My kids were born with obstructive sleep apnea

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Before I was a childbirth educator, I was a mom of a little girl. I’ve written about her birth before; I haven’t really ever thought to talk about how both of my kids were born with sleep apnea, and how it took forever to find a pediatrician who would actually believe me.

When I first brought her home from the hospital, I noticed almost immediately that my baby girl would regularly stop breathing for a couple of seconds, only to gasp for air. Initially, my new mama instinct wasn’t sure if I was just being overly paranoid, or if she really did stop breathing for a couple of seconds before the big gasps I didn’t think were normal. Her Mayo Clinic doctor (who was a total and complete ass, BTW), ignored my concerns– he told me she was just congested, and moved on to something else.

(As an aside, I should tell you some day about the nonsense “parenting education” material they would give me every visit. Knowing what I know now, there was very little actual evidence behind it. All it did was foster doubt an insecurity by creating parenting expectations that would never be biologically normal. Even better, if I could find the sheets, it’d be a total hoot to go through it with a big red marker!)

When my daughter was about 4 weeks old, after sleepless nights and too many days nodding off during the day while I fed her on the couch, a friend encouraged me to look into safe bedsharing. I found the safety guidelines online, and during one nap time, I latched her on while in the side-lying position in my bed, and we both fell asleep for a life-changing 2 hours. I was a convert from then on out. It wasn’t until much later that I realized that since she and I started sharing a safe sleep surface, I no longer noticed that she would stop breathing. Instead of sleeping next to me in her bassinet on her back (which, until very recently, was the only AAP-sanctioned sleep scenario), she spent her nights cuddled up next to me, on her side. Sometimes I’d wake up and find out that I’d been feeding her without remembering when or how the feeding started. And then, when she was 9 months old or so, she started to turn sideways in the middle of the night and stretch out as much as she possibly could. That’s when we transitioned her to a crib in her own room. And at 9 months, she would sleep in whatever position she felt like sleeping in that night. By that point, she was not only rolling and crawling, but walking on her own, too. SIDS and back-to-sleep stuff was no longer technically an issue for her.

However– she was back having very, very audible sleep apnea. We’d listen to what I now understand was the sound made when her tongue would fall into the back of her mouth, then the little “kuh” sound she’d make right before the gasp as she started breathing again. We’d joke in a moribund manner that the gasp at least told us she was breathing…eventually. Moreover, we’d started to notice that when she slept, she always slept on her stomach or he side with her head tilted back to straighten and open her airway.

When she was 2 years old–maybe?– we brought it up again with her doctor. Keep in mind, smart phones weren’t a thing yet. iPods were big and bulky and only had hard drives and were only for music. We could really only convey what we were noticing by trying to recreate it ourselves. Her family med doc was again dismissive, though he did say he could refer us for a pediatric sleep study, but that it would take 6 months before we’d be able to get in. Shortly after that, our basement flooded, my husband got a new job that required him to commute 90 minutes each way, and then I got pregnant with her little brother… and life got super chaotic.

Once my son was born, bedsharing was started from day 1. However, he didn’t really nap on his own until he was about 8 months old, and when he did, he’d do what his sister did– he’d stop breathing. As he neared the 9 month mark, when I would put them both down for a nap in the same room, I’d listen to the baby monitor as they took turns having apnea episodes (which I’m sure did NOT help my anxiety). I can’t remember if it was at a well baby visit for him or a well child visit for her, but I mentioned the apnea episodes their pediatrician, who referred us to a pediatric ENT. She got her tonsils out shortly after her 4th birthday. At that point, they had grown so large that she barely had any room to breathe while she slept. A few days after the tonsillectomy, we noticed that when she slept–there was silence.

My son had his tonsils and adenoid out when he was 3 years old. He was also able to breathe perfectly while sleeping a couple days after surgery.

So there you go. My kids had obstructive sleep apnea, and now they don’t. I do think that both of them had and have tongue ties for a BUNCH of reasons. I had recurrent mastitis, nursing was super painful at first with my daughter, she didn’t gain weight all that fast, both kids had EPIC spit-ups. One child had speech issues that have been resolved. The other one tongue-thrusts to swallow and is very sensitive to food texture.I often wonder if I had had them sleeping on their own in a room from day 1, on their backs and not near me–would we have had a different outcome? We know (and the AAP recognizes this) that babies NEED to sleep in close range to their parents for at least the first 9 months, in part to help them regulate their breathing. When humans sleep on their backs, the tongue can fall to the back of the mouth, causing snoring and apnea.

Finally, I do want parents to know that if your little one stops breathing and then gasps for air, that is NOT NORMAL. If they sleep with their head always tilted back—again, not normal. Listen to your gut, and if your child’s care provider dismisses you–get a second opinion. Or a third. I know that there’s so much more to learn about this, SIDS, and other sleep issues, but I do think that parents can go a long way if we share our stories and compare notes.

On that note, Happy New Year!

Warmly,

Veronica

 

Announcing Twin Cities Hospital Birth Costs at a Glance!

After last year’s epic process of compiling costs for births and newborn care, I was trying to figure out a more accessible way for parents to get the 2015 data. So, I created a more streamlined guide-at-a-glance.

This guide has a few features: health system affiliation is listed, allowing you to see how they differ in cost from company to company. It’s just two pages, making it easy to flip back and forth. I had fun compiling the information, and I hope you find it useful!

Warmly,

Veronica

Get your copy of Twin Cities Hospital Birth Costs at a Glance

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What confident births look like

The weekend, during the Ready for Birth: Express class, I took a couple of minutes to show a birth video that I don’t always show; it was a larger class, and it was wonderful to have so many different families. Some were giving birth in birth centers, others in hospitals, some with OBs, others with midwives. There are a billion birth videos out there, but I love this first one because it’s a wonderfully accurate depiction of birth: the mom has intense contraction waves, but is able to still laugh a little during the breaks in between. It shows her moving around and changing positions. And more importantly, it shows how gorgeous birth can be when the person giving birth is surrounded by caring providers in a calm, patient environment. On Saturday, after this video, there weren’t many dry eyes.

The birth of Cody Taylor | Waterbirth at Mountain Midwifery Birth Center in Denver, CO from crownedbirthphotography on Vimeo.

Why do I want to show you these? Because birth is usually talked about in a way that’s scary. Because birth isn’t shown realistically on TV or in the movies. Because most people never hear about the amazing empowering, positive births– only the traumatic ones.

Here’s a birth in a hospital. It is another water birth, and I’m not terribly thrilled with how long it took to get baby to the surface, but it’s cool.

Milo’s Water Birth from David Mullis on Vimeo.

Here’s a hospital breech birth–keep in mind, these care providers are taught how to deliver vaginal breech births. It is something that is possible, but ONLY when the care providers know how to handle it. There are still quite a few places where vaginal breech birth is a skill still emphasized during education and training. Unfortunately, it’s not taught in the US on anything approaching a regular basis.

Nascimento Mariana, parto natural hospitalar pélvico – 04/jul/2013 – Natural breech hospital birth from Além D’Olhar fotografia on Vimeo.

A preterm birth of a wee double rainbow baby; again, the care provider is calm, patient, and caring. Births of rainbow babies are emotionally challenging. When a family gets pregnant after a previous stillbirth or miscarriage, there’s the very reasonable fear that another loss can happen. BUT, and this is important– in these cases, it’s even more critical to have a calm, caring, supportive birth environment rather than a fearful, negative birth environment.

Double Rainbow Baby, the Birth Story of Emilia from Jennifer Mason on Vimeo.

A hospital birth in—well, not the US. I love everything about this video. Again– you see calm, patience, and encouragement.

Thomas | Parto natural hospitalar from Ana Kacurin on Vimeo.

So here’s the deal: Everyone deserves this kind of environment during birth. Full stop. It’s not about medicated, unmedicated, natural, vaginal–it’s about understanding that birth is a normal biological process. It’s about a mother who is confident in her body’s abilities. It’s about having care providers and support people present who hold the space. Birth can be positive. It’s a lot of work, it’s never easy, but it doesn’t have to suck. A triumphant experience is possible.

Fact vs Fiction in Modern Birth: An Intro

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Childbirth is distinctly different than any other discipline of modern medicine: Unlike every other medical specialty, humans have been giving birth for as long as– well, for all of human existence. As modern medicine started to really develop at the turn of the 20th century, childbirth– once looked at a normal life process– was taken over by doctors who at first really didn’t know at all what they were doing and had very little actual understanding of the female body or birth. That either the mom or baby made it through the process of birth in early hospitals was often a matter of luck.

I joke sometimes in class that so much of what’s wrong with birth in the US, with our rising maternal morality rates, is thanks to the arrogant, misogynistic, vain, and ignorant decisions made by men of the medical establishment since at least the 1850s. Who came up with the idea that episiotomies should be routinely done without evidence to prove their claims? Men. Who decided, without any evidence otherwise that once a mom had a cesarean, all births should be cesareans after that? A man–in 1912. And I’m not saying this to make a generalization that men are terrible, but to point out so many aspects of modern birth came from those without any real knowledge of the process. Once medical research really kicked in in full force in the 1950s, we saw some outcomes in maternity care improve, but not always.  Here’s where I strongly suggest that you read Tina Cassidy’s fantastic book Birth: The Surprising History of How We Are Born. If you want to know the full play by play of modern maternity care–this is the book you need to read.

The reality is, while there are a few things that can be measured and quantified about pregnancy and birth (hypertension really being one of the most obvious situations, followed maybe by cholestasis of pregnancy), many doctors who provide maternity care struggle to fully grasp that birth can be really hard to study. However, just because some aspects about birth can be difficult to study or quantify, that doesn’t mean that evidence-based maternity care doesn’t exist–because it does. In addition to the 6 Healthy Birth Practices as laid out by Lamaze International, other strong resources and proponents of evidence-based care can be seen in the Report from 2008 called Evidence-Based Maternity Care: What It Is and What It Can Achieve and in the joint consensus statement  Safe Prevention of the Primary Cesarean Delivery from ACOG and SMFM, originally published in 2014 and reaffirmed this year.

I am a strong proponent of intellectualism. Our shift to anti-intellectualism in all facets of life is more than a little disturbing. And while I can’t address everything in the world, I can go through some of the aspects of maternity care in the US and abroad, explain where they originated, what the original motivations were, and place those beliefs in the continuum between fact and fantasy. This post is an introduction to what I hope will be a interesting project. The next couple of posts will cover the rise of early birth “methods”…and then see where that takes us.

Are you ready? Let’s do this.

Warmly,

Veronica

More birth options at Fairview!

This month marks a decade since I attended my doula training at a hotel in Bloomington. I’ve been a huge birth nerd for a decade. Regular readers know I’m a birth nerd. Anyway….

I’d written in the past when hospitals have significant policy changes. I think the last time I wrote about it was when Allina instituted a waterbirth ban and Hudson Hospital banned VBACs. Or maybe it was as nitrous became an option at pretty much every hospital and birth center in the area.

A couple of weeks ago, I was SHOCKED (in a good way) to learn that Fairview had bought the Paul Larson Clinic practice. Evidently I was living under a rock, because that happened in the 3rd quarter of 2015. BUT…now they have a midwife group at the clinic. The midwives attend births at Southdale. If this doesn’t seem like much, consider the fact that Fairview, if you took the U of M hospital out of the equation, was one of only 2 systems that didn’t have a midwife group. Allina doesn’t have a midwife group that’s on staff (and they even went so far as to restrict access for HealthPartners midwives at Abbott). I was also told that they are working on hiring midwives for South of the River.

So here’s the thing: In the 2012 report, the Paul Larson clinic was the 2nd to worst in the Twin Cities for primary cesarean rate– way above the median rate in the state. The new midwives at the clinic under Fairview’s ownership have a cesarean rate of 5% so far. That is a REALLY big deal. Some people have complained that it’s not enough, but change happens slowly at first, and then there’s an avalanche of progress.

Also, Fairview Southdale began offering waterbirths as an option as of November 7th. Fairview was pretty much the last holdout (except for that time when Allina didn’t have them, but was still advertising that they did) on offering waterbirths.

Full disclosure: I haven’t attended a birth at a Fairview hospital in years. However, I have been impressed by the speed they have been adopting certain things: Fairview’s hospitals adopted nitrous oxide before St. John’s and Woodwinds. Having one, much less two, midwife groups on staff is….well, I still can’t wrap my head around it. It’s a huge as heck step.

Now, let’s celebrate the increase in options!

Warmly,

Veronica

From the Archives: Writing a Birth Plan

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The subject of using online birth plans came up last night, so I wanted to distill my advice here on the blog. Turns out, I wrote about it 4.5 years ago. Ha! Ah well, it’s still good advice.

-Veronica

Originally published February 7th, 2012:

First of, let me say this:  I know you can’t plan your birth.  You can’t decide it’ll last only 20 minutes, or that you’ll only push twice.  Do you know this?  I hope you know this.  Rather, a birth plan is a tool that should be used by a mother to sort out her options and to communicate those preferences to her care provider.  While she can not plan what will happen, she can give a good amount of thought to how she will handle what happens.  Also?  I believe very, very much that it’s something that should be done no matter the place of birth.  Even moms planning home births need to think about what they want or don’t want.  So, after giving much thought over the last couple of days as to what makes a birth plan good, and what can make it very, very bad, I give you the following advice:

DON’T: Go to a website that “writes” a birth plan for you by having you check off a couple of boxes that sounds good.  Why?  Well, it comes across that you put very little thought into writing your birth plan.  Also, you can end up “choosing” things that are not even an issue at your desired birth place (like saying you don’t want to be told what to wear during labor at a home birth).  However, if you feel completely stuck, you can check out one of those websites for some ideas, just make sure you rewrite things in your own words.

DO: start with an introductory couple of sentences. Think along the lines of: This is my second birth.  My first birth was very long, and very difficult, with many things that felt like I was not listened to.  I am hoping for a much calmer, more supported birth. Or whatever fits your specific situation.  Make it short, to the point, and applicable to this birth. It will help the people who are part of your birth team know very quickly what you are looking for, which means that (hopefully) they will be supportive of where you are physically and emotionally, not where they think you should be.

DON’T introduce anyone and everyone in your life in the birth plan.  A birth plan is not an autobiography.  Please don’t use it  to introduce the nursing staff to your cats, or your turtles, or your childhood home that you haven’t been to in 25 years.  And for goodness sakes– no pictures of these things!

DO keep the information relevant.  If there is something about your medical history that is relevant to this specific labor and birth, include it.  Yes, it’s in your chart…somewhere.  But save everyone a headache and confusion and include that important information right at the top of your birth plan. Have you already met with an anesthesiologist and found out that you are not, for a specific reason, a candidate for an epidural?  Include that!  Is the father of the baby not participating in the birth because of religious or cultural reasons?  Include that! Trust me, it will save so much time and frustration of everyone is, almost literally, on the same page.

DON’T make your birth plan more than a page long, two at the most.  Very important information gets lost in long birth plans, and it can seem like not much actual thought went into writing the plan.

DO make sure only time-specific information is in the plan.  Don’t bring a plan to the hospital that talks about laboring at home (or how long you’ll wait before calling your midwife for a home birth). You do need to think about things like that, but it can end up burying the more relevant information.

DO write out a really long plan, if you feel you need to.  You can include things like how long you want to labor until calling your doula, or at what point you want to o to the hospital, or fill up your birth tub at home–whatever.  But then sit down with someone and go through that list with a very critical eye, and think, “What will people need to know at the time?” Then start to cut things out, leaving a shorter version.

DON’T list things that are not done at your chosen place for giving birth. If they don’t do routine IVs, don’t say, “I do not want a routine IV.” On the flip side, be reasonable.  Don’t list things that just CAN NOT happen, like, “If I have an epidural, I do not want an IV.”

DO take good, comprehensive childbirth classes so you can understand all of your options and help you understand how to avoid those things you do not want.  So, for instance, if you don’t understand why IVs might be used, you might need a class.  If you were never told the many different ways an induction might be done, you need a better class.  This might ruffle a feather or two, but knowing about something doesn’t mean it’ll happen.  Ignorance IS NOT bliss.  Hopefully there are things you’ll never need to go through, but knowing about them, just in case, is always a good idea.

And finally:

DON’T assume that writing something down means that it will be so.  Make sure that your care provider (and, since most people see a group practice, ALL the possible providers) will take the time to listen and respect your voice.  There is nothing sadder to me than telling families prenatally to address specific things with a care provider, only to watch those parents find out that  Midwife X won’t allow it, or Doctor Y doesn’t believe in it while mom is in labor.  Yes, you are the patient, but birth time should not be battle time, and if there are options, find the very best care provider to fit what you want.  And yes, it is worth it.

Quickly, in my opinion, what should a birth plan touch on?

  • support people
  • environment
  • comfort measures
  • labor positions/ tools
  • medication preferences
  • pushing and birth positions
  • newborn procedures (right after birth and the few days after birth)
  • post-birth maternal procedures

I’m sure I missed a thing or two (or three).  What do you think?  What tips would you add?  What else do you think is a MUST INCLUDE?  Add it in the comments below!

Warmly,

Veronica

Twin Cities Cesarean Rate Trends, 2005-2015

OK, so I’ve been collecting historical data on Cesarean rates in the Twin Cities metro hospitals from as far as I could go back, which was 2005. I’ve finally had enough time to pull it all together. There are some pieces of info missing, but here’s a decade’s worth of Cesarean rates:

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Back in March, I made some predictions for 2015 overall Cesarean rates. I had written:

Speaking of 2015 Cesarean rates, that info isn’t available, but I’m going to throw caution to the wind and make a few guesses. I think we’ll see an increase in rates at Woodwinds, a slight increase at Methodist and a larger increase at Maple Grove (largely as a result of the high primary rates from OBGYN West and Western OBGYN), increases at Ridges, Southdale, and Regions. I’m going to predict a drop in the overall censarean [sic] rate at Abbott Northwestern, St. Joe’s, and North Memorial. I don’t think there will be many changes at St. Francis, St. John’s, or United. As far as the Unity and Mercy…who knows. Now, we’ll have to see if I’m right.

 

So, how did I do?

I was right about Woodwinds, Methodist, Maple Grove, Regions, Abbott, and North Memorial. St. Francis saw a significant increase. St. John’s held pretty steady, and United had a teeny drop, but still a decrease in their Cesarean Rate. St. Joe’s saw the trend continue, with an increase in their rates that began in earnest in 2010. Woodwinds trended higher again in 2015 after a decrease from 2012 to 2014. Regions, Waconia, and St. Francis had the most significant increases, While Stillwater and Mercy had the largest decreases. And THANK HEAVENS that Abbott has made significant strides in reducing their overall cesarean rate after 2010.

See my previous post if you have questions about why this stuff matters. Otherwise, these trends are very interesting to look at! Now to wait again until data comes out in March again….if it comes out. If you’re looking at this data and mad that more isn’t out there, well, start pulling together the resources to get laws like the ones in New York passed. Without a state grassroots effort, we get what we get and we don’t throw a fit, unfortunately.

Warmly,

Veronica

Corrected 2015 Minnesota Cesarean Rates and Insights

First of all, I had warned that last week’s post may have some numbers that end up changing. Yeah, a few numbers changed. The reality is, to calculate one hospital’s rate, you have to go on 6 separate screens to get 6 different numbers before you can figure out a cesarean rate for one hospital. And since I calculated numbers for the 89 hospitals that provide maternity care, that….that’s a lot of screen toggling.

Second, while I’ve been blogging about these rates every time they come out, the backlash to releasing the numbers was abnormally defensive. Comments on social media were not what I’d seen previously. There are a few things I want to get straight first:

  • From the joint statement from ACOG and SMFM: “In 2011, one in three women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused.” You can read through the full Obstetric Care Consensus here.
  • The sad fact is, while there are times that Cesareans are truly needed, our rising Cesarean rate is causing a rise in maternal mortality rates in the United States. Overall, Minnesota is better than the national average, but some rural hospitals have rates that are too high. Discussing these numbers is critical for protecting the health and safety of pregnant patients and their babies.
  • Multiple studies, including studies published by Consumer Reports and Blue Cross Insurance networks, continue to affirm that the biggest factor in if a birth will be done vaginally or by cesarean is the place of birth and care provider preference.
  • If you’re questioning how different clinics affect each hospital’s rates, check out my blog post from the beginning of the year with that information.

This information does matter- a lot. We believe that childbirth education and informed choices are the key to empowering families that will allow them to make the choices that best suit their situations. And I do want to point out that, at least in the Twin Cities, Cesarean rates peaked in 2009, with Abbott Northwestern reaching 37.1%. Rates have gone down overall since then.

In the next blog post, I’ll compare this year’s results with those over the last decade.

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2015 Minnesota Cesarean Rates

Update 10/12/16: Corrected tables have been posted below and the old numbers have been removed.

I have had a very, very long day. Very long. A long week, actually.

But enough about me. It’s my favorite thing ever! Time to figure out 2015 Cesarean rates!!!!!!!

I can’t even tell you how excited I was when the raw data from the Minnesota Hospital Association was available. I’m SO excited that I’m going to post all of the rates for hospitals with more than 100 births. There are some limits to the info that’s released publicly, but this is true for any health information that’s made public: numbers that were small than 5 were not reported. There is a whole category that only 5 hospitals in the entire state had numbers high enough to count. This info is the best I can do right now with what info there is. It may change after a good night’s sleep and my eyes are no longer crossed.

More posts will come in the next few days, including some handy-dandy printables you can use because, while I’m thankful for the Pawlenty Administration for mandating this info get released, ease of use was not a priority.

Enjoy, and be peaceful to one another.

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Insurance reimbursement for childbirth education

With third-party reimbursement for childbirth education, one of the biggest barriers that exists in policy discussions is that not all stakeholders, including the educators themselves, understand what the current system is. The system is intricate and always changing, but on the surface, it boils down to three things: What is covered, who can render services, and how much are they paid.

Part of our existing insurance system is controlled by the federal government. A good example of this would be how the Affordable Care Act mandated that breast pumps and breast-feeding support was a covered benefit. Otherwise, most healthcare regulation decisions are made on the state level. This is where childbirth education falls right now: the coverage varies from state to state, and can change as new statutes are passed.

In Minnesota, childbirth education is considered a mandatory covered service by the Department of Human Services for residents who have coverage through Medical Assistance programs. Strangely, newborn care education is not considered essential, so as a standalone class it is not a covered service, but birth classes that include this information can be billed to insurance. Residents who are on Medical Assistance are either enrolled directly through the state’s Medical Assistance or MinnesotaCare coverage. Some of the plans are managed though the state itself, but most are have PMAPs (Minnesota Prepaid Medical Assistance Project plans) that are administered through Managed Care Organizations.

So then, in Minnesota, not all employer-based insurance plans or plans purchased by individuals have the same coverage parameters. So while some do reimburse providers for in-person group classes, other health plans consider access to online information or sending pregnant patients a book as an acceptable way to deliver childbirth “education”.

Most state’s health departments then decide who can provide services– what kind of credentials they need to have and if they have to bill under a supervising provider. Again, in Minnesota, I have to operate under a “supervising provider” as an LCCE. It usually doesn’t take much digging, but each state is different, so what applies here may be different, but states are currently in charge of the “Who.”

As for the how much…that gets really complicated. Reimbursement rates for Medical Assistance services are set at the state level, and many of the rates haven’t been adjusted for inflation in 10-20 years. Employer-based plans set their own reimbursement rates, and those rates can vary even within the same insurer as determined by what the employer has negotiated. For example, you could have Blue Cross Blue Shield insurance and the contracts would say that if the provider bills the insurer for a procedure at $150 and the contractual obligation would be to only reimburse $110 of that money; Somebody else with a Blue Cross Blue Shield insurance plan with a different employer might have that same service reimbursed at $97 when it was billed for $150. And then you have some other insurers who would take that $150 that was billed and only reimburse $35.

Not just anybody can bill insurance though, even if you are providing care within the state’s parameters. If you are not contracted with an organization as a provider, then anything billed would be out of network and would be subject to reimbursement rates set by the plan for out of network reimbursement. This really only applies to employer-based or individual plans; I’ve yet to find a state that allows billing reimbursement for out of network providers.

Hopefully this brief explanation helps you understand the very basics of third-party reimbursement for childbirth education as it exists today. If childbirth education is covered depends on which state you are in. Who can provide that childbirth education in a way that’s billable is also up to each state. The how much is something spelled out by each plan coverage. It’s not an ideal situation in the slightest; however, anyone who  wants to fix something first needs to understand how it works, otherwise it’s very likely any attempts to fix it will break it.

I am hosting a series of workshops, first for doulas locally, later for birth professionals via webinar. If you’d like to notified of upcoming dates, sign up for the professional development newsletter below.

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