Though Martin and her husband, Mark Willett, are both professionals with health insurance, her 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 though the American health care bazaar, sorting through services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts.

At a prenatal class in March, she was told about epidural anesthesia and was given the option of using a birthing tub. To each offer, she had one gnawing question: “How much is that going to cost?”

LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car seats, Renée Martin was struggling with bigger purchases.


When she became pregnant, Martin called her local hospital 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,” 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. She ended up paying $655. “I feel like I’m in a used-car lot,” said Martin, who is starting graduate school in the fall.

Plenty of 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 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 about 4 million annual births is well over $50 billion.


And though maternity care costs far less in other developed countries, 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. “It’s that we pay individually for each service and pay more for the services we receive.”

Those payment incentives for providers also mean US 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.

Financially, they suffer the consequences. In 2011, about 62 percent of US women covered by private plans that were not obtained through an employer lacked maternity coverage. But even many women with coverage are feeling the pinch as insurers demand higher co-payments and deductibles and exclude many 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 Caesarean 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 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 room or television.

In most other developed countries, comprehensive maternity care is free or cheap for all.

Ireland, for example, guarantees free maternity care at public hospitals, though women can opt for private deliveries for a fee. The average price spent on a normal vaginal delivery tops out at about $4,000 in Switzerland, France, and the Netherlands, where charges are limited through a combination of regulation and price setting; mothers pay little of that cost.

That chasm in price is true even though new mothers in France and elsewhere often remain in the hospital for nearly a week to heal and learn to breast-feed, while American women tend to be discharged a day or two after birth, since insurers do not pay costs for anything that is not considered medically necessary.

Only in the United States is pregnancy generally billed item by item, a practice that has spiraled in the past decade, doctors say. No item is too small. Charges that 20 years ago were lumped together and covered under the general hospital fee are now broken out, leading to more bills and inflated costs: There are separate fees for the delivery room, the birthing tub, and each night in a semiprivate hospital room, typically thousands of dollars. Even removing the placenta can be coded as a separate charge.


Add up the bills, and the total is startling.

“We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, executive director of Childbirth Connection.

Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations, although the fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures.

Some social factors drive up the expenses. Mothers are now older than before, and therefore more likely to require or request more expensive prenatal testing. And obstetricians face the highest malpractice risks among physicians and pay hundreds of thousands of dollars a year for insurance, fostering a “more is safer” attitude.

But less than 25 percent of America’s high payments for pregnancy typically go to obstetricians, and they often charge a flat fee for their nine months of care, no matter how many visits are needed, said Dr. Robert Palmer, at the American College of Obstetricians and Gynecologists. That fee can range from a high of more than $8,000 for a vaginal delivery in Manhattan to under $4,000 in Denver, according to Fair Health, which collects health care data.


With costs spiraling, some hospitals are starting to offer all-inclusive rates for pregnancy. Maricopa Medical Center, a public hospital in Phoenix, began offering uninsured patients a comprehensive package two years ago.

“Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right,” said Dr. Dean Coonrod, the hospital’s obstetrics and gynecology chief.

The hospital charges $3,850 for a vaginal delivery, with or without an epidural, and $5,600 for a planned C-section — prices that include standard hospital, doctor, and testing fees.

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.

To control costs in the United States, patients may also have to alter their expectations, including the presence of an obstetrician at every prenatal visit and delivery. “It’s amazing how much patients buy into our tendency to do a lot of tests,” said Eugene Declercq, a professor at Boston University who studies international variations in pregnancy. “We’ve met the problem, and it’s us.”

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 Martin.

But the law is not explicit about what services must be included in that coverage.