The birth of a child is momentous for any person and family. New parents may face a range of challenges, including a lack of paid family leave, the rising costs of childcare, and potential health-related complications for the birthing person and new baby. In the midst of this major life transition, parents also face new financial burdens. A major cost – even among those with health insurance – is the out-of-pocket cost of the birth itself. Although the Affordable Care Act requires employer-sponsored insurance plans to cover maternity care, birthing people may pay thousands of dollars out-of-pocket, which may threaten access to high-quality care. Using HCCI's commercial claims database, which includes claims for over one-third of the population with employer-sponsored insurance, we find that birthing people in the U.S. paid nearly $2,000 out-of-pocket, on average, when they had a baby in 2020. These out-of-pocket costs include deductibles, coinsurance, and copayments.
The high out-of-pocket cost associated with childbirth, which accounts for delivery expenses only, not including prenatal or postpartum expenses or other costs such as newborn care, can pose a major burden for families at a time when they are facing a range of decisions, adjustments, and expenses. Overall, 87% of birthing people in our data had some out-of-pocket spending for their delivery. Exactly how much they paid varied based on where they live and the kind of delivery (i.e., c-section vs. vaginal delivery). Differences in out-of-pocket spending only partially reflect differences in overall costs; differences also are affected by factors like benefit design and whether a birthing person has reached their out-of-pocket maximum. In this brief, we examined the average cost for childbirth, nationally as well as in each state and a range of local metro areas, overall and separately for c-sections and vaginal births.
Out-of-Pocket Spending on Childbirth Varied Almost Threefold Across States
Nationally, the average out-of-pocket spending for childbirth was $1,905. Average out-of-pocket spending for a vaginal birth was $1,875; the average out-of-pocket cost of a c-section was about 5% higher at $1,962.
As shown in Figure 1, the average out-of-pocket cost for a delivery varied across states from $974 in Michigan to $2,685 in Nebraska. Although out-of-pocket spending was generally lower for vaginal deliveries than for c-section births, we observed similar variation in costs for both delivery types. Average out-of-pocket spending on c-sections ranged from $1,026 in Michigan to $2,809 in South Dakota. For vaginal deliveries, out-of-pocket spending was lowest in Michigan ($949) and highest in Nebraska ($2,670).
Our data show that average out-of-pocket spending was higher for c-sections than vaginal deliveries in 39 of the 46 states we examined. Birthing people in Connecticut, Florida, New York, Ohio, Rhode Island, South Carolina, Wisconsin who had c-sections had lower out-of-pocket spending on average than those who delivered vaginally. In states where average out-of-pocket spending for c-sections was higher, the difference ranged from 0.2% ($3) higher in New Jersey to 14% ($268) higher in Iowa.
Even birthing people who lived in neighboring states faced significantly different out-of-pocket costs when they had a baby. For example, in Wisconsin, birthing people paid $2,250 on average out-of-pocket for delivering the baby, 18% ($345) higher than what birthing people paid on average nationally. In neighboring Illinois, however, a birthing person paid an average of $1,538 out-of-pocket, which is 19% ($367) lower than the national average. Figure 2 shows how overall out-of-pocket spending in each state compared to the national average.
Within Metro Areas, Out-of-Pocket Spending on Childbirth Varies by More than $4,000 on Average
As shown in Table 1, the amount birthing people paid out-of-pocket differed across and even within local metro areas. Across the metro areas studied, average out-of-pocket spending ranged from almost $800 in Flint, Michigan, to nearly $3,000 in Anchorage, Alaska. Within the same state, out-of-pocket spending varied by metro area. For example, across the seven North Carolina metro areas in our sample, the average out-of-pocket cost of delivery in Asheville was nearly double the cost in Durham-Chapel Hill ($2,705 and $1,353, respectively).
Even within most local metro areas, birthing people faced dramatically different out-of-pocket costs, as shown in Figure 3. For example, in San Antonio, out-of-pocket spending at the 90th percentile ($4,800) was more than 300x spending at the 10th percentile ($14). In the Baton Rouge and Houston metro areas, the difference between out-of-pocket costs at the 10th and 90th percentiles were more than 250x, and the difference within the Virginia Beach-Norfolk-Newport News metro area was more than 150x.
Our data show that it cost close to $2,000 out-of-pocket to deliver a baby in the U.S. in 2020. This is higher than families' average monthly spending on housing and more than three months of average spending on food. Our data also show that how much birthing people pay out-of-pocket varies widely depending on where they live and what type of delivery they have (i.e., c-section or vaginal delivery). The variation in out-of-pocket spending we observe reflects a variety of factors, including prices of health care services, benefit design, and intensity of services, including the percentage of c-sections deliveries in the area and the percentage of complicated deliveries.
The wide variation in costs observed across states, within states, and even within local areas, is indicative of underlying issues in the health care system and related markets. Patient out-of-pocket costs reflect overall health care prices, which are negotiated between health insurers and providers (e.g., hospitals). In this context, meaningfully different prices for the same service in the same area are a signal that the market is not functioning in a competitive way and instead, that hospitals with greater market power use their leverage to raise prices without accompanying increases in quality.
For birthing people, this variation makes it very difficult to plan financially for the cost of delivery. People in two parts of the same local metro area might face meaningfully different out-of-pocket costs depending on the specific hospital in which they deliver their baby, even if they have the same type of delivery (e.g., a vaginal birth). Often, individuals may not be choosing the hospital where they give birth; it may instead be based on admitting privileges of or referrals from their physician. In other cases, birthing people may need or want specific services available in a specific hospital (e.g., midwife care) but not be aware that their choice of the hospital may have substantial implications for the bill they receive following their delivery.
Although policy cannot address the full range of challenges new parents may face, the close to $2,000 cost of childbirth and the variation in this cost is something that policymakers can target. Implementing standard payment amounts or out-of-pocket caps for uncomplicated deliveries could help improve the affordability of childbirth for all birthing people in the U.S. and reduce new parents' financial uncertainty allowing them to focus on their and their baby's health and well-being.
Using diagnostic information, we obtained a sample of more than 400,000 admissions for delivery from the 2020 inpatient delivery claims. We linked these inpatient claims with associated professional claims.
We aggregated claims to state/CBSA level and reported on states/CBSAs that had data on deliveries from at least 5 providers in 2020 and performed at least 400 deliveries, including 100 vaginal birth deliveries and 100 c-section deliveries in 2020. Our final analytic sample included 46 states and 136 CBSAs.
Constructing Outcome Measures: Spending per Birth, C-section Rate
We defined a delivery admission by the unique combination of individual, diagnostic related group (DRG), and admission and discharge dates. See the table below for DRGs with descriptions. For each admission, we associated all facility claims with professional claims which occurred during admission and discharge dates.
We measured the out-of-pocket cost per admission as the sum of the amount the member pays for a specific service as defined in their benefit plan, the amount applied to the member's deductible, and the fixed amount the member pays for a specific service. We measured the cost per birth as total out-of-pocket spending divided by a count of admissions for delivery.
Our analysis is limited to the population captured in HCCI's commercial claims dataset. Our data cover over one-third of the population in the U.S. with employer-sponsored insurance, however, our findings may have limited representativeness in some states and CBSAs. In particular, these results do not speak to the childbirth experiences of those on Medicaid or the uninsured. We are also limited to reporting data for areas with enough sample in terms of births and facilities to generate reliable statistics. Therefore, our results may not generalize to more rural regions where births are less frequent. Further, Black and Hispanic individuals are underrepresented in the population with employer-sponsored insurance and thus are underrepresented in this analysis.
Table 4 DRG Classifications for Deliveries
section w sterilization w mcc
Cesarean section w sterilization w cc
section w/o sterilization w mcc
Cesarean section w/o sterilization w cc|
section w sterilization w/o cc/mcc
section w/o sterilization w/o cc/mcc
Vaginal delivery w sterilization/d&c w mcc
delivery w sterilization/d&c w cc
delivery w sterilization/d&c wo cc/mcc
delivery w/o sterilization/d&c w mcc
delivery w/o sterilization/d&c w cc
delivery w/o sterilization/d&c w/o cc/mcc
delivery w o.r. proc except steril &/or d&c