Make Birth Free
Bioethics in Law & Culture Winter 2023 vol. 6 issue 1
Catherine Glenn Foster, M.A., J.D.
President/CEO of Americans United for Life
Executive Director of Democrats for Life of America
We are in awe of America’s mothers. Every day, a mother gives her heart unreservedly to her family. She leads with love for her children and her family.
But the American family is threatened. We all feel it. Everyday costs are skyrocketing. Marriage, and especially family, increasingly seem like luxuries. Many feel as though they cannot afford to have a child, particularly when the costs of pregnancy, birth, and post-natal care are exorbitantly expensive. The average cost of childbirth in the United States is nearly $19,000, and even privately insured mothers will likely pay more than $3,000 out-of-pocket simply for delivery.
Today, the American dream is out of reach for too many. Too many couples feel they cannot start or grow their families because of our disordered politics and warped economy. The existing model that erects barriers to family formation and imposes dizzying costs for childbirth is both unworkable and untenable.
Now is the time to make it obsolete. To change the future, we need a new model, a better paradigm.
Birth in the United States of America should be free.
The Cost of Childbirth
Childbirth is the number one reason for hospitalization in the United States, and that hospital visit can be extremely pricey. A recent study by the American Academy of Pediatrics found that between 2016 and 2019, one in six privately insured moms were on the hook for more than $5,000 in out-of-pocket expenses. Costs are even higher for families whose babies need to be treated in the neonatal intensive care unit (NICU), and one in eleven of those families paid more than $10,000 out-of-pocket for the birth of their baby.
Maternity care in the United States is uniquely expensive. Childbirth costs far less in other developed countries and comprehensive maternity care is free or cheap for all. Ireland, which boasts one of the lowest maternal mortality rates in the world, guarantees free maternity care at public hospitals. In Finland, it is “almost free” to have a child and “giving birth is a family affair that emphasizes the mother and baby’s well-being.” Unsurprisingly, it is also one of the safest countries for a baby to be born, with extremely low infant mortality.
Mothers in the United States, however, face staggering medical bills for labor and delivery. According to Elizabeth Bruenig’s reporting in The Atlantic, “a hospital in Texas charged one couple north of $10,000 for labor and delivery, with some $3,000 paid out of pocket in the run-up to the due date, and another $1,500 charged after the birth; in Indiana, a high-risk delivery this year totaled more than $24,000; in Colorado last year, a hospital sent a mother a $14,000 bill for her uncomplicated hospital delivery without so much as an epidural, $5,000 of which she was forced to pay out of pocket.”
Given the average cost of childbirth and the approximately 3.6 million annual births in the United States, a basic program to Make Birth Free would cost about $68 billion. But 42% of U.S. births are already financed through Medicaid, meaning that only $39.5 billion of that amount would be new spending. (This is approximately equal to the amount spent in 2022 to modernize transit.) If an additional $60 billion were allocated to assist with perinatal care, baby supplies, and expanded paid leave under the federal Family Medical Leave Act program, the total additional cost to Make Birth Free in America would still be less than $100 billion per year. (This is approximately equal to the amount of aid spent  to support Ukraine in 2022.)
Although this spending is significant, it represents a mere fraction of the federal budget. The federal government spends nearly two and a half times more on education and more than sixteen times more on healthcare overall. America’s mothers and infants are worth the marginal spending increase it would take to Make Birth Free. There is no better investment than healthy mothers and a thriving next generation.
Making Birth Free To Mothers Would Also Make Childbirth More Cost-Effective
A comprehensive program to Make Birth Free would also reduce pregnancy and childbirth costs overall, making the program more cost-effective over time. This is because many of the sticker costs associated with pregnancy and childbirth result from misaligned financial incentives for healthcare providers.
For example, hospitals frequently charge higher rates for C-section births than vaginal deliveries—usually around 30% more. But these prices charged to families and insurers rest on crude generalizations that do not reflect the true cost to the healthcare provider. Indeed, the more physicians are paid for C-sections compared to vaginal delivery, the higher the c-section rate, and vice versa.
By requiring hospitals to provide births free of charge to the consumer and reimbursing them equally for C-Section and vaginal deliveries, Make Birth Free can address disconnects in the marketplace and align incentives with desired outcomes. This in turn improves patient outcomes—the medical consensus shows that C-sections, on average, entail greater risks of infection, blood loss, and other complications—while simultaneously reducing the price of childbirth, in both the short and long term.
In the short term, maternity costs—including those related to longer hospital stays and operating room use—decline because unnecessary C-sections are deterred. And because women who have C-sections are vastly more likely to have C-sections in subsequent pregnancies, the initial avoidance of unnecessary surgery reduces future childbirth costs as well, reducing costs to Make Birth Free in the long term. As economists have argued, policies that reduce unnecessary C-sections in the first instance can significantly reduce overall healthcare costs for childbirth.
To take another example, Make Birth Free can incentivize the use of midwives and doulas for pregnancies where there are no complications or serious risk factors. Under the current system, midwives attend only 8.3% of U.S. births. Studies indicate that midwives tend to be less expensive, decrease the risk of C-section and preterm birth, and are well-equipped to safely perform most births with higher patient satisfaction. Indeed, many countries with low infant and maternal mortality rates center midwives at the core of their healthcare delivery to expectant mothers. By expanding reimbursement to providers like doulas and midwives and incentivizing home-births and delivery at birthing centers, a federal program to Make Birth Free can lead to significant savings, better patient outcomes, and a more humane experience for mothers and families.
Why free? Why not create a subsidized or means-tested program to reduce costs for pregnancy and childbirth? Although such policies might improve the existing model, they will not achieve the same benefits. Administrative burdens, such as learning costs (to navigate complex bureaucratic systems) and compliance costs (time spent completing paperwork and collecting documentation, transportation, lost wages, child care, etc.), impose significant barriers to those seeking assistance. Many mothers and families would fail to participate due to the administrative burdens involved. A free birth paradigm is an accessible and easily administrable one.
Making Birth Free Is Good Social Policy
In addition to correcting marketplace disconnects and misaligned incentive structures, free pregnancy and childbirth would improve maternal and infant health outcomes. These effects are not limited to reduced C-sections and expanded use of midwives: High costs deter women from seeking or obtaining prenatal and postpartum care, delaying identification of high-risk pregnancies or intervention to treat complications from birth. Uninsured and underinsured patients, as well as Medicaid recipients whose postpartum coverage ends shortly after birth, face life-threatening barriers to care simply due to cost.
Indeed, a 2020 Commonwealth Fund report identified these barriers as a significant contributing factor to maternal mortality in the United States, which is far higher than peer countries that spend more on mothers and infants. The U.S. maternal mortality rate in 2020 was 23.8 deaths per 100,000 live births, while Canada’s was only 8.3. Tragically, infant mortality rates in the United States are also higher. In 2020, the infant mortality rate in the United States was 5.4 deaths per 1,000 live births, while in Canada it was 4.4. By removing barriers to prenatal and postpartum treatment, physicians will be able to identify and prevent complications earlier, protecting the health and safety of both mother and child.
Make Birth Free enables mothers to make the choice for life. Whether pro-life or pro-choice, everyone should agree that no woman should feel coerced into choosing abortion as her only or most cost-effective option. According to several analyses, women rank concerns about financial preparedness as their top reason for choosing abortion. The pro-abortion Guttmacher Institute asserts that three-quarters of women seeking abortion listed financial affordability as a reason for obtaining an abortion.
In other words, pregnant women in the United States often lack real and effective choices when making decisions about birth. And even families that have health insurance are often surprised to learn that contraceptives and even abortions are often covered, but childbirth is not. (For instance, Affordable Care Act-compliant insurance plans currently make contraceptives co-pay free, but not prenatal care such as ultrasounds.) This economic coercion belies the claim that abortion is the result of a woman’s free and autonomous decision. Abortions compelled by external social and economic factors should be unacceptable in any society. Natural experiments in countries like Italy, Spain, and Russia have shown that removing financial barriers to childbirth can reduce abortion rates. Improving healthcare accessibility by addressing problems of economic coercion may also help resolve well-known challenges in the United States of socioeconomic and racial disparities in the patient experience that can reinforce the perceived necessity of abortion. By making birth free, Americans can transcend the politics of abortion partisanship and enable mothers to make the choice for life.
The economic coercion inherent in the current healthcare system prevents women from achieving their dreams. American women consistently say they want to have more children than they actually have. Yet our present cultural reality is not serving what women say they want: “the gap between the number of children that women say they want to have (2.7) and the number of children they will probably actually have (1.8) has risen to the highest level in 40 years.” Financial concerns are one of the leading causes preventing men and women from creating the families they say they want. The economic conditions that discourage men and women from starting families or from having another child create social realities that threaten America’s future.
Encouraging mothers and families to make the choice for life is an important investment in America’s future. Human beings are a nation’s most precious natural resource. Human beings are not mere consumers of scarce resources, but rather natural and equal contributors toward America’s common good. Human beings are creative producers of new and innovative technologies, medicines, and businesses. Men and women are more than mouths; they are minds, with limitless capacity for innovation. Yet the total fertility rate in the United States—a measure of the average number of children born to a woman over her lifetime when present fertility rates and lifespans are held constant—has declined to record lows. If sustained, fewer Americans will be born each year than will die, leading to negative population growth.
The economic and social impacts of fewer and fewer youth are massive, not least for states whose tax base will be too small to satisfy liabilities. Public finances and workforce stability are at risk from declining populations. This is not to say that making birth free would alone solve these challenges. But it would certainly help: A five-year RAND health insurance experiment found that women assigned free medical care experienced 29% more births than those assigned to a high-deductible plan. Make Birth Free would remove a significant financial hurdle to childbirth, helping to fuel the engine of American economic growth and investing in the human capital essential to national security and prosperity.
A Roadmap to Congressional Legislation
America has faced similar challenges before and risen to the challenge. There is precedent for Make Birth Free, and it has worked effectively for almost 50 years. Launched during the Nixon administration, the Medicare End-Stage Renal Disease (ESRD) program covers the cost of dialysis and kidney transplants for patients of all ages, even those who would not typically qualify for Medicare benefits.
This expansion of Medicare was extremely successful: studies show that the costs associated with end-stage renal disease have been contained better than those of healthcare generally, partly because the ESRD program created a system of incentives that involves physicians in the medical marketplace and encourages cost-control. Similar healthcare initiatives have required plans and insurers to cover—at no cost to the insured—preventive healthcare costs, including qualifying COVID-19 preventive services and even HIV-preventive (PrEP) services.
A similar program could Make Birth Free for every American mother. Elements of a comprehensive plan to Make Birth Free could include:
Exempting prenatal and birth-related expenses from deductibles and co-pays in public and private insurance plans compliant with the Affordable Care Act, much as preventative care is exempted under the existing healthcare system.
Adapting innovative Medicare/Medicaid policy precedents such as those for dialysis and HIV treatment to provide mothers in America with comprehensive prenatal, childbirth, and postpartum care. This approach would eliminate the reimbursement disparity between C-section and vaginal births, and create financial incentives to use midwives and doulas or choose home-birth or birthing centers. States would also be required to extend Medicaid’s postpartum coverage cut-off from 60 days to a minimum of 1 year after birth.
A monthly maternal stipend equivalent to a social security monthly payment for the first two years of a child’s life. The stipend would come with no strings attached so that families can use the money however they wish to address their family’s needs.
Making birth free to American mothers can and should be a national unifier in a particularly divided time. Together, we can rise above the rancor of partisanship, leaving behind the disproportionate financial burdens imposed on mothers and families and forging a new path that transcends the existing paradigm. Together, we can invest in the American family and promote the choice for life by making birth free. Any candidate seeking federal office in 2024 must be expected to support that investment.
Let’s empower American families and encourage a thriving future for the next generation. Let’s make law and policy that affirms and uplifts every American mother and child. Let’s Make Birth Free.
 Ceron, Ella, “Want to Have a Baby in the US? Get Ready to Pay a Big Bill,” Bloomberg, July 13, 2022, retrieved at https://www.bloomberg.com/news/articles/2022-07-13/how-much-does-it-cost-to-have-a-baby-in-the-us.
 Chua, Kao-Ping, et al, “Out-of-Pocket Spending for Deliveries and Newborn Hospitalizations among the Privately Insured,” Pediatrics, Volume 148, Issue 1, July 2021, retrieved at https://publications.aap.org/pediatrics/article/148/1/e2021050552/179972/Out-of-Pocket-Spending-for-Deliveries-and-Newborn?autologincheck=redirected.
 Stieg, Cory, “It’s Almost ‘Free’ to have a Baby in Finland – And Feels Like ‘The Whole Country is Providing for the Child,” CNBC, February 22, 2020, retrieved at https://www.cnbc.com/2020/02/21/why-finland-is-the-best-place-to-give-birth-childbirth-costs-compared.html.
 Durando, Jessica, “These are the Safest Countries for a Baby to be Born,” USA Today, February 20, 2018, retrieved at https://www.usatoday.com/story/news/world/2018/02/20/these-safest-countries-babies-born-unicef/355217002/.
 Bruenig, Elizabeth, “Make Birth Free,” The Atlantic, July 9, 2022, retrieved at https://www.theatlantic.com/ideas/archive/2022/07/post-roe-pro-life-parental-support/661473/.
 “Delivering Results from President Biden’s Bipartisan Infrastructure Law”, White House, retrieved at https://www.whitehouse.gov/build/.
 Wasson, Eric, “Congress Clears $1.7 Trillion Funding Bill with Ukraine Aid,” Bloomberg, December 22, 2022, retrieved at https://www.bloomberg.com/news/articles/2022-12-22/senate-passes-giant-spending-bill-with-ukraine-aid-election-change?leadSource=uverify%20wall#xj4y7vzkg.
 Pallero, Bianca, and Parlapiano, Alicia, “Four Ways to Understand the $54 Billion in US Spending on Ukraine,” New York Times, May 20, 2022, retrieved at https://www.nytimes.com/interactive/2022/05/20/upshot/ukraine-us-aid-size.html.
 Hoelle, Tara, “Your Biggest C-Section Risk May be Your Hospital,” Consumer Reports, May 10, 2018, retrieved at https://www.consumerreports.org/c-section/biggest-c-section-risk-may-be-your-hospital/.
 Oster, Emily and McClelland, W. Spencer, “Why the C-Section Rate is so High,” The Atlantic, October 17, 2019, retrieved at https://www.theatlantic.com/ideas/archive/2019/10/c-section-rate-high/600172/.
 Moynihan, Donald, et al, “Administrative Burden: Learning, Psychological, and Compliance Costs in Citizen-State Interactions”, Journal of Public Administration Research and Theory, Volume 25, Issue 1, February 27, 2014, retrieved at https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer
 “Maternal Mortality in the United States: A Primer”, The Commonwealth Fund, December 16, 2020, retrieved at https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer
 Hoyert, Donna, “Maternal Mortality Rates in the United States, 2020”, CDC, retrieved at https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm.
 Biggs, M Antonia, et al, “Understanding Why Women Seek Abortions in the US,” BMC Women’s Health, July 5, 2013, retrieved at https://www.statista.com/statistics/806726/infant-mortality-in-canada/#:~:text=In%202020%2C%20the%20infant%20mortality,deaths%20per%201%2C000%20live%20births.
 Chae, Sopia, et al, “Reasons Why Women Have Induced Abortions: A Synthesis of Findings from 14 Countries,” Contraception, Volume 96, Issue 4, October 2017, retrieved at https://www.sciencedirect.com/science/article/pii/S0010782417301889.
 Sobotka, Tomas, et al, “Policy Responses to Lo Fertility: How Effective Are They?,” UNFPA, May 2019, retrieved at https://www.unfpa.org/sites/default/files/pub-pdf/Policy_responses_low_fertility_UNFPA_WP_Final_corrections_7Feb2020_CLEAN.pdf.
 Stone, Lyman, “American Women Are Having Fewer Children than They’d Like,” New York Times, February 13, 2018, retrieved at https://www.nytimes.com/2018/02/13/upshot/american-fertility-is-falling-short-of-what-women-want.html.
 “Americans are having Fewer Babies. They Told Us Why,” New York Times, July 15, 2018, retrieved at https://www.tampabay.com/news/nation/Americans-are-having-fewer-babies-They-told-us-why-_169763913/.
 “The Long-Term Decline in Fertility – And What It Means for State Budgets,” Issue Brief, Pew, December 5, 2022, retrieved at https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2022/12/the-long-term-decline-in-fertility-and-what-it-means-for-state-budgets.
 See https://www.jstor.org/stable/145672
 See https://pubmed.ncbi.nlm.nih.gov/7019710/.
 McClellan, William M., “Improving the Care of ESRD Patients: A Success Story,” Health Care Finance Review, Volume 24, Issue 4, Summer 2003, retrieved at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194811/.