Childbirth is the most common cause for inpatient admission in the United States while Cesarean section (C-section) is the most common operating room procedure conducted during inpatient hospital stays. However, according to data from a recent Health Care Cost Institute (HCCI) report, the cost of childbirth can vary greatly depending on which state the birth takes place in. The procedure can cost roughly $8300 in Arkansas, while that total rises to nearly $20,000 in New York.
Researchers analyzed data from over 350,000 commercially insured deliveries across 35 states between 2016 and 2017. Using allowed amounts, researchers determined the cost of childbirth, defined as the combination of all insurer and patient out-of-pocket spending. Facility and professional claims associated with each inpatient admission were combined to determine total cost.
The average national cost of childbirth admission for an individual with employer-sponsored insurance was $13,811. When it comes to out-of-pocket spending, the average amount ranged from around $1000 in Washington, D.C., to roughly $2500 in South Carolina. Variations in both the cost of childbirth and benefit design accounted for the wide range of out-of-pocket expense totals.
Data show the main driver of geographic spending variation was the difference in the cost of a vaginal birth. “In general, California and northeastern states had higher spending per vaginal birth compared to midwestern and southern states. These differences in average spending per vaginal delivery could be due to a combination of variation in provider prices and the intensity of cases presenting in different states,” the researchers said.
In contrast, births via C-section, a more intensive surgical procedure, are typically associated with longer, more expensive admissions. The investigators found overall spending on C-section deliveries depend in part on the frequency with which the procedure occurs in each state.
Of the data collected, C-sections accounted for nearly 33% of births, while the remaining 67% consisted of vaginal births.
Although the procedure can be lifesaving for women and newborns when complications occur, such as bleeding, fetal distress, hypertensive disease, and infants in abnormal positions, C-sections are associated with complications in future births and are not without risk. The surgery is also associated with adulthood obesity, diabetes, respiratory infections, and delay in microbiota development.
Around the world, C-section births nearly doubled from 12% to 21% of all births between 2000 and 2015. But according to the World Health Organization, the recommended C-section rate is just 10%.
HCCI data show the C-section rate ranges from 20% in Utah to 39% in Florida, with it most often fluctuating between 25% and 35% in most states. “Southeastern and northeastern states had some of the highest C-section rates compared to C-section rates in the Midwest and West.”
Rising rates of often unnecessary C-sections may lead to increased overall costs. “Among our 2016 and 2017 pooled sample of people with employer-sponsored insurance, average spending per vaginal birth nationally was $12,235. Average spending per C-section, in contrast, was $17,004,” the researchers said.
Differences in spending per vaginal birth and C-sections were measured in each state. Despite all states reporting higher spendings on C-section, the gap widened and narrowed depending on the region. “States with higher spending per vaginal birth tended to have greater differences in per procedure spending between vaginal births and C-sections,” the researchers said.
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Postpartum Care Costs
“Such geographic variation should encourage policy makers to think beyond national policies and address the needs of pregnant people at a regional or state level,” they noted. The findings also underscore the importance of variations in provider childbirth price to curb the cost of birth based on geographic location.Although high out-of-pocket and insurance spending is associated with childbirth, many mothers may incur additional costs when it comes to receiving postpartum care. Postpartum complications can include psychological conditions, such as postpartum depression, which affects approximately 1 in 8 women in the United States. In addition, many birth parents experience physical ailments in the months following birth, such as infection, cardiomyopathy, other cardiovascular conditions, and cerebrovascular accidents that can lead to death.
From 2000 to 2014, the maternal mortality ratio in the United States increased from 9.8 to 21.5 deaths per 100,000 live births. The crisis is especially acute among African American mothers, who are 3.5 times more likely to die in childbirth, or shortly afterward, than white women, according to the CDC.
According to the HCCI authors, “More than half of pregnancy-related deaths occur in the postpartum period, with nearly 12% of those (for which timing was known) occurring between 6 weeks and the year after delivery.”
Due in part to increasing maternal mortality in the United States, the American College of Obstetricians and Gynecologists recommends birthing parents receive comprehensive physical, social, and psychological care during the postpartum period.
A separate HCCI report details postpartum spending on commercially insured birth parents throughout the full year after birth. Researchers found that “although nearly 20% of overall postpartum spending was in the first 60 days, and almost 30% of spending was in the first 90 days, approximately 70% of spending occurred over the rest of the year.”
Data showed per person spending was slightly above $3100 over the course of 1 year after birth and that higher average spending was associated with birthing parents over the age of 45.
Surgery accounted for the largest percentage of postpartum health care spending (26%) followed by emergency department and ambulance services (17%) and evaluation and management services (12%). According to the authors, these percentages highlight the critical role insurance coverage pays in individuals’ ability to access and afford care in the year following childbirth. However, they note that in many states, birthing parents' access to Medicaid coverage ends after 60 days.
“The care that parents receive before, during and after childbirth represents a substantial proportion of national health care spending and utilization,” said Niall Brennan, president and CEO of HCCI. “Better information about how and when new parents use care can help drive improvements in quality and value.”