The Cost of Birthing Life

A breakdown of the numbers and personal experience of a medical provider giving birth in an Oregon hospital vs. home.

Young and naive - that is how I felt during my first pregnancy in 2019. Despite growing up very privileged in a suburban middle-class family as a cis-gender female, I was unprepared to navigate how to give birth in the United States. You would think, at the least, my doctorate in nursing would have prepared me to undertake such a task, but I was left in the dark. Not when it came to the actual birthing process but how to financially navigate the large-scale conglomerate that was the hospital I was forced into using. Like most people, I received my insurance from my employer. I had just graduated from my nurse practitioner program and had taken a job at a small local clinic, which I loved. My husband and I were so excited to start our family, so we started trying during the last six months of my doctorate program. Miraculously, it only took two months for a wave of nausea to hit me like a ton of bricks, spurring me to take a pregnancy test. The test, of course, was positive, and we were thrilled. I was additionally insured through my school but knew that would end before my due date. I planned to start working full-time, qualifying me and my husband for insurance through my employer. I cannot recall when I told my employer that I was pregnant, but I do remember being mildly nervous. I had only been working there for a year but felt no urge to look elsewhere, as it seemed like a perfect fit. Two women managed the clinic, so I foolishly assumed that I would be met with excitement and support. However, as many women before have demonstrated with their harrowing stories, it would not go well. 

At first, I was met with enthusiasm, as my maternity leave date was still a far-off reality floating off in the distance. I planned to take three months off to bond with my new little one, which my boss agreed to without difficulty. Off the bat, I was made aware this would be an unpaid maternity leave as they did not offer short-term disability insurance, and paid maternity leave was not a benefit they provided their employees. This was a hard pill to swallow, but I had no choice. I remember kicking myself for not doing more research before trying for a baby. How could I have not planned better? Was this all my fault? As a nurse working for a large hospital, I paid for short-term disability every year as a just-in-case, but I never had to use it. Now that I needed it, it was nowhere to be found.

A few months later, as I was nearing my third trimester, my employers nonchalantly told me they would remove my health insurance coverage during my maternity leave as I would not be working. I remember coming home, tears of fury streaming down my face, venting about the cruelty to my husband. How was I supposed to pay for the hospital bills, postpartum care, or pediatric visits without health insurance? I started to look into my legal rights, realizing that because they are a small company with under 25 employees, they were not required to help me in any way. As I sat and stared at the fine print on my computer, a crushing sense of abandonment took root from my employers and government. I decided to leverage my job, hoping that if they fired me, I would find additional work or at least be eligible for state insurance.

After informing them that I felt uncared for despite being an exemplary employee and that I would seek employment elsewhere, they decided to give me the three months off unpaid but continue my insurance coverage. What saints - but wait, it gets better. The insurance they so generously decided I deserved as a human being bringing another human being into the world was the lowest tier possible. It was associated with one of the significant medical players in the area, making it so that not only was my coverage minimal, but my options on where I could seek care were very limited.  My deductible alone was a staggering $8,000. I would later hear a rumor that one of the female owners joked with staff when picking the plan that no one better get pregnant on this insurance. You may be wondering why I even took this job in the first place. And believe me, I ignored some red flag signs. But despite the mismanagement, the actual clinic was excellent. I met the most inspiring people - both patients and co-workers. One of them is still one of my best friends. But yes, this job was an extensive education in negotiating my future employment contracts. I recall feeling particularly discouraged when thinking I would have been better off financially if I got a large clinic or hospital job. However, as a primary care provider, I was passionate about my patients, NOT feeling like they were cogs in a wheel. I would not accept seeing them back-to-back in 15-minute slots. This is why I chose small medicine; I do not regret it. Thinking back, I am still shocked to this day by the way I was treated. A medical provider caught in the medical complex she fights against every day. 

How It Turned Out

My insurance forced me to choose from one hospital system if I wanted to deliver in a hospital. At the time, due to my medical knowledge, I did not feel safe birthing anywhere else, as my mind could quickly run through too many possible adverse outcomes to feel safe delivering anywhere else. Within their hospital system, I had the autonomy to choose my provider, and opting for the midwifery clinic was easy. I had a wonderful time working with the midwives during my family nurse practitioner program. The reality was awful. I remember waiting an average of 45-60 minutes after my appointment time EVERY VISIT. Can you imagine the amount of hormones surging through my body as I am waiting for my midwife? I kept thinking how rude and disrespectful that was as a provider. If I know I will be more than 10-15 minutes late for my patient, I either check in with my next patient or have my medical assistant check in, offer a different visit time, and give them an ETA. When I asked them about this, they said, “Well, we would offer you the same amount of time if needed.” Well, guess what? I never needed it, so that doesn’t help now, does it?

On top of that, there were somewhere between eight and twelve midwives, so I rarely met with the same one. They wanted me to meet with all of them as they did not know who would be on call the day I delivered. I’m not saying that was a bad plan, but go figure the night I delivered, I had the only midwife I had never met. And he was a male. Yes, you read me correctly. I signed up to be in the care of women and, in my most vulnerable state, was given a man I had never met before.

When the time came for me to deliver, it was 10 PM when my water broke, and my husband drove me straight to the emergency department. I was wheeled immediately up to the delivery ward and waited until they confirmed it was amniotic fluid. After confirmation, I transferred to a sizable delivery suite, where I briefly met my midwife before he disappeared. My RN was extraordinary, and I am grateful for her caring demeanor. However, she was busy, which is why I am a strong advocate for doulas. My best friend happens to be one of the best doulas in Portland. She was seriously a godsend as she walked me through positioning, breathing, and offering a calming female presence that, to no fault of my husband, he could not provide.

My labor was swift, and by 1:15 AM, I was holding my little boy in my arms. Unfortunately, I had a 2nd-degree vaginal tear and spent the next 2 hours in stirrups while my midwife sewed me up. That time was such a blur, but after I got the most delicious burger I had ever had, my family came in to meet our little one. The room was spacious, and they were ecstatic, passing him around from one loving set of arms to the next. Once everything calmed down and people went home to crawl into their beds, we were transferred to the maternity ward around 6 AM. We left our spacious delivery room for a tiny room that barely fit a bench for my husband, a hospital bed for me, and a bassinet for my son. I remember asking if I could go home, but they said they recommended I stay as my son’s blood sugars were running mildly low. He was doing great, but they continued to come in hourly to prick his heel. For the next 24 hours, I was in and out of a sleepy stupor nursing my son. I remember wondering where the heck all the nurses were. We were honestly just left there unless a test needed to be performed. When discharge came the following day, I was ready to go. I will admit I was exhausted, but I genuinely don’t recall being given any instructions surrounding my vaginal delivery or tear. I went home and did what moms do, including getting out of bed on day one. I thankfully had a fantastic support system of friends and family, so I did not have to do nearly as much as some moms, but I still did not give my body any strict precautions. 

I woke up the following day with excruciating pain over my vaginal tear. Taking a mirror, I looked at my incision to find I had a quarter-sized purple area of swollen tissue between my stitches. I called the nursing line, and they said to come for a same-day evaluation. On top of this pain, I was also experiencing an allergic reaction to the MMR vaccine I was given on discharge. My eyes and face were swollen, I couldn’t sit, and I was still so puffy from all of the fluids I was given in the hospital. I have a picture of me giving my husband a thumbs up, and it may be the worst-looking picture of me on the face of this earth. The cherry on top was that I was also having nursing issues. 

The ride to the hospital was excruciating as I literally could not sit. I got there to find out it was a vaginal hematoma which is a common complication of vaginal tears. However, it was too small for them to drain it. They told me it would go away and to come back if it didn’t or it got worse. We then went straight to our lactation consultant appointment, where my little guy was able to latch with the magical powers of a nipple shield.

The rest of my maternity leave was a haze. To this day, people will ask me how we did XYZ, and I will genuinely say I have no idea. I was so thankful that my husband and I had enough savings to allow me to stay home for the whole three months. We put the accrued healthcare debt on a monthly payment plan for $153 for the next two years, as medical debt does not accrue interest. We were held accountable for a total of around $3,855.97. Miraculously, my little guy decided to come early, and I was admitted on the last day of my school’s insurance! The double coverage ended up saving us $4,000. I cried happy tears when we got our first bill. Thinking maybe we could have another child in the future if we wanted. The next time, I would be prepared, or so I thought. 

Round Two

Fast forward to 2023 - my husband and I were surprised when that same wave of nausea hit me again. We wanted a second child; however, we were about six months from “pulling the goalie.” But life always has its own timeline. I was so excited yet filled with dread at the prospect of telling my employer. My love of small medicine placed me in a similar environment to where I was in 2019. I was technically an independent contractor and had been waiting for W2 status. As an independent contractor, I did not qualify for maternity leave payment, short-term disability, or employer-offered insurance. I had bought insurance through the state marketplace, but it was costly. My husband and I were paying around $900 monthly for him, my son, and myself for a Regence plan with a deductible of $6500 (my husband is also an independent contractor). Although it was a middle-tier plan, I had not vetted the maternity benefits as I was still on birth control. However, I had been down this road before and reminded myself that it could be worse. I went to therapy, and my therapist helped me draft an e-mail to break the news to my employer. My employer conveyed excitement and promised support through this journey. I remember thinking, sure until it came down to giving me time off. When the time came to discuss that I would like to take a full three months off, my employer told me he would like to re-negotiate my contract to cover my maternity leave. I was shocked and hesitantly agreed to the update, the feeling of relief washing over me like the ocean waves on a hot summer day. Knowing I would receive paid leave enabled me to explore different maternity care options this time.

Aware of my high deductible, I explored alternatives, specifically home delivery. My first pregnancy was so fast that I was very nervous that I would not even make it to the hospital for my second delivery. I interviewed two midwives in the Portland area and immediately felt a kinship with Sarah Mcclure, CPM, LDM, LM, of Home and Hearth Midwives. She spent 30 minutes listening and answering my questions during a consultation. At one point, I was brought to tears when she said, “It sounds like you could have used some more TLC during your first pregnancy and delivery.” I felt so heard and knew I wanted to continue with this team for my obstetrics care as I felt less nervous the second time knowing full well my body's capabilities. 

Being a student of science statistics brings me comfort. Home birth for women with low-risk pregnancies has very similar outcomes to those with similar pregnancies who give birth in the hospital setting (Hutton et al., 2019). There are even some studies that have shown there is a decreased risk of perineal tearing, cesarean delivery, and bleeding (Scarf et al., 2018). I was also aware that since I was able to have a vaginal delivery with my first pregnancy, I was more likely to have a successful vaginal delivery with my second. 

Additionally, I felt set up for success since I was lucky enough to have a large bathtub in my home where I would be able to give birth. The midwives were very upfront about the cost from the beginning. They charged an overall fee of $6,200, cheaper than my deductible. This balance did not include ultrasounds or blood work,  but I could utilize my insurance to cover those costs. Home and Hearth were out of network, along with all the other in-home midwives I looked into, so insurance did not cover them. Home and Hearth gave me a super bill to submit to my insurance company so that I could meet my deductible for the year, making any future care more affordable. However, my insurance informed me they would not take this bill as I don’t have out-of-network benefits. Their denial still baffles and infuriates me. I hoped to do a mini mommy makeover after my second and last baby. This makeover would include pelvic floor therapy, a hemorrhoidectomy (if you know, you know), and consulting with a specialist to address some other benched health concerns. But since they did not accept the super bill, those things inevitably went to the end of my to-do list because I was not motivated enough to spend money on them after recently paying for my entire pregnancy. The kicker is how much money I saved them. The average cost of a non-complicated vaginal hospital birth in the United States seems to vary greatly, but estimates range from $ 10,000 to $20,000 before insurance. The average amount due by the individual post insurance is anywhere from $2,500 to $8,000 (Health System Tracker, 2023). How can women and families prepare when no one can estimate accurately? Also, the cost can skyrocket at the first sign of complications. Regardless, let’s say I was conservative and saved them $10,000 while still paying them $900 monthly for my premium. Yet, they still refused to accept my superbill and waive my deductible for the year. How in the world is that justifiable? The truth is it’s not; it’s gross, which is one of the main reasons I am writing this article here. 

My obstetric care with Home and Hearth was such a fantastic experience. They were ALWAYS on time. Not only that, but they set aside one full hour for our appointments. I felt spoiled, which honestly is crazy, but this is just unheard of in our current medical system. They had an on-call phone for any urgent concerns and would always reply quickly to e-mails with non-urgent questions. The package included two of them to be present with me at my birth at home. I decided not to have a doula this time as I felt their support and the knowledge I gained from my first birth were enough. However, I cannot stress enough how valuable doula care is in pregnancy. At 36 weeks, they did a home visit to ensure everything was ready for the big day. We all thought I would have an early baby, but my cozy girl waited until 41 weeks to appear on our side of the world. There were quite a few false alarms, but on the day she came, I had been having contractions all morning. I had been in for a membrane sweep which is where the midwife inserts her finger into the vagina and sweeps away the mucous at the cervix. Membrane sweeps can often stimulate labor, and sure enough, later that day, my contractions became more consistent. I was bouncing on my ball and watching reality TV around 430 PM when my husband came to check on me. He started to time my contractions, and by 5 PM, they were five minutes apart.

We called Home and Hearth, and they said they would be at our home by 6 PM. I had gotten in the bathtub and enthusiastically told them I felt much better. To which my other midwife, Charli Zarosinski, CMP, LDM, LM, replied, yes, but I need you to get out and sit on the toilet for at least an hour so you don’t slow down labor. I reluctantly agreed and got out of the bath. I turned up the Taylor Swift Eras Tour playlist loud enough to hear over my pain and went into an alternate reality. I was singing and breathing to get through the contractions. Sarah and Charli arrived on time and began preparing everything, encouraging me that I was doing an excellent job. I remember feeling like I was having an out-of-body experience during my labor. Pain can take your mind to different places, and I truly felt a spiritual presence during my laboring. I started to cry as I recalled all the loss my family and I had experienced over the last few years. I felt the family we had lost help me usher this new life into the world while silent tears trickled down my face. 

Once an hour passed, the contractions started to get more intense. I asked if it was bath time, and they said if I was ready, that was perfect. I was AMAZED at the ability of the water to help control my pain. I immediately felt the urge to push in the water. I pushed in the tub for about 45 minutes with Charli periodically monitoring my girl’s heart rate. Toward the end, she recommended that I come out of the tub to change positions as the monitor showed some changes in my girl’s heart rate. I got on my knees in my tub to get out, but she asked if I could feel her head before I could stand. I reached down and touched her soft head of hair. I looked up and said I think I can do this. She told me to go for it. With one final push, I was able to help guide my little girl out of me through the water and onto my chest. My husband was there filming the beautiful, wild process. She was perfect. And we had the most wonderful time taking each other in for the first time in the warm water. 

After acclimating, my husband took our newborn daughter, along with Charli, for a quick evaluation and cleanup. Sarah helped me get into the shower because all the body fluids you could ever think of were in that tub. But I honestly barely noticed. The hot shower felt amazing, but more remarkable was the feeling of crawling into my own bed. Charli and Sarah performed a vaginal exam while I held my daughter. Unfortunately, I did tear again, in the same place I tore with my son, but it was very superficial. The tear I endured during my first pregnancy was botched. I had to have reconstructive surgery on my outer labia and musculature as my male midwife left me with chronic irritation. It only took 15 minutes for my midwife to stitch me up. They recommended bedrest for one week but would be monitoring our progress closely.

My family and close friends had been downstairs during the whole process. They slowly made their way up to greet the new addition to our family. It was amazing to have these essential people present and comfortable while they awaited my little girl's arrival. They were having a party with food and music downstairs, eagerly awaiting my daughter's first cry. It was a different experience for them than the sterile hospital lounge. 

Sarah and Charli quietly retreated after we were all tucked in and promised to return in 24 hours. The care I received in the following two weeks at home was incredible. I did not have to stress about making pediatric visits or hauling my sore self to appointments. I was on bed rest for a total of ten days, and I healed so much faster than I did with my first delivery. Bedrest would not have been possible without my husband, family support, and Netflix. After the first couple of weeks, my girl and I went to their office to meet them. She did not need to establish a relationship with her pediatrician until eight weeks. They offered everything done by the hospital minus a hearing test, which we could get covered for free at a clinic down the street from my house when she was a bit older. They were fully present for both me and my daughter the entire time, which genuinely changed my whole birthing experience. 

Is It Even a Comparison?

Writing down these two very different experiences on paper continues to boggle my mind about the stark differences in care and cost. Home birthing is not for everyone, but our society has taken options away from women in so many ways, including the birthing process. The good news is that many insurance companies have started recognizing midwifery care at home as a viable option and offering full coverage for these amazing services. Although that was not the case for me, Home and Hearth informed me that many women they work with can get amazing reimbursement for their services, some even with full coverage. Although I did want to highlight the ridiculous cost women experience when dealing with populating the earth, I would never want this to deter anyone from looking fully into their benefits. I hope this article empowers women to know that they can reclaim autonomy over their birthing decisions. Call your insurance and look into all your options. Ask around and seek out other women who may have personally worked with the entities you are looking at. Advocate for yourself with your employer or your partner's employer. As women and as mothers, we do so much. If we persist in challenging the current medical and economic systems, perhaps when our daughters prepare for this experience, they will face fewer obstacles. 

Sources

Health System Tracker. (2023, June 30). Health costs associated with pregnancy, childbirth, and postpartum care. Health System Tracker. https://www.healthsystemtracker.org/brief/health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/

Hutton, E. K., Reitsma, A., Simioni, J., Brunton, G., & Kaufman, K. (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. EClinicalMedicine, 14, 59–70. https://doi.org/10.1016/j.eclinm.2019.07.005

Scarf, V. L., Rossiter, C., Vedam, S., Dahlen, H. G., Ellwood, D., Forster, D., Foureur, M. J., McLachlan, H., Oats, J., Sibbritt, D., Thornton, C., & Homer, C. S. E. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis. Midwifery, 62, 240–255. https://doi.org/10.1016/j.midw.2018.03.024