LACONIA, N.H. -- Seven months' pregnant, at a time when most expectant couples are stockpiling diapers and choosing car seats, Renee Martin was struggling with bigger purchases.
At a prenatal class in March, she was told about epidural anesthesia and was given the option of using a birthing tub during labor. To each offer, she had one gnawing question: "How much is that going to cost?"
Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip through the American health care bazaar, sorting through an array of maternity services that most often have no clear price and -- with no insurer to haggle on their behalf -- trying to negotiate discounts from hospitals and doctors.
When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. "It was unreal," Ms. Martin said. "I was like, How could you not know this? You're a hospital."
Midway through her pregnancy, she fought for a deep discount on a $935 bill for an ultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician's time using a machine that had been bought years ago. She ended up paying $655. "I feel like I'm in a used-car lot," said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.
Like Ms. Martin, plenty of other pregnant women are getting sticker shock in the United States, where charges for delivery have about tripled since 1996, according to an analysis done for The New York Times by Truven Health Analytics. Childbirth in the United States is uniquely expensive, and maternity and newborn care constitute the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs. The cumulative costs of approximately 4 million annual births is well over $50 billion.
And though maternity care costs far less in other developed countries than it does in the United States, studies show that their citizens do not have less access to care or to high-tech care during pregnancy than Americans.
"It's not primarily that we get a different bundle of services when we have a baby," said Gerard Anderson, an economist at the Johns Hopkins School of Public Health who studies international health costs. "It's that we pay individually for each service and pay more for the services we receive."
Those payment incentives for providers also mean that American women with normal pregnancies tend to get more of everything, necessary or not, from blood tests to ultrasound scans, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies the cost of women's health care.
Financially, they suffer the consequences. In 2011, 62 percent of women in the United States covered by private plans that were not obtained through an employer lacked maternity coverage, like Ms. Martin. But even many women with coverage are feeling the pinch as insurers demand higher co-payments and deductibles and exclude many pregnancy-related services.
From 2004 to 2010, the prices that insurers paid for childbirth -- one of the oldest and most universal medical encounters -- rose 49 percent for vaginal births and 41 percent for cesarean sections in the United States, with average out-of-pocket costs rising fourfold, according to a recent report by Truven that was commissioned by three health care groups. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying out an average of $18,329 and $27,866, the report found.
Women with insurance pay out of pocket an average of $3,400, according to a survey by Childbirth Connection, one of the groups behind the maternity costs report. Two decades ago, women typically paid nothing other than a small fee if they opted for a private hospital room or television.
The Catalyst for Payment Reform, a California policy group, has proposed that all hospitals should offer such bundled prices and that rates should be the same, no matter the type of delivery. It suggests that $8,000 might be a reasonable starting point. But that may be hard to imagine in markets like New York City, where $8,000 is less than many private doctors charge for their fees alone.
One factor that has helped keep costs down in other developed countries is the extensive use of midwives, who perform the bulk of prenatal examinations and even simple deliveries; obstetricians are regarded as specialists who step in only when there is risk or need. Sixty-eight percent of births are attended by a midwife in Britain and 45 percent in the Netherlands, compared with 8 percent in the United States. In Germany, midwives were paid less than $325 for an 11-hour delivery and about $30 for an office visit in 2011.
Starting next year, insurance policies will be required under the Affordable Care Act to include maternity coverage, so no woman should be left paying entirely on her own, like Ms. Martin. But the law is not explicit about what services must be included in that coverage.