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Many different reasons have been proposed to explain why the U.S. birthrate has been declining since the 1990s, but nearly everyone agrees that financial factors play a major role. My new research shows exactly how expensive it is to give birth in this country, and the results point to a serious health inequity that must be addressed: The cost of pregnancy in the U.S. has become astronomical — much higher than in other developed nations — and that imposes massive and unequal financial and emotional burdens in a time when reproductive autonomy is no longer guaranteed.

Working alongside an attending OB/GYN physician at Columbia University Irving Medical Center and other researchers, I examined the causes and trends associated with rising pregnancy costs in the U.S. We also looked at whether certain other medical conditions impose a higher financial burden on pregnant patients. Our work has important implications for health policy and clinical leadership and can help inform guidelines for clinicians as well as pregnant patients and their families.

Our study analyzed data from more than 1.9 million documented pregnancies in the U.S. between 2009 and 2019. The results clearly indicate rapidly rising medical costs in an already overburdened healthcare system:

  • Median total pregnancy costs increased by more than $5,000 over the 10-year time period.
  • Median inpatient service costs increased by nearly 40%, with the amount that women are paying out-of-pocket nearly doubling in the same time frame.
  • Out-of-pocket costs for inpatient services rose 65%, and there was a 30% increase in insurance liability.

To uncover factors that contribute to these high (and ever-growing) expenses, we took a closer look at cases in which the pregnant patient had a comorbid condition, such as hypertension or diabetes. These conditions can put women at increased risk for serious health complications like eclampsia or preterm labor, and we found that both conditions are linked to higher median total pregnancy costs, as well as higher outpatient and inpatient expenses.
Our research reveals that over the past decade, medical costs associated with pregnancy have been climbing and show no signs of slowing down, creating a significant financial burden that we must take steps to mitigate. 

In the U.S., maternity and newborn care constitute the single largest category of hospital payouts for most commercial insurers and Medicaid programs. And while having insurance can help prevent medical bankruptcy, it’s certainly not a panacea, since these plans don’t always provide the necessary coverage: Up to 62% of women in the U.S. who have private health insurance, for example, do not have access to maternity coverage at all.

And despite the country’s steep maternal care costs, the U.S. has one of the highest rates of both infant and maternal death among industrialized nations. Women who live in poverty, uninsured women, and women whose insurance does not cover childbirth are likely major contributors to these figures. 

The increased costs faced by certain groups of women can be partially explained by maternal morbidity (health problems caused or aggravated by pregnancy and childbirth). Maternal morbidity is also on the rise in the U.S. and disproportionately affects people of color and those with social disadvantages. A 2019 study estimated that total maternal morbidity costs for all U.S. births in 2019 would amount to over $32 billion from conception through a child’s fifth birthday. 

Maternal morbidity is an important metric to examine when looking at pregnancy costs, as these conditions can lead to costly, adverse outcomes for women, such as cesarean section delivery and stroke, as well as adverse outcomes for children, such as preterm birth, suboptimal breastfeeding, and asthma. 

To begin improving upon pregnancy costs and maternal morbidity, we can invest in evidence-based maternal health initiatives, such as community-based models of care that extend beyond birth as well as telehealth integration for maternal health. These initiatives could serve to improve access to care and reduce unnecessary expenses faced by pregnant women. 

Additionally, we can address inequities surrounding maternal morbidity through policy changes that tackle social determinants of health associated with maternal morbidity, such as unstable housing and lack of transportation. 

In summary, the landscape of maternal healthcare in the U.S. reflects staggering costs, inequities in care, and surprisingly high rates of morbidity and complications — all of which are especially disconcerting now that childbirth is no longer a choice in many states. 

There has certainly never been a better time to ensure that we all have a complete understanding of the financial burdens associated with pregnancy. Our reproductive health policy has reached a critical point: We must restructure our systems to afford more flexibility to women, alleviate costs associated with pregnancy, and address the root causes of inequities in maternal health.

Maleeha Rahman ’23 is a student at Barnard College and an undergraduate research assistant at Columbia University.