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

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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 a baby's birth.

That's why when Elizabeth Bruenig, an opinion writer at The Washington Post who is currently on maternity leave, tweeted a photo of her hospital bill with the caption "$8,000 to give birth. son of a b", the tweet went viral.

Her mentions quickly filled with photos of other families' hospital bills, stories of impossibly high bills and stories from parents who gave birth in other countries (and walked out of the hospital with a baby and no bill at all).

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With more than 100,000 Twitter followers, Bruenig was perfectly positioned to prompt a conversation about the cost of giving birth in America, and we're glad she did. Because she is far from the only mother dealing with this. Giving birth in America means going into debt for some mothers.

Here are some of their stories:

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.'"

[A version of this story was first published April 17, 2018. It has been updated.]

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As a mid-Spring holiday, we never knew exactly what to expect from the weather on Easter when I was growing up in Michigan: Would we get to wear our new Sunday dresses without coats? Or would we be hunting for eggs while wearing snowsuits?

Although what the temperature had in store was really anyone's guess, there were a few special traditions my sister and I could always depend on—and it won't come as a surprise to anyone who knows me that my favorite memories revolved around food. After all, experts say memories are strongest when they tie senses together, which certainly seems to be true when it comes to holiday meals that involve the sounds of laughter and the taste of amazing food.

Now that I'm a parent, I'm experiencing Easter anew as my children discover the small delights of chocolate, pre-church brunch and a multi-generational dinner. While I still look forward to the treats and feasting, I'm realizing now that the sweetest thing of all is how these traditions bring our family together around one table.

For us, the build-up to Easter eats is an extended event. Last year's prep work began weeks in advance when my 3-year-old and I sat down to plan the brunch menu, which involved the interesting suggestion of "green eggs and ham." When the big morning rolled around, his eyes grew to the size of Easter eggs out of pure joy when the dish was placed on the table.

This year, rather than letting the day come and go in a flash, we are creating traditions that span weeks and allow even the littlest members of the family to feel involved.

Still, as much as I love enlisting my children's help, I also relish the opportunity to create some magic of my own with their Easter baskets—even if the Easter Bunny gets the credit. This year, I'm excited to really personalize the baskets by getting an "adoptable" plush unicorn for my daughter and the Kinder Chocolate Mini Eggs that my son hasn't stopped talking about since seeing at the store. (You can bet this mama is stocking up on some for herself, too.)

At the same time, Easter as a parent has opened my eyes to how much effort can be required...

There is the selection of the right Easter outfits for picture-perfect moments.

There is the styling of custom Easter baskets.

There is the filling of plastic eggs and strategic placement of them throughout the yard.

But when the cameras are put away and we all join together around the table for the family dinner at the end of the day, I can finally take a deep breath and really enjoy—especially with the knowledge that doing the dishes is my husband's job.

This article was sponsored by Kinder. Thank you for supporting the brands that support Motherly and mamas.


Our Partners

Pink opened up about her family's fight against coronavirus late Friday, taking to Instagram to make a big announcement.

"Two weeks ago my three-year old son, Jameson, and I are were showing symptoms of COVID-19," Pink revealed, noting that she tested positive and has since recovered.

She continued: "My family was already sheltering at home and we continued to do so for the last two weeks following the instruction of our doctor. Just a few days ago we were re-tested and are now thankfully negative. It is an absolute travesty and failure of our government to not make testing more widely accessible. This illness is serious and real."

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After dealing with the virus on a personal level and recognizing her privilege in being able to access testing, Pink decided to donate $1 million to fight coronavirus and hopefully protect others.

"In an effort to support the healthcare professionals who are battling on the frontlines every day, I am donating $500,000 to the Temple University Hospital Emergency Fund in Philadelphia in honor of my mother, Judy Moore, who worked there for 18 years in the Cardiomyopathy and Heart Transplant Center. Additionally, I am donating $500,000 to the City of Los Angeles Mayor's Emergency COVID-19 Crisis Fund," she announced via Instagram.

Pink ended her update by thanking the brave healthcare workers on the front lines and reminding the rest of us to stay home.

For more information on COVID-19 and how it is impacting families, visit mother.ly/coronavirus.

News

On Friday President Trump announced that the Centers for Disease Control is now advising people to wear a cloth mask if they need to go out in public. It's not a rule, he says, but a recommendation.

"It's really going to be a voluntary thing," President Trump told reporters. "I'm not choosing to do it."

First Lady Melania Trump is urging others to do it, tweeting, "As the weekend approaches I ask that everyone take social distancing & wearing a mask/face covering seriously. #COVID19 is a virus that can spread to anyone—we can stop this together."

What the CDC says about cloth face masks:

The CDC says it's recommending cloth face masks because recent studies show that people can have COVID-19 while asymptomatic, meaning they feel fine and because they don't know they are sick they might still be going about their daily routine in their community.

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Basically, masks don't protect the wearer as much as they protect people from the wearer (who might not know they are sick) by blocking respiratory droplets

"So it's not going to protect you, but it is going to protect your neighbor," Dr. Daniel Griffin at Columbia University, an expert on infectious diseases, tells NPR.

CDC experts are "advising the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others. Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure."

They say if you're going somewhere where it's hard to maintain the proper social distance of six feet, like a grocery store or a pharmacy, then it's a good idea to wear a simple cloth mask.

"The cloth face coverings recommended are not surgical masks or N-95 respirators. Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance," the CDC states.

"You may need to improvise a cloth face covering using a scarf or bandana," the agency notes on its website.

A DIY cloth mask is an extra layer of protection:

The CDC still says that staying home and practicing good hand hygiene is the best protection against COVID-19, but a cloth mask would be an extra layer of protection if you must go out to get food or unavoidable medical care.

According to Dr. Scott Segal, chair of anesthesiology at Wake Forest Baptist Health in Winston-Salem, North Carolina, certain types of fabric are better than others when it comes to making a mask. While he CDC says improvised bandanas or scarfs are better than nothing, Segal says DIY mask makers should aim a little higher for the masks to be effective.

"You have to use relatively high-quality cloth," Dr.Segal, who is researching this topic, tells NBC News.

According to Segal you don't want to use a knit fabric (like an old T-shirt) but rather a woven fabric. He suggests a double layer of heavyweight cotton with a thread count of at least 180 (like quilters cotton). If you don't have a cotton with that high of a thread count, line it with flannel.

For more tips on how to sew a fabric face mask, check out these instructions from Kaiser Permanente.

No-sew methods:

If you're not a sewer you can still fashion a mask, and there are plenty of no-sew tutorials online showing you how. Use heavyweight woven fabric like Segal suggests and make one of these without a sewing machine.

How To Make a Pleated Face Mask // Washable, Reusable, No-Sewing Required youtu.be

Should kids wear masks? Talk to your doctor.

The CDC is not recommending masks if you're just going for a walk around the block or playing in the backyard (which is the extent of most kids' outings these days). The masks are more for grocery runs, which many parents are opting to do alone these days.

But solo parents and those with partners who are in the military know that leaving the kids behind isn't always an option if you're the only adult in the home. If that's your circumstance, choose delivery options when possible to avoid taking your children to public places like grocery stores and pharmacies (the kinds of places the CDC recommends masks for).

If you are concerned that you may need to take your child somewhere where a mask would be required, call your pediatrician for advice on whether a mask is appropriate for your child's age and circumstances. Babies' faces should not be covered.

If you have no one to watch your children while you get groceries and cannot get them delivered try contacting your local government, community groups and churches for leads on grocery delivery help. They may be able to put you in touch with someone who can fetch groceries for you so that you don't have to take your children to the store with you.

News

Starting this weekend Target and Walmart will be limiting the number of people allowed in its stores to give shoppers and staff more space to spread out and adhere to social distancing recommendations during the coronavirus pandemic.

"Beginning April 4, Target will actively monitor and, when needed, limit the total number of people inside based on the store's specific square footage," Target notes in a news release.

Walmart's corporate message is similar: "Starting Saturday, we will limit the number of customers who can be in a store at once. Stores will now allow no more than five customers for each 1,000 square feet at a given time, roughly 20 percent of a store's capacity."

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At Target you will also notice staff wearing gloves and masks over the next two weeks as the company steps up its coronavirus protection measures.

Many people are choosing to stay home and order groceries online, but that's not an option for everyone as long lines at some Target's prove.

"We're incredibly proud of the commitment our more than 350,000 frontline team members have demonstrated to ensure millions of guests can count on Target, and we'll continue to focus our efforts on supporting them," says Target's Executive Vice President and Chief Operating Officer, John Mulligan.

Target is open this weekend but—along with Costco, Aldi, Publix and Trader Joe's—Target stores will be closed on Easter Sunday to give the essential employees in these stores a much-deserved break.

News

As a mom of three and former social worker working for many years in the fields of adoption, Sara Ester of Sara Liz Photography knows firsthand the importance of family time. When she learned that families all over the country are self-isolating due to the coronavirus outbreak, she knew it was the perfect time to capitalize on moments of connections. Her mission was simple: promote family time to ease stress and promote happiness.

Liz reached out to dozens of families on social media asking if they would like to be photographed on their porch for a "Front Porch Session" and the responses were huge.

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Photo by: Sara Liz Photography

"Amid all the COVID-19 stuff going on I asked if families would be interested in a quick five-minute session on their front porches to document what a crazy experience it has been to be quarantined at home," Ester told Popsugar. "The people participating ran with it! So many families made funny or encouraging signs, showed up in their pajamas or yoga pants, and just really embraced the whole 'quarantine chic' idea. It was really reaffirming to see how everyone is in the same boat. We're all just trying to do the best we can with a crappy situation!"


Photo by: Sara Liz Photography

We're living in perilous times and it's nice to see families using the lockdown as an opportunity to bond. After all, it doesn't matter how big or small your house is, it's the love inside that counts.

Photo by: Sara Liz Photography


"Photography, specifically documentary photography is a big part of how I see and function in the world a lot of the time," Ester shared in an Instagram post. With everything being so overwhelming the last week or so, it has helped me to also keep in mind that what we are dealing with is historical."

News
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