Lori Flanagan of Broad Run said she paid nothing to have a midwife assist in the birth of her first child at a maternity center in Maryland two years ago. Flanagan's insurer picked up the tab in full.

But when Flanagan gave birth again six months ago, she paid $2,000 to the midwife who attended.

The difference? Flanagan had decided to have her second child at home, and her carrier is one of those that don't support home births.

"We were just not satisfied" with the birth center experience, said Flanagan, a 28-year-old veterinarian. "It was so very medically managed . . . and there were treatments that we wanted to decline, that my husband and I did not feel were medically necessary."

"Only about 2 percent of the women in this country have their babies at home, as far as we can tell," said Marion McCartney, director of professional services at the American College of Nurse-Midwives.

"I think women should have choices, and as long as they're healthy they should be able to deliver at home," she said, "and their insurance . . . should pay for it."

Tarsha Geddie said BirthCare, a nurse-midwife practice where she works as the billing administrator, assists in 25 to 30 deliveries a month, half of them home births. BirthCare charges $3,950 for its standard package of prenatal care and delivery, either at home or at its birthing center in Alexandria.

Most insurers cover births at the center, said Geddie, but Aetna, Mamsi and Kaiser Permanente are among those that do not cover home births.

"Aetna considers planned deliveries at home . . . not medically appropriate," the insurer says on its Web site. The insurer cites a policy statement from the American College of Obstetricians and Gynecologists that home delivery "clearly presents hazards to both the mother and fetus before and after birth. These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation."

Not all insurers frown on home births.

"Blue Cross Blue Shield has been pretty good about paying for them," said Geddie, as have UnitedHealthcare and TriCare, which covers U.S. military families. "We have a lot of military clients who come to us who prefer not to go on base" for obstetrical care, she said.

Joni Seidenstein of Vienna said she's hoping that her insurer will cover a midwife-assisted at-home birth for her next child, due early next year. "It's much more convenient for us to stay at home," she said. But if the arrangement is considered out-of-network care, it could cost her $1,500. "I don't know if the convenience is worth fifteen hundred dollars," she said.

Flanagan has no such doubts. Assuming she had no reason to expect a complicated delivery, "I would go unassisted before I would go into a hospital," she said.

-- Tom Graham

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