Having a Baby

The concept of Hauora well-being is a Māori philosophy of health unique to New Zealand. It is recognised by the World Health Organisation and encompasses four dimensions of health:

Taha tinana - Physical well-being
The physical body, its growth, development, ability to move, and caring for it.

Taha hinengaro - Mental and emotional well-being
Coherent thinking processes and constructive responses, acknowledging and expressing thoughts and feelings

Taha whanau - Social well-being
Relationships with family, friends,and others; social support and feelings of belonging, compassion, and caring.

Taha wairua - Spiritual well-being
The values and beliefs that determine the way people live, the search for meaning and purpose in life, and personal identity and self-awareness. For some, spiritual well-being is linked to a particular religion; for others, it is not.

Each of these four dimensions of hauora is evident in policies and cultural attitudes about childbirth. I asked several new mothers in New Zealand about their prenatal, antenatal, and postnatal experiences. Here are descriptions from two of them:

Experiences 
Prenatal visits 
NZ New Mother #1: Initially I visited the midwife monthly, then every fortnight, then weekly in the last month before my due date. I have a friend in the US who was pregnant at the
same time and this was a sharp contrast to her experience. She said the weigh-ins always
gave her stress and the constant measuring, testing and checking gave her more anxiety
than reassurance, even though both our babies were born healthy. When I asked my
midwife why I wasn’t having any weight checks, more scans, and general poking and
prodding, she said she was more concerned about my mental and emotional well-being and
preparedness for childbirth and motherhood, so these checks were only performed if there
was a problem, such as swelling/water retention.

NZ New Mother #2: My visits with the midwife were initially monthly, then got more
frequent as I got closer to due date. Every visit I did the pee-on-the-stick test and I had blood tests to follow almost all of the midwife appointments. I had quite a few scans, maybe 9 in total.

Childbirth experience
NZ New Mother #1: I originally planned for a home birth, but after being in labour at home
for more than 55 hours and not dialating past 5 cm we decided to escalate and go to the
hospital, where I continued labouring in the pool for 5 hours, and then ultimately delivered
via C-section after the baby began showing signs of distress. The midwife was reluctant to
move sooner, trying to respect my wishes to let labour progress naturally. In retrospect,
advice I would give to other pregnant women would be to discuss this and other specific
scenarios in advance with your midwife to have clarity about preferences and when to
escalate. The midwife probably could have advised discussing options earlier in the process
and been a little more decisive once I clearly was too worn out to think straight. The csection
went very well. The post-op care I received was in an outdated room, but the nurses,
midwives, and surgeons at the hospital were all helpful, caring and attentive during my
three day stay.

Blogger's Note: This birthing experience appears to have been an outlier. NZ midwives said active labor for a first birth usually averages 18 hours, which is consistent with US experiences.

NZ New Mother #2: I wanted a water birth, however I had been diagnosed with
preeclampsia the night before going into labour so we were expecting complications.

I ended up having an easy and short first delivery with no complications.

Postnatal follow-up
NZ New Mother #1: This was my first baby and I do not have any family in the area, so the
midwife was really helpful to me with managing a brand-new infant, breast-feeding, eating
right, and coping with post-partum stress. She visited us at home every day for the first
week, then once/week for five weeks. After that, I was referred to a home health provider,
who sends a registered nurse to do check-ups, developmental measurements, and give my
baby immunization shots, which was a lot better than travelling with a newborn to a clinic or
doctor’s office.
NZ New Mother #2: Follow up care from midwife was amazing.... just wish I could have had
her longer than the 6 weeks! She visited me at home every other day when I got home. My
midwife sent me back to the hospital due to extremely high blood pressure at one point, so
the 1st week home she came every 2nd or 3rd day, then week 2 she came to our home
twice and called twice to make sure I was ok with blood pressure then her visits were
weekly for the last 4 weeks.

Costs 
NZ New Mother #1: All costs were covered for the baby and myself, with the exception of
the prescriptions for post-cesarean pain medication and laxatives ($25 in total). I decided to
do acupuncture in the weeks leading up to labour to help with the stress, persistent nausea
and thinning my cervix and these six appointments cost $390 in total. I also paid out-of pocket for prenatal vitamins ($270 in total) rather than receiving prescriptions for iodine,
iron, and folic acid.
NZ New Mother #2: All costs were covered, except for the scans, which were $45/each, so I paid $405.

The cost of having a baby in New Zealand is free for New Zealand residents. Women may be charged for a negative urine pregnancy test, additional room services provided by a maternity facility or an extended stay in a maternity facility, some tests in a private laboratory, ultrasound scans and antenatal classes. According to the NZ Ministry of Health, the vast majority of women (96%, 2014) give birth in hospitals or associated birth centres (86% and 10%, respectively). Most choose a midwife for their lead maternity carer (94%) versus having an obstetrician/general practictioner (6%), which costs additionally between $3000-4000. Women who are not residents are asked to provide a bond (NZ$ 9000, US$6300) for their maternity care.

The costs of having a baby in the US varies widely, depending on geography and insurance. The best source of costs of having a baby was a study by Truven Analytics, published in January 2013 using 2010 claims data: Average total commercial insurer payments for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively. Medicaid payments for all maternal and newborn care involving vaginal and cesarean childbirths were $9,131 and $13,590, respectively.

The Truven study noted these amounts paid by insurers represent part of the total cost, as the insurer pays part of the bill and the new family pays part of the bill. According to National Conference of State Legislators (www.ncsl.org), insurance premiums averaged $18,764 for family coverage in 2017, with the family usually paying about $5,714 and their employer picking up the rest. In addition to their insurance premiums, women with commercial insurance typically paid about 10-12% of the total maternity care cost out-of-pocket (about $2000-3000). Women with Medicaid insurance typically paid about 1-2% of the cost (about $90-260). Also note the Truven study is a little dated. A US government website, www.cms.gov, reports that amounts for maternity care increased about 7% from 2010 - 2016. 

The vast majority of US babies are delivered by physicians. The US National Center for Health Statistics (2014) reported only 8.3% of US women had their babies delivered by certified nurse-midwives (CNMs) and certified midwives (CMs). Similar to their New Zealand counterparts, these midwives delivered in hospitals (94.3%), birth centres (3%), and homes (2.7%).

The midwife vs. physician-led maternity care might be part of this story, so I looked at rates of midwife-attended births in countries experiencing favorable outcomes in maternal mortality (deaths per 100,000 live births) and neonatal mortality (deaths per 1,000 live births). In Norway, Sweden, and Denmark, the rate of physician-attended births is about 1 out of 4, but nearly all (>95%) experience some midwife care. 

The countries with successful midwifery programmes have high standards on training and guidelines. The US midwives are regulated by state, resulting in high variability of standards and outcomes.

Not discussed here are the financial maternity/parental leave benefits during the baby’s first year offered in New Zealand, Canada, and other countries where there is societal value in parents having more than 6 weeks to be with their new babies. After controlling costs, the US might figure out how to help parents spend more time with their children.