-D models and focus on the mechanics of labor and birth, discussing the related maternal and fetal changes, and what we can do to support the process.
Rehearsal of labor and birth - At the last prenatal meeting, we have a “dry run” of labor in your home, reviewing the phases of labor and the position changes and other practical support that will assist the process.
Education about taking care of yourself in early labor to get off to a good start.
In addition, I provide items that can significantly help you to have an easier labor and birth:
Prenatal relaxation and visualization – I provide an audiotape I have recorded so that you can develop a relaxation response to the sound of my voice. This will increase your ability to relax in response to intense guided imagery during labor if needed. In addition, I am available for extra hypnotherapy sessions if there are special issues you would like to work on.
Special prenatal herbal supplements to help ripen your cervix in order to avoid a postdates situation with threat of induction, and to help you have an easier labor.
Comfort Measures - I find it best to arrive at your home just as you're shifting from early labor into active labor. My goal is to provide support that will help your body start generating endorphins so that you can relax and ease into active labor. This will help your body's production of natural pain relief to keep ahead of the increasing intensity of labor.
I am available to provide the level of direct emotional labor support that is appropriate for you. Generally, the situation that seems to work best for everyone is for your partner to be your primary emotional support through labor, holding your hand and simply being there with you. Meanwhile, I can keep an eye on the clinical situation, provide massage, keep the fluids coming, and make suggestions as appropriate so that labor progresses as efficiently as possible. As needed, I am available to provide full support so that your partner may take a break, get some rest, or take care of any family matters that may need attention.
Typically, when I first arrive at your home, I do a quick clinical assessment of your well being, the intensity of labor and your baby's position and heart rate. Then, if you're open to massage, I'll help you get comfortable on the birth ball; I'll sit behind you and provide back massage while your partner sits in front of you, holding your hand, providing eye contact and encouragement, and helping you to relax.
Then, as labor becomes more intense, I may encourage you to spend some time in the tub or shower, or provide suggestions for different changes of position. As necessary, I can also provide short-term hypnosis or guided imagery to assist you in coping with the intensity of the contractions if you want.
In the Hospital - Once we are at the hospital, my role changes slightly. The hospital staff takes over responsibility for your clinical care, and I provide advocacy for your choices, working to ensure that the family's birth plan is followed as closely as possible. I continue to provide comfort measures and suggestions about helpful position changes. I am glad to provide clinical services such as helping you shift into the pushing phase, applying hot compresses near crowning, and assisting with perineal support to prevent tearing. However, it is better if you discuss this with your provider ahead of time, as they may find it unsettling for non-hospital personnel to provide clinical services in the hospital.
Equipment - I bring an assortment of labor support aids, including a birth ball and hot and cold packs and a TENS unit (Transcutaneous Electrical Nerve Stimulation) if requested. I carry a variety of aids for special situations and my midwifery birth equipment, in case of emergency. I can provide an AquaDoula birthing tub for women who want to labor in water, although this must be arranged several months in advance. I carry all my regular midwifery equipment in the car.
Miscellaneous - I am happy to take photographs as the family wishes. I am also a singer and am more than happy to sing simple songs, show tunes, chants or lullabies if it helps.
Typically, I stay for an hour or two after the birth, until everything is stable and the family is ready simply to enjoy their quiet time together. During this time, I provide assistance with baby's first breastfeeding sessions, and I continue to advocate for the family's wishes, particularly in keeping your baby near you. I can also provide information about any additional procedures that may be suggested for your baby's care. My standard labor support package also includes a postpartum office visit or extended phone call to discuss your birth experience; I let you determine the timing of this visit.
Some of my clients have asked me to offer additional postpartum support.
I am generally glad to do this, depending on my schedule. My fee for a
two-hour home visit is $250; this is half the usual and customary fee for
this area for a home medical visit for 2 patients. If you have asked for
an early discharge from the hospital and this visit takes place within
48 hours after the birth, your health insurance should cover it at the
standard out-of-network rates. It's much less expensive than an extra
day in the hospital for mother and baby, so you may choose to plan on this
for your second day of postpartum care for an uncomplicated birth.
I will provide an invoice that you can submit to your health insurance
carrier for reimbursement.
Your Availability - Your baby may reasonably be ready to be born anywhere up to 3 weeks before your due date. If you are too busy with other things in your life, such as work, your mind may keep putting off labor to the point where your baby's head has started to harden, which may make labor and birth very difficult. In my experience, clients who plan to work up until the due date put themselves at very high risk for a very difficult labor and ultimately a cesarean birth. These labors are exceedingly difficult on the women, their partners and their doula. Rather than have a blanket policy against accepting clients who plan to work up until their due date, I have decided simply to charge an additional $700 for the extra 12-24 hours I expect to be spending at your labor. It is my hope that this will convince you of the importance of making room and time in your life to prepare for your baby.
By the way, some women have told me they planned to work late into their pregnancy based on a misunderstanding that they would then get more disability coverage after the birth. This is not true for the California State Disability Insurance program. You are entitled to 4 weeks coverage before your due date and 6 weeks coverage after the birth. Some private insurance plans or supplemental disability plans may work differently.
Your Emotional Preparation - Giving birth is a physiological function that is significantly affected by your mental and emotional state. Women who have experienced birth trauma or traumas involving their genitals may find that their body resists progress in labor so as to avoid a re-triggering of those traumatic experiences. Some books that can be a big help to you in empowering you to overcome your past traumas are: Birthing from Within by Pam England and An Easier Childbirth by Gayle Peterson. Blossom Birth Services in Palo Alto (650-856-2140) has sometimes offered prenatal support groups that include exercises from Birthing from Within. Gayle Peterson is a therapist in the Berkeley area and may be available to provide individual therapy that would be very helpful to you. Optionally, you may schedule a separate hypnotherapy appointment with me so that I can create a visualization tape that specifically reinforces positive affirmations that will help you during labor. (More resources are available on my website - http://www.gentlebirth.org/archives/abuse.html)
As a homebirth midwife, I have a higher level of responsibility to my homebirth clients, for whom I am a primary birth attendant. It is important for you to know that if there is a conflict, my homebirth clients are a higher priority than my labor coach clients, for whom I am a secondary birth attendant.
If you would like, I can try to arrange to have an apprentice doula working with me for your birth. She would be a relatively new doula working as a volunteer in order to get more experience. She would attend our prenatal meetings, and I would call her to come to your labor at about the same time that I arrive. If I needed to go to another birth, she would be able to remain with you while I’m away, and I could provide direction to her by phone if needed.
Fees - The fee for my services as described above is $1800 for first births or VBACs, or $1500 for women who have had a previous vaginal birth. A non-refundable retainer of $300 is due when you hire me, and the balance is due at the first prenatal meeting. (I require pre-payment for my services because when you hire me, I reserve a spot on my calendar that I cannot give out to anyone else - you have already received the service that is most precious to many of my clients and most difficult to get from most healthcare providers - the near-guarantee that I will be the one to provide these services, whenever you go into labor during your one-month on-call period and for however long it takes; I have never needed to call in a backup doula.)
There is no charge for an initial half-hour interview in my home office so that you can meet me in person. If you have lengthy questions about your particular situation, these are best addressed at one of our prenatal meetings, or you may arrange a special consultation appointment. Some people want to schedule a consultation appointment along with the initial interview; the fee for a two-hour initial consultation is $75 in my office or $100 in your home.
Limited Labor Support Package - If you have a type of health insurance that will not cover my services, and if you are convinced that you are going to have a short labor, I offer a limited labor support package for $1100 plus $50 for each hour after the first six hours spent at your labor and birth. This package includes the same on-call availability and response and the same high level of support at your labor and birth, but I limit the time I spend with you at your birth, and I don't provide extra phone and e-mail support during the last weeks of pregnancy. Our prenatal meeting is a two-hour meeting in my office where we review the labor support questionnaire and your prepared birth plan. When you call me to your labor, I note the time when I first arrive and the birth time, and I charge extra for any time over six hours, at the rate of $50/hour. Typically, I stay for one additional hour after the birth. A non-refundable retainer of $300 is due when you hire me, and the balance of the $1100 fee is due at the first prenatal meeting. I also request a separate check(s) for $700, which I will return if my time before the birth is under four hours; otherwise, I will cash it after the birth and refund any overpayment.
Spontaneous Homebirth - I don't encourage an unplanned homebirth because I can't provide optimal homebirth midwifery services without information about your medical history and labwork and a deeper relationship than we can develop in two prenatal meetings. However, I oppose forced hospitalization for childbirth, and I am professionally obligated not to abandon you, so I will attend your birth at home if you spontaneously decide not to go to the hospital. If you decide to stay home to give birth, there is an additional fee of $2000 to cover my midwifery services at your birth and postpartum and those of a second midwife to be called to assist at the birth.
Working with your Primary Care Provider - Many care providers may become nervous if you talk to them about hiring a midwife as your doula; they may worry that you're really planning a homebirth and using them as an unwitting backup provider. I encourage you to reassure them that you are planning to labor at home and give birth in the hospital. Oddly, this situation seems to be more pronounced when your primary care provider is a hospital-based midwife. If this is your situation, please talk with your midwife about this before meeting with me.
Geographic Considerations - Please let me know if you live more than ten miles from Mountain View or if you are planning to give birth in a hospital that is not near your home. Also, I'm a flatlander. If getting to your home requires driving on hilly, winding, twisting roads with cliffs, it may not be possible for me to provide services in your home. Please discuss this with me before we meet.
Insurance Reimbursement - I am a California Licensed Midwife. As a licensed provider, my labor support services are covered by many insurance plans at out-of-network rates when you have a prescription from your care provider. If you discuss this with insurance representatives, you'll need to avoid the use of the word "doula", which implies unlicensed personnel. The services I provide in your home are technically labor management services provided by a Licensed Midwife. If it would be helpful to you, I can send you a statement of proposed services with diagnosis and treatment codes so that you can discuss details with your insurance representative or their supervisor. If the insurance representatives are not helpful, you might consider talking with the Human Resources people who co-ordinate your health benefits.
Professional labor support has been shown to offer these medical benefits:
§ 50% reduction in the cesarean rate
§ 25% shorter labor
§ 60% reduction in epidural requests
§ 40% reduction in oxytocin use
§ 30% reduction in analgesia use
§ 40% reduction in forceps delivery
[Kennell J, et al. Continuous emotional support during labor in a U.S. hospital. Journal of the American Medical Association, 1991:265:2197-201. ]
It may be helpful to quote the above statistics to your insurance representative, and they should quickly realize that they will save money overall by encouraging birthing women to engage professional labor support services.
It may be possible for you to arrange to contract for my services through your Preferred Provider so that my services are covered at the Preferred Provider or In-Network rates. It is always helpful to have a written prescription of recommendation from your primary midwife or doctor recommending professional labor support. Most birth attendants are happy to encourage hiring professional labor support, especially for women at higher risk of interventions - first-time moms, moms who have previously had cesarean surgery, or "elderly" moms (humorously defined as anyone over 35). Here's a sample "prescription", which they may want to re-word:
<Pregnant woman's name here> is under my care for pregnancy, due on or about <due date>. This will be her first baby. Pregnancy has been uncomplicated. [Or describe complicated circumstances, such as VBAC, previous vacuum extraction, epidural, whatever.]
I have advised her to engage a professional birth assistant for home care before and after the birth and for labor support in the hospital.
I have recommended Ms. Ronnie Falcao, who is a professional childbirth assistant and a Licensed Midwife. [Or: I understand that my client/patient has engaged the services of Ms. Ronnie Falcao, a Licensed Midwife who is qualified to provide labor management services in the client/patient's home.]
I feel that this support is medically necessary because of her desire to have an unmedicated birth and because of limited nursing support in the hospital.
After your birth, I will provide an invoice for you to submit to your insurance company. It may take a little effort on your part to make some phone calls or write some letters, but most PPO plans are legally required to cover the medically necessary services of a licensed provider, so you should be able to have my fees reimbursed. However, even with a prescription from your primary provider certifying medical necessity, it is possible that my services aren't covered by your plan, or that you would need to obtain pre-authorization for my services. There is more information about third-party reimbursement for doula services online at: http://www.dona.org/3PR_How_to.HTM
Technicality - I am required by law to notify you that I do not carry malpractice insurance.
My goal in doing labor support work is to facilitate the birth experience
that the family desires, with a focus on a calm, gentle birth. Please
let me know how I can best meet your needs.
I make a special effort to ensure that my presence makes it easier for your partner to provide the one element that only they can provide - their love. By taking care of the physical maintenance aspects of labor support, I free up your partner to spend more time with you. By offering a knowledgeable assessment of your labor progress and gentle guidance to your partner about how they can best support you, I help them to feel more confident about their role, so they can be more fully present for you.
The bonding hormones that you generate during your labor will affect
those around you, and it is my goal that your labor and birth bring you,
your partner and your baby together in a positive bonding experience.
What are the different kinds of professional labor support?
Regulation and Training - Labor support professionals are completely unregulated; anyone can call herself a doula. Some women are so enthused about birth after their own birth experience that they begin offering their services to other birthing women without any formal training. Most professional doulas are certified, meaning they have taken some kind of official doula training course; this course may have taken just a few hours, or it may have taken several weeks or months of guided correspondence study, followed by a weekend workshop. Some doulas are also Licensed Midwives, which means that they have a birth-related education equivalent to a three-year midwifery program.
Services Offered - Every doula determines the unique set of services
that she offers. Most doulas do not provide any clinical services,
such as assessment of the mother's or baby's physical well-being; their
services are generally limited to comfort measures, reassurance and some
patient rights advocacy. Some doulas also offer specialty services,
such as aromatherapy, massage, acupressure or hypnotherapy. A very
few doulas are Licensed Midwives, who are trained and licensed to provide
a full range of clinical midwifery services while providing labor support
in your home; this group is most appropriate for women planning to stay
at home for part of their active labor.
What do you provide that other doulas don't offer?
I am the only doula in this area who offers a complete range of services that you might need during your late pregnancy, labor and birth:
· Midwifery care - I pay particular attention to making your labor and birth easier. I provide prenatal herbs to help your cervix open more easily; I assess your baby's position during the last weeks of pregnancy and in early labor to help your baby get into the most favorable position; I recommend position changes appropriate to your individual circumstances. In particular, I help you avoid painful back labor from a posterior baby, and I can help correct a situation where your baby's hand or elbow is alongside the head, blocking progress. I provide clinical care (checking your blood pressure, listening to your baby's heart rate and assessing your baby's response to the stresses of labor) so that you can confidently labor at home, where your labor will be easier and shorter. In the hospital, I provide the continuous one-on-one clinical care that you deserve, working in co-operation with hospital staff - I can use my personal, waterproof, hand-held Doppler to check your baby's heart while you labor in the shower, if you want. On more than one occasion, I've helped stabilize your baby's heart rate through maternal position changes so as to avoid a fetal scalp electrode or amnioinfusion. I've taught a labor and delivery nurse a new trick or two about pushing positions. I can provide hot compresses for your perineum and even provide additional perineal support (with your birth attendant's approval) to assist in preventing tears. After the birth, I offer assistance with breastfeeding.
· Massage - In my experience, gentle massage is the best way to help ease a woman into active labor; it helps her to relax so her body isn't fighting the uterine contractions, and it actively generates endorphins, your body's natural pain relief. This is different from typical massage.
· Hypnotherapy - I provide an audiotape containing guided imagery, a form of self-hypnosis. I incorporate post-hypnotic suggestions regarding all aspects of a normal, progressive labor and birth. Because this tape is recorded in my voice, you will develop a conditioned relaxation response so that when you hear my voice during labor, you will automatically relax. In addition, I am available to provide live hypnotherapy as needed during labor, typically during transition.
· Advocacy - I provide the information you need when you need it. During our prenatal visits, we discuss your values and goals, and I make recommendations that are appropriate for you and in line with your values. At the hospital, I ensure that you get your questions answered and work to see that your birth plan is respected as much as possible. I can provide feedback about recommendations for interventions as the need arises. I am fully trained to interpret fetal heart monitoring, beyond the training level of the nurses who are monitoring your machines; I can tell when the machines are incorrectly picking up the pulse from your uterine arteries instead of your baby's heartbeat, thereby avoiding an unnecessary alarm about imagined fetal distress. After the birth, I can tell you when the neonatal team has finished with any necessary resuscitation and has begun a routine newborn exam, so you can get your baby back in your arms sooner.
In general, my clients have been wildly enthusiastic in their evaluations
of all aspects of my work, and many have said that the high quality of
my services was well worth my fee. If you’re unsure how my services
can be helpful to you, please do not hesitate to request references.
What about epidurals or other pain medications?
It is impossible to know in advance how your labor will progress or how you will feel about the pain. My goal is to work with you prenatally to prepare your body and mind for an easier labor and birth and then to work with you during labor to generate endorphins to provide natural pain relief. Laboring at home, where you can be monitored while having full control over your environment, is one of the best ways to ease into labor with high endorphin levels providing good pain relief. Sometimes the pain is less than the woman expected, and sometimes it is more. I spend time at our prenatal meetings discussing your values and your feelings about pain medication so I can provide support that is appropriate for you and your individual circumstances.
I do this work to help birthing families get to the other side of birth in the best possible shape. I have found that women who give birth without any medications seem to recover better and have fewer postpartum complications. However, there have been some occasions where I have recommended an epidural as the most appropriate choice for some unusual circumstances.
In general, even for women who are planning to get an epidural, I recommend trying to delay getting the epidural in order to minimize the subsequent cascade of interventions, and to minimize your baby's exposure to the drugs that are used in the epidural. (These drugs are administered through the epidural catheter and do not get to your baby immediately, but they are absorbed from your tissues into your bloodstream, at which point your baby is also exposed to them. If you can delay getting an epidural until a small number of hours before your baby is born, this greatly reduces your baby's exposure to the drugs, but provides pain relief for the most intense part of labor. This can be a good compromise for women who feel that they want an epidural but are concerned about baby's exposure to the drugs.)
Even women with epidurals benefit from professional labor support. Epidurals introduce additional risks: epidural fever, fetal distress, stalled labor, posterior or asynclitic heads, pushing with no urge). A private-duty midwife who understands the clinical complications of an epidural can help work to prevent or mitigate them.
How do you set your fees?
The economics of professional labor support work are a mystery to many people; I offer this information so that you'll have a better idea of what you're paying for:
Hours - Couples having a first baby may imagine that I'll be spending only a few hours with them during the labor and birth. In reality, an eight-hour labor would be considered pretty zippy; most first labors last longer than 16 hours; the longest continuous time I've spent providing labor support is 38 hours. Average time spent with a woman for her labor and birth is about 16 hours. I spend another 10 hours in prenatal and postpartum meetings, and another hour or two in phone calls. My fee translates to an hourly rate of about $50/hour, before expenses and self-employment taxes, and about $25/hour when those are taken into account.
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 is that one client per week is a full schedule. Since most of my clients are first-time mothers, I find that 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 two-week vacation, I have to add another four weeks during which I cannot accept clients. A full calendar is 32 clients per year; in reality, there are some weeks where I have to turn clients away and then there are other weeks where I have no births on the calendar.
Consultant Factor - 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, health insurance, and business expenses. As you may imagine, my communication expenses are high - business phone, pager, cell phone and computer connection; I also have routine professional and office expenses and unusual transportation and supplies expenses. In addition, I bring about $12,000 worth of equipment to your birth as part of providing midwifery care.
Putting It All Together - The annual income of someone providing labor support services with a responsible client load and a strong commitment to being available for your birth is 1/2 the number of clients per year times their fee per client. This is about 16 times the fee per client, and, yes, that's before taxes, including extra self-employment taxes. 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 beeped awake 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 two trips to their home and being beeped awake twice. This past year, I spent most of my birthday at a labor, I spent Thanksgiving Day in a hospital, and I was beeped away from a big family gathering. I cannot take weekend trips away from the area, and even day trips to Santa Cruz or San Francisco have to be planned around traffic conditions. 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 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. Given all this, I'm sure you can understand why I bristled when someone once asked me why I charge "so much". In fact, I could not support myself if all my clients were doula clients; in effect, the homebirth midwifery part of my business subsidizes my doula work.
Bottom Line - Nobody's getting rich doing labor support work. 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 return to working as a software engineer. There are people offering doula services at significantly reduced prices. They are either offering significantly reduced services or availability, are still in training, or are basically offering charity. If you need charity, I encourage you to get labor support however you can; 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.
Advocacy Suggestions - My services are covered by many health insurance plans because I'm a licensed provider; however, most non-midwife doula services are not. 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. Additionally, you could talk with your primary 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, although 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.
Contact Information
If you would like more information or to arrange an interview, please
phone me at 650-961-9728 or e-mail me at falcao@best.com.
[ Ronnie Falcao's homepage ]
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