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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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Pop quiz, mama! How many different types of car seats are there? If you guessed three, you're partially correct. The three main types are rear-facing car seats, forward-facing car seats, and booster seats. But then there are a variety of styles as well: infant car seats, convertible seats, all-in-one seats, high-back booster seats, and backless boosters. If you're not totally overwhelmed yet, keep reading, we promise there's good stuff ahead.

There's no arguing that, in the scheme of your baby and child gear buying lifetime, purchasing a car seat is a big deal! Luckily, Walmart.com has everything you need to travel safely with your most precious cargo in the backseat. And right now, you can save big on top-rated car seats and boosters during Best of Baby Month, happening now through September 30 at Walmart.com.

As if that wasn't enough, Walmart will even take the carseat your kiddos have outgrown off your hands for you (and hook you up with a sweet perk, too). Between September 16 and 21, Walmart is partnering with TerraCycle to recycle used car seats. When you bring in an expired car seat or one your child no longer fits into to a participating Walmart store during the trade-in event, you'll receive a $30 gift card to spend on your little one in person or online. Put the money towards a brand new car seat or booster or other baby essentials on your list. To find a participating store check here: www.walmart.com/aboutbestofbabymonth

Ready to shop, mama? Here are the 9 best car seat deals happening this month.


Safety 1st Grow and Go Spring 3-in-1 Convertible Car Seat

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From rear-facing car seat to belt-positioning booster, Grow and Go Sprint's got you covered through childhood. Whether you choose the grey Silver Lake, Seafarer or pink Camelia color palette, you'll love how this model grows with your little one — not to mention how easy it is to clean. The machine-washable seat pad can be removed without fussing with the harness, and the dual cup holders for snacks and drinks can go straight into the dishwasher.

Price: $134 (regularly $149)

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Baby Trend Hybrid Plus 3-in-1 Booster Car Seat in Bermuda

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When your toddler is ready to face forward, this versatile car seat can be used as a five-point harness booster, a high-back booster, and a backless booster. Padded armrests, harness straps, and seat cushions provide a comfy ride, and the neutral gray seat pads reverse to turquoise for a stylish new look.

Price: $72.00 (regularly $81)

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Baby Trend Hybrid Plus 3-in-1 Booster Car Seat in Olivia

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Looking for something snazzy, mama? This black and hot pink car seat features a playful heart print on its reversible seat pad and soft harness straps. Best of all, with its 100-pound weight limit and three booster configurations, your big kid will get years of use out of this fashionable design.

Price: $72.00 (regularly $81)

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Evenflo Triumph LX Convertible Car Seat

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This rear- and forward-facing car seat keeps kids safer, longer with an adjustable five-point harness that can accommodate children up to 65 lbs. To tighten the harness, simply twist the conveniently placed side knobs; the Infinite Slide Harness ensures an accurate fit every time. As for style, we're big fans of the cozy quilted design, which comes in two colorways: grey and magenta or grey and turquoise.

Price: $116 (regularly $149.99)

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Disney Baby Light 'n Comfy 22 Luxe Infant Car Seat

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Outfitted with an adorable pink-and-white polka dot Minnie Mouse infant insert, even the tiniest of travelers — as small as four pounds! — can journey comfortably and safely. This rear-facing design is lightweight, too; weighing less than 15 lbs, you can easily carry it in the crook of your arm when your hands are full (because chances are they will be).

Price: $67.49 (regularly $89.99)

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Graco 4Ever 4-in-1 Convertible Car Seat

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We know it's hard to imagine your tiny newborn will ever hit 100 lbs, but one day it'll happen. And when it does, you'll appreciate not having to buy a new car seat if you start with this 4-in-1 design! Designed to fit kids up to 120 lbs, it transforms four ways, from a rear-facing car seat to a backless belt-positioning booster. With a 6-position recline and a one-hand adjust system for the harness and headrest, you can easily find the perfect fit for your growing child.

Price: $199.99 (regularly $269.99)

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Graco SlimFit All-in-One Convertible Car Seat

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With its unique space-saving design, this 3-in-1 car seat provides 10% more back seat space simply by rotating the dual cup holders. The InRight LATCH system makes installation quick and easy, and whether you're using it as a rear-facing car seat, a forward-facing car seat, or a belt-positioning booster, you can feel confident that your child's safe and comfortable thanks to Graco's Simply Safe Adjust Harness System.

Price: $149.99 (regularly $229.99)

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Graco Snugride Snuglock 35 Platinum XT Infant Car Seat

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Making sure your infant car seat is secure can be tricky, but Graco makes it easy with its one-second LATCH attachment and hassle-free three-step installation using SnugLock technology. In addition to its safety features, what we really love about this rear-facing seat are all of the conveniences, including the ability to create a complete travel system with Click Connect Strollers and a Silent Shade Canopy that expands without waking up your sleeping passenger.

Price: $169.99 (regularly $249.99)

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Graco Snugride Snuglock 35 Elite Infant Car Seat

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With just one click, you can know whether this rear-facing car seat has been installed properly. Then adjust the base four different ways and use the bubble level indicator to find the proper position. When you're out and about, the rotating canopy with window panel will keep baby protected from the sun while allowing you to keep your eye on him.

Price: $129.99 (regularly $219.99)

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

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Having children isn't always as easy as it looks on Instagram. There's so much more to motherhood than serene baby snuggles and matching outfits. But there's a reason we've fallen so deeply in love with motherhood: It's the most beautiful, chaotic ride.

Every single day, we sit back and wonder how something so hard can feel so rewarding. And Eva Mendes just managed to nail the reality of that with one quote.

Eva, who is a mama to daughters Esmerelda and Amada with Ryan Gosling, got real about the messy magic of motherhood in a recent interview.

"It's so fun and beautiful and maddening," the actress tells Access Daily. "It's so hard, of course. But it's like that feeling of…you end your day, you put them to bed and Ryan and I kind of look at each other like, 'We did it, we did it. We came out relatively unscathed.'"

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And just like that, moms all over the world feel seen. We've all been there: Struggling to get through the day (which, for the record is often every bit as fun as it is challenging), only to put those babies to sleep and collapse on the couch in sheer exhaustion. But, after you've caught your breath, you realize just how strong and capable you really are.

One thing Eva learned the hard way? That sleep regressions are very, very real...and they don't just come to an end after your baby's first few months. "I guess they go through a sleep regression, which nobody told me about until I looked it up," she says "I was like, 'Why isn't my 3-year-old sleeping?'"

But, at the end of the day, Eva loves her life as a mom—and the fact that she took a break from her Hollywood career to devote her days to raising her girls. "I'm so thankful I have the opportunity to be home with them," she says.

Thank you for keeping it real, Eva! Momming isn't easy, but it sure is worth it.

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Nannies and early childhood educators do incredibly important work. Parents and children need these workers, they are vital to families and our economy. And they are woefully underpaid.

On average, nannies in the United States make less than Amazon delivery drivers, and day care workers earn less than either.

According to Sittercity's most recent data, the typical hourly rate of nannies in 2019 is $17.50 per hour. According to Amazon, most delivery drivers earn $18 - $25 per hour. And day care workers make only a couple dollars more than they would working in fast food, earning $11.17 per hour on average, according to the U.S. Bureau of Labor Statistics.

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What does it say about our society that we value the delivery of consumer goods more than we value care work?

Yes, parents are struggling to pay for childcare, but those caring for our children are struggling to pay their bills, too, and it is hard to retain talented professionals when there is more money to be made in other fields. "It is stressful. Everybody loves these children, and that's why they're there, but the love can't pay their bills," day care operator Danielle Frank told KSNB News this week.

Frank owns Smiling Faces Academy in Kearney, Nebraska, but the problem of high turnover and low wages in the childcare industry is an issue all over the United States. This isn't a uniquely American issue, either. In Japan, day care workers are desperately needed, the New York Times reports, but childcare workers there earn about a third less than workers in other industries and report struggling to cover the basic necessities.

Back in North America, this week day care workers in Nova Scotia, Canada who are frustrated with low wages have threatened to walk off the job, a move similar to one made by YMCA childcare workers in Chicago last year. "I make $15.50 an hour, and I have a BA in early childhood education with a certification in infants and toddlers," childcare worker Tahiti Hamer told WGN last year.

From Nebraska to Nova Scotia to the story is the same: Parents pay a lot for childcare while workers make very little, even though some licensed day cares require employees to have training in early childhood education, or even a bachelor's degree. And when you've got student loans, maybe carrying Amazon packages starts to look better than caring for children.

According to a recent study by the Indeed Hiring Lab, the childcare industry has two big problems right now.

"As the labor market has strengthened in recent years, more workers need child care. At the same time, growth in interest in child care jobs has slowed," Indeed Hiring Lab economist Nick Bunker notes. He suggests low-wage earners who work in childcare have more options these days, and employers should consider raising workers' pay.

It's easy to see why the industry has a hard time keeping workers, especially as other lower-wage job sectors (like Amazon delivery) expand. Unfortunately, for many childcare centers, paying workers more is just not doable without some help from levels of government.

And help is needed, not just to ensure that parents have access to quality, affordable childcare, but also to ensure that those providing it aren't living in poverty.

A study out of the Center for the Study of Child Care Employment at the University of California, Berkeley, found childcare workers' earnings are not keeping pace with increases in similar professions or with the costs of childcare and living. "Childcare workers have also experienced no increase in real earnings since 1997, and, as was true in 1989, still earn less than adults who take care of animals, and barely more than fast food cooks. Those who work as preschool teachers have fared somewhat better; their wages have increased by 15 percent in constant dollars since 1997, although their wages remain low. In contrast, parent fees have effectively doubled," the researchers note, highlighting that many childcare workers earn so little they actually qualify for public assistance.

The researchers continue: "While there are no available data to explain this glaring gap between trends in parent fees and teacher wages, it is abundantly clear that families cannot bear the burden of addressing the imperative to provide more equitable compensation for their children's early childhood teachers."

Speaking to the Education Writers Association last year one of the reports' writers, Marcy Whitebook, the founding director of the Center for the Study of Child Care Employment at the University of California at Berkeley, said the problem is that our society devalues the work of looking after and educating children under 5, even though it is as demanding and important as teaching those ages 5 and up.

"Americans aren't used to funding early childhood care and instruction like they do K-12 education," Whitebook said. "We don't look at it as education. And we don't look at it as education everyone should have access to."

That may change in the future, as presidential candidates float plans for universal pre-K and childcare, but right now, having access to childcare is a privilege. And those who are privileged enough to employ a nanny should pay them fairly if they want to keep them, says Elizabeth Harz, CEO of Sittercity. "It's also worth noting that when parents are proactive and offer systems and official paperwork that give nannies protection in the relationship, it goes a long way," says Harz.

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It may seem like there are a lot of recalls for kids' products these days, but it's actually a good thing. In some cases, the recalls indicate that companies are being proactive. They're often taking action before the Consumer Products Safety Commission has to get involved, and that's the case for the latest car seat recall.

This week WAYB voluntarily recalled thousands of PICO Travel Car Seats. The lightweight, foldable car seats are a favorite with parents who fly frequently as they're designed for use in cars and planes.

"A small number of customers have experienced a break in the headrest support tubes (the part that connects the headrest to the back of the seat) on their Picos. Each of these customers informed us of the issue directly, and we provided them with a replacement Pico under our warranty policy," the company states.

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There have been no injuries, but "even one warranty replacement of this sort is too many" according to WAYB.

The company says it has reported the issue to the National Highway Traffic Safety Administration (NHTSA) and is working on a recall plan to replace the headrests on affected Picos, free of charge.

If you have questions about your PICO, contact Customer Experience team at 1-888-924-9292 with any questions (phone or text, Monday through Friday, 7am to 4pm Pacific Time), or email us at help@wayb.com.

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There have been a lot of iconic entertainment magazine covers featuring pregnant women over the years. Who can forget Demi Moore's bare baby bump on Vanity Fair or Britney Spears' similar nude pose on Harper's Bazaar?

Pregnant women on a magazine covers is nothing new, but a visibly pregnant CEO on the cover of a business magazine, that's a first and it happened this week.

Inc. just put The Wing's CEO Audrey Gelman on the cover and this is a historic moment in publishing and business.

As Gelman told Today this week, "You can't be what you can't see, so I think it's so important for women to see that it's possible to run a fast-growing business and also to start a family."

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She continued: "It's so important to sort of burst that bubble and to have new images of women who are thriving and working professionally while balancing motherhood … My hope is that women see this and again feel the confidence to take greater professional risks while also not shelving their dreams of becoming a mother and starting a family."

The Wing started in 2016 as a co-working space for women and has grown rapidly. As Inc. reports, The Wing has eight locations in the U.S. with plans for more American and international locations by 2020.

Putting Gelman on the cover was an important move by Inc. and Gelman's honesty about her early pregnancy panic ("I can't be pregnant. I have so much to do." she recalls thinking after her pregnancy test) should be applauded.

Gelman says pregnancy made her slow down physically, and that it was actually good for her company: "I had this realization: The way to make my team and my employees feel proud to work for me and for the company was actually not to pretend to be superhuman or totally unaffected by pregnancy."

We need this. We need CEOs to admit that they are human so that corporate leadership can see employees as humans, too. Humans need things like family leave and flexibility, especially when they start raising little humans.

There are a lot of iconic covers featuring pregnant women, but this one is different. She's wearing clothes and she's changing work culture.

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