Why Birth Costs So Much
To make birth free, we must address our deference to medical management that is driving up charges in the first place.
Two women want to make birth free for all American mothers. It’s an admirable proposal. A brief of the white paper by Catherine Glenn Foster, president and CEO of Americans United for Life, and Kristen Day, executive director of Democrats for Life of America, published in Compact magazine last week, has earned some stirring responses. (The American Conservative’s own Bradley Devlin defended the initiative against those who said, “but socialism.”)
What none has questioned, however, is the cost of birth in the United States, and why it has tripled since the 1990s while remaining much the same in peer countries.
The Make Birth Free proposal aims to solve these high costs. For the same price as the financial aid sent to Ukraine in 2022, the federal government could cover the costs of child delivery for every American mother who is covered by the Affordable Care Act, as well as pre- and post-natal care, baby supplies, and even expanded paid leave under the Family Medical Leave Act. Surely this is a cause far more immediately related to our national interest than keeping the Donbas Ukrainian, and a use of federal dollars even fiscal conservatives should deem more worthy than nine out of 10 items on the congressional budget.
Yet these costs are high, and something drives them up—likely several things, not least of which is our hypermedicalized approach to pregnancy. Fixing the cost of birth requires more than just paying the bill; it also requires fixing our approach to childbearing.
My husband and I tasted these high costs for ourselves last year. Our daughter was born within 20 minutes of our arrival at the hospital, after a long midwife-attended labor at home. For less than half an hour of the doctor’s time, the charge was almost $3,000. That was just for the moment of birth. The hospital also charged $21,000 for our stay (regardless of whether we chose to remain two full nights, as is routine), while other fees tallied to an additional $1,700.
Much of this was paid by insurance, of course. Regardless, the charges were so far removed from reality as to have been impossible to meet without help. This was for a largely trouble-free birth: I received no anesthesia, needed no surgery, and neither the baby nor I required medical intervention afterward. The nurses didn’t even have time to start me on an IV, though they tried. I can’t imagine what the bill would have looked like had we needed a serious medical intervention.
Our experience was indicative, but it was also nothing new. Medical costs have been skyrocketing since the 1950s with no end in sight, aided by (among other things) expensive new medical technology and a corresponding deference to medical interference. This is especially true for childbirth, which, though neither an illness nor an injury, has been treated as a high-risk medical condition since the early 1900s.
Prior to this, few pregnant mothers ever saw the inside of a hospital. The introduction of the obstetric ultrasound and prenatal diagnosis, though helpful in preventing many stillbirths, also changed the national perspective around pregnancy and birth from that of a natural process for the female body to that of a year-long condition requiring constant medical management. The result was exorbitant bills and rich doctors.
This constant monitoring, however, has not necessarily resulted in better outcomes for mothers or children. In fact, it might be making things worse. The most common example of this is the United States’ abnormally high rate of cesarean deliveries.
The cesarean is a major surgery with irrevocable consequences for the mother and her future childbearing ability. It is necessary in some instances, but almost certainly not as frequently as it has been prescribed. Between 1996 and 2009, the rate of C-sections in the United States shot up 60 percent. Despite a slight decline in the decade following, that rate began to increase yet again in 2020. At 32 percent, it is currently higher than that of the United Kingdom, Canada, and much of Europe.
This is not necessarily due to an increase in high-risk births. Rather, it is a result of what is sometimes called the “cascade of interventions,” in which one attempt to coax birth along according to “norms” necessitates a string of other interventions, each attempting to solve the side effects of the previous one. In this manner, like a sleep-deprived coffee drinker, we attempt to construct through props what the human body does on its own, more often than not, when given time. Also like the coffee drinker, the effect the props produce is only somewhat like the real thing.
Of course, birth used to be free, or close to it. A midwife in the community would show up when the contractions began and maybe take a chicken for her services, no licensing or insurance needed. Somewhere along the line, however, we decided to trade this for safety—or rather, the perception of safety, which is not always the same thing.
There may be any number of reasons why we fell into this pattern, but one reason we have held to it in the United States, despite abnormally high maternal and infant mortality rates, is financial. Hospitals are paid more when a woman has a cesarean—up to $10,000 more.
Hospitals are also paid more when a woman has an epidural anesthetic, and when she is induced. Both of these are elective procedures that neither guarantee a healthier mother or child, and even sometimes cause problems (spinal headaches as a result of epidural anesthesia are typically underdiscussed; so is hypertension as a result of synthetic oxytocin, the drug used to induce labor). Yet they are routinely presented to laboring women as either risk-free, medically recommended, or in some extreme cases, hospital policy. Giving birth without these interventions requires something like an iron will from the laboring mother, who is already (need we say it?) taxing herself for more important purposes. They are offered, recommended, and even pushed at every turn.
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Foster and Day recommend tying some of their federal dollars to incentives to counterbalance this. They propose a financial incentive for women with low-risk pregnancies to use midwives and have out of hospital births. “Many countries with low infant and maternal mortality rates center midwives at the core of their healthcare delivery to expectant mothers,” they write. They also recommend paying hospitals the same amount regardless of the method of delivery, cesarean or vaginal.
This would be a good start, one which would help reduce the cost and improve the outcomes of many births, if effective. But until we change the way we think about birth, the advantage remains in the hands of the medical industry, and the cost will remain high, no matter who foots the bill. Midwife-attended births are already significantly more affordable than hospital births, and fairly accessible, yet most women still choose to give birth in a hospital, showing our cultural deference to the white coat.
While we perceive the hypermedicalized approach to birth to be safer, and while the appearance of safety remains our highest aim, we will continue to pay the most exorbitant price. It is not enough to propose good incentives to counter the perverse ones that currently exist in the medical industry. To truly make birth free, we must first take off the shackles of obsessive medical management, and treat birth as what it is.