America's Pregnancy-Care Paradox: Paying Ever More for the Same Bad Results

The infant-mortality rate in the U.S. is extremely high, especially considering how much people are spending to give birth.

Andrew Kelly / Reuters

America is an expensive place to give birth—the “costliest in the world,” according to The New York Times. Giving birth in most other countries is free or cheap for just about every citizen.

But in prenatal and pregnancy care, as is the case with medical care at large, America’s high-cost system does not lead to first-rate outcomes. On the contrary: The website Mapping Health has observed that when it comes to maternity care, costs have been increasing without any corresponding increase in results. The average cost of a delivery doubled between 1993 and 2009, and yet the mortality rate for mothers actually rose. In other developed countries, that rate declined during that period. Likewise, the rate of infant death and the incidence of low birth weight (one proxy for unhealthy babies) in the United States has unfortunately remained steady. Since 2009, the nation has made no progress in matching its peer countries’ lower infant-mortality rates. In terms of maternal mortality, the CIA’s World Factbook puts the U.S. on par with Iran.

Poverty certainly plays a role in this—the gap between infant-mortality rates among America’s rich and poor mirrors those in developing countries—but it’s not the case that less-affluent citizens alone are responsible for America’s low averages. “Even highly advantaged Americans are in worse health than their counterparts in other ‘peer’ countries,” a 2013 report from the National Academies Press concludes.

American parents, then, are paying more and more for prenatal services and getting less and less for their money. Because they have not banded together to demand any change to this status quo, it stands to reason that they’re paying for a service that they consider satisfactory. That je ne sais quoi is most likely comforting personalized attention, or what researchers call “high-touch” prenatal care.

According to Gerard Anderson, the director of the Center for Hospital Finance and Management at Johns Hopkins, the maternal-care system is designed with a well-insured, high-earning woman in mind. It’s assumed that since the typical patient will only experience one or two pregnancies over the course of her life, she will want cutting-edge, high-touch care—and won’t mind paying out of pocket for her share of that. Indeed, she may even expect to. “We’re not having very many babies,” he told me, “so we want it to be a really pleasant experience.”

Rebekah Tilley, a freelance writer who lives in Iowa, has had four children. All of her births were low-risk and none presented any serious complications. The prices of them ranged from free (one in Denmark, with socialized medicine, and one in Minnesota, with Medicaid) to well over $1,000 (one in Kentucky, with conventional insurance). Tilley’s favorite experience was in Iowa with her fourth child. Her family insurance plan cost $250 a month and covered everything, including her hospital stay. “I didn't even have a co-pay,” she says. That she knew her insurance would cover costs led her to agree to certain treatments, encouraged by her obstetrician, that were, she admits, “largely unnecessary.”

And, though her all-expenses-paid experience in Copenhagen was excellent, Tilley notes that the Danish system is much more low-tech and hands-off than what she was used to. She puts it in grocery-shopping terms: “It was like prenatal care at an Aldi, where you bag your own groceries and return your own cart, rather than a HyVee, where you can get pull-up service or order your groceries online.” The Danish practitioners offered fewer tests and procedures and expected her to carry her own paperwork with her. That’s partly why she preferred the American way—so long as she was comfortably and affordably insured.

Holly Noonan, who currently works at a dog-daycare center in Charleston, South Carolina, had two C-sections while teaching English in Turkey. “Private hospitals in Turkey overall are very clean and inexpensive, by U.S. standards,” she says. Moreover, “the price is great. I paid the equivalent of about $2,500 for my first son's C-section in 2007 and it wasn't much more for my second C-section in 2009.” But she chafed at the expectation that patients should assume much of the responsibility for their own care. “Not even two hours after my surgery I asked a nurse to hand me a blanket so I could nurse my baby and she told me it was not her job and I needed to do it,” she says. “She then scolded me for not having someone with me to help me.”

Noonan, Tilley, and other Americans accustomed to the high-touch model might feel even more alienated by Chinese prenatal care, which, though good at keeping babies and mothers healthy, has been described as impersonal, even “factory-like.” Indeed, the Chinese model may seem spartan to Westerners, but it is cost-effective. Most “routine” care is free and what co-pays are required are quite modest. Even C-sections, which are alarmingly popular on the mainland, cost less than $1,000. By contrast, the average cost of a C-section in America, including what both patient and insurance pay, is over $50,000, or 50 times as much.

Women restricted to the United States for their pre- and post-natal experiences can still encounter a significant difference in the cost of care, as Noonan discovered when she found herself pregnant once in Iowa and once in Kentucky. According to a 2013 report, even with commercial insurance, a patient’s share of the expenses can vary greatly: Among the five states studied, researchers found that, for a consumer, a vaginal birth was most affordable in Louisiana ($10,318), and a C-section was least affordable in California ($21,307).

Even with this variance, no state in the U.S. has fully figured out how to limit costs to levels considered normal everywhere else in the world. That won’t change as long as parents want memorable prenatal and birth experiences and continue to insist that hospitals are full of expensive machines and highly paid specialists on the off chance that something rare occurs. “In many cases, [patients] do have a very good personal experience,” Anderson says, “until they see the bill.”