Total Spending Averaged $24,336 across the Prenatal, Childbirth, and Postpartum Periods among ESI Enrollees
HCCI has highlighted the high cost of childbirth in the United States, but delivery is only one component of the full financial cost of having a baby. The cost of prenatal and postpartum care may cause people to forgo appropriate services, even as this care could help improve maternal health outcomes. This brief highlights total spending on health care services among birthing people in the 9 months prior to and 12 months following the birth of their child, including the costs of the delivery itself. We used HCCI's dataset of health care claims for individuals with health insurance through their job (employer-sponsored insurance, or ESI) to identify individuals who gave birth in 2018-2020. We do not limit our estimates to care that is specifically pregnancy- or birth-related; instead, we capture the full costs of care that birthing people with ESI receive over this period.
On Average, 60% of Spending was on the Delivery
Across the study period, we identified more than 460,000 births for which we have data on the full prenatal period and 12 months post-delivery. Among those, average total spending over the course of the prenatal, delivery, and postpartum periods was $24,336. The birthing person paid for 14% of this spending out-of-pocket on average.
The largest share of total spending—60%—was associated with the delivery itself. Just over a quarter of spending occurred in the prenatal period, on average, with the remaining 15% occurring in the 12-month postpartum period.
Figure 1 shows average per delivery total and out-of-pocket spending for the prenatal, delivery, and postpartum periods, overall and for c-sections and vaginal deliveries separately. The delivery type a birthing person experiences has implications for spending since c-sections are, on average, more expensive than vaginal births.
To understand how spending was distributed over the course of the prenatal and postpartum periods, we examined monthly spending. In the prenatal period, average monthly spending was highest in the month just before delivery, with 20% of total prenatal spending occurring in this month. Spending was lowest in the earliest month of pregnancy. In other prenatal months, average monthly total spending was just over $600. In the postpartum period, spending was highest in the month following delivery ($524, 15% of total spending in the 12 months post-delivery) and then declined over the next three months to reach steady monthly spending of about $250 in months 4 through 12 following delivery. Monthly spending data are available in the downloadable data accompanying this brief along with data on prenatal, delivery, and postpartum spending by state.
What Services Accounted for Most Spending among Birthing People in the Prenatal and Postpartum Periods?
On average, over half of spending during the prenatal period was on ultrasounds (35%) and lab services such as blood tests, gestational diabetes tests, and urine tests (18%) (Figure 2). Just under 20% of spending was on evaluation and management (E&M) services, including physician office visits and behavioral health visits as well as any E&M services that occurred in an emergency room or other setting. Administered and other drugs (including vaccines) made up about 4% of spending. The remaining spending was on tests, procedures, and durable medical equipment.
In the post-delivery period, 30% of spending was on office visits and 9% was on labs. Procedures (8%), imaging, durable medical equipment, including breast pumps and intrauterine devices, drugs, and tests (each 7%) made up another 37% of spending.
Addressing High Prenatal, Delivery, and Postpartum Spending Can Help Increase Access to Care
Appropriate care for birthing people, from the prenatal period throughout the year after delivery, is critical reduce high maternal mortality rates in the U.S. Increasing the share of pregnant people who receive "early and adequate" prenatal care is a Healthy People 2030 objective, and an objective related to postpartum mental health is under development.
Yet, unmet health care needs among birthing people persist. In one study, almost a quarter of pregnant and postpartum women reported an unmet health care need. Additionally, 60% reported challenges in the affordability of care, with women enrolled in commercial insurance more likely to report affordability challenges than those with public insurance.
Childbirth is the most frequent reason for a hospital admission in the HCCI data. Therefore, the challenge of high costs associated with having a baby remains a critical one to address in the ESI population. Ensuring that all birthing people receive appropriate prenatal and postpartum care depends on addressing the high costs that birthing people and their families, their employers, and insurers face, especially during the delivery and months just before and after, in which prenatal and postpartum spending are concentrated.
Birthing people shoulder a meaningful share of total spending directly through out-of-pocket spending; they may also experience higher premiums, lower wages, less generous benefits, and other effects of higher health care costs for their insurer and employer. Efforts to improve maternal morbidity and mortality, which remain shockingly high in the United States, will depend at least in part on addressing the high costs of care.
Our analysis is limited to female members between the ages of 18 and 44 who give birth in a hospital. This analysis includes the cost of the prenatal period, delivery, and postpartum period (12 months) for the birthing person. The cohort was defined by the presence of a diagnosis related group (DRG) related to vaginal birth or c-section between January 1, 2018 and December 31, 2020, and the birthing person's continuous enrollment in the HCCI data for 10 months prior to the delivery and 12 months following the delivery. We excluded deliveries where the length of stay in the hospital was greater than 10 days (those above the 99th percentile). We further restricted the sample to those who had one birth during their prenatal, delivery, and postpartum periods.
We measured the cost of childbirth admissions using allowed amounts, combining professional claims associated with each inpatient admission for childbirth. We calculated spending for the prenatal and postpartum period using outpatient, professional, and inpatient claims.
Approximately 60% of deliveries in our sample have an associated global maternity CPT code. These codes (CPT codes 59400, 59510, 59610, and 59618) may be billed (typically at the time of delivery or shortly thereafter) for the provision of a combination of prenatal, delivery, and postpartum care. Nearly all (99%) of global codes observed in the HCCI data in our sample occur during the delivery period. While global codes include many of the health care services included in prenatal and postpartum care (e.g., office visits), other services (e.g., ultrasounds) are billed separately. To ensure that inclusion of global code-related spending is not driving our allocation of spending across the prenatal, delivery, and postpartum periods, we compared our results using a sample of deliveries without global codes and found consistent results.