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Giving birth means going into debt for some mothers in America, but why?

For American parents, the reward in childbirth is, of course, the baby. Yet, the existing incentives in the healthcare industry are all backward: Costs for mothers and babies continue to climb as health outcomes worsen. And behind these statistics are real parents who often feel out of control or unprepared for the bills that follow baby's birth.

When she was expecting her second child in 2009, Jessica Pennington was already well aware of the steep costs associated with giving birth in the United States. Hoping to brace for the financial impact, Pennington and her then-husband set aside close to $2,000 to pay the bills that were sure to follow her hospital delivery—despite their private insurance coverage.

"I had no way of knowing the birth was going to be anything but normal," Pennington tells Motherly.

A 2013 report prepared by Truven Health Analytics based on 2010 data shows Pennington could have expected a bill of approximately $3,400 for a standard vaginal delivery or $5,100 for a cesarean birth.

But all did not go according to plan.

Endometriosis further weakened Pennington's uterus after her first birth and the strain of pitocin, a labor-inducing drug, caused Pennington's uterus to "split like a banana peel."

Thankfully her baby was unaffected by the traumatic delivery, but doctors had to fight to first save Pennington's life and then her reproductive system—even though she says a hysterectomy would have been her first choice if she or her husband had been consulted.

"They were using things like brand new technologies they never used before," Pennington says, adding surgeons performed a hysterectomy after exhausting their other options. "One procedure alone was $40,000 and it didn't work."

By the time she was released from the hospital, the costs for her medical care topped $140,000. After petitioning for more insurance coverage, that left Pennington and her ex with a bill of $30,000—an unfathomable amount on their full-time student, part-time employee budgets.

"My education got put on hold so that I could make any kind of money to even buy groceries," Pennington says, adding the couple was initially unable to make the minimum $150 monthly payments. "Now, looking back it doesn't seem like much, but when you're not working and trying to pay for college and trying to raise two kids and maintain a normal house and lifestyle and groceries, it was just unheard of."

Childbirth costs in the United States continue to climb, even as outcomes worsen

Although Pennington's experience was more dramatic than most, even by-the-books deliveries come with growing price tags for American families: According to the report prepared by Truven Health Analytics, out-of-pocket costs for maternal care quadrupled from between 2004 and 2010.

Upon a close inspection of bills, some medical charges may seem exorbitant—such as a single pill of acetaminophen (or Tylenol) topping $30, according to the 2016 Trends in Hospital Inpatient Drug Costs report from NORC at the University of Chicago.

Other charges may even be inexplicable. That was the case for Amy Sallie, a mother of four, who delivered her second baby on the floor of the emergency room minutes after walking into the hospital.

"Here's the fun thing, I got billed for all of the normal expenses," Sallie tells Motherly. "Labor and delivery room, all the normal stuff. And I'm just thinking like, 'I literally gave birth in your hallway. What are you talking about?'"

For parents who are trying to navigate life with a newborn, it can be hard enough to scan the intrapartum bills in detail—let alone figure out how to start debating charges or requesting more insurance coverage. To limit potential surprises, Hector De La Torre, executive director of Transamerica Center for Health Studies (TCHS), tells Motherly that expectant families should consider their health insurance options and make sure they will be in-network for care.

"A substantial subset of millennials do not feel very informed about the health insurance options available to them and find decision making about health insurance plans difficult," he says.

While costs have been rising, outcomes for mothers have been worsening: According to a 2017 report from the Centers for Disease Control and Prevention, the maternal mortality rate in the United States has steadily climbed since the mid-1980s. This gives America the distinction of having the worst rate of maternal deaths in the developed world, according to a 2016 report published in the journal The Lancet.

The current maternal healthcare system rewards complications

The current rate of cesarean births in the United States is nearly 32%, which is more than double the number that is estimated to be medically necessary by the World Health Organization. This single data point is representative of the larger trend of intervention-intensive maternity care, which is often not in the best interest of low-risk mothers—or their bank accounts.

"Birth costs are inflated by probably a lot of things that people don't need and things that can also unintentionally pose harm," says Carol Sakala, Director of Childbirth Connection Programs at the National Partnership for Women & Families, which collaborated with Truven Health Analytics on the 2013 report. "You have a greater likelihood of things like bleeding and infection and so forth when you're taking surgical steps and giving powerful drugs."

While options such as medically inducing labor or offering an epidural are often presented as "not an issue" to mothers, Sakala says these steps may be the start of "a very intervention-intensive birth for a population that is by and large low-risk and healthy."

However, the dominant healthcare structure doesn't actually offer incentives for positive outcomes.

"The essential point is that the fee for service system we have now, adding up all these different fees from all these different services, is not tied in the least to value," Sakala says. "It doesn't matter if you did something that was a good thing to do or not, it doesn't matter if you got a good outcome or not."

'We're heading in the direction' of a better option

Although it hasn't yet been reflected by healthcare costs or outcomes, Sakala says there is reason to be optimistic due to a growing movement behind "bundled" or episode-based care. Currently offered through Medicaid programs in Ohio, Tennessee and Arkansas, as well as with some Cigna plans, this payment structure controls the costs for families and encourages better outcomes from the very start of maternal care.

Unlike the current standard, this system rewards healthcare providers for positive outcomes—such as lower rates of C-sections and higher rates of breastfeeding—or, in some cases, penalizes them for negative outcomes.

"Now it gets their attention that they're not only providing services and business as usual, as we are accustomed to in the current cultural ethos of maternity care," Sakala says, "but they are paying attention to what is going to get the best outcome and trying to work together to do that."

What can expectant parents do to control costs?

For what it says about transparency in the healthcare system in general, it is actually difficult to find estimates for childbirth costs in the United States. De La Torre recommends expectant parents familiarize themselves with their insurance policies from the beginning of maternal care. And tools such as that provided by the non-profit consumer group FAIR Health can help individuals estimate childbirth costs in their own states.

Beyond that, remember you are your best advocate. One surprising finding from the Truven Health Analytics report is that uninsured women paid less on average for childbirth services than mothers with insurance. The reason behind that may be twofold—and comes with a lesson for all families: For one, uninsured women may be slower to accept unnecessary interventions, which lowers their overall costs.

They may also be more proactive about petitioning their bills, which is something all families can do. As Sakala says, "This figure told me that hospitals by and large are ready to negotiate."

Looking back on her experience, Pennington says her insurance company was also easy enough to work with—but it was the pure scope of their debt that cast a shadow over a time that should have been happier.

"To be honest, the whole first year after that was a blur," she says. "It was rough. I think we have everything paid off now, eight and a half years later, but every once and a while something will creep up from 2009 and we're like, 'Oh my gosh.'"

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