Friday, 21 November 2014

BIRTH WEEK: Across the 'ole fish pond: What's it like having a baby in the US of A?

So according to the movies, sitcoms and HBO box sets, life for mums in the US is good. They seem to have a pretty decent healthcare system. How many times have you heard American women refer to having their own gynaecologist or dermatologist, as though they have expensive specialists at their beck and call to do their smears or check their wrinkles. Similarly, American parenting books often advise you to take your child to your paediatrician to check minor symptoms, as opposed to the long drawn out process in the UK involving begging your GP for a referral. And what about maternity rights? Well, it’s a modern, liberal democracy, mothers probably have pretty decent access to rights and services, right?

Wrong! I was shocked when I read this article, "4 ways the US is hostile towards mothers". The facts were astonishing.

  • US women have poor access to healthcare leading to rising maternal mortality (The Lancet)
  • A woman giving birth in the U.S. is now more likely to die than a woman giving birth in China (as above)
  • The US is the only high income country that does not have a statutory right to paid maternity leave for employees (International Labour Organization)

So, I wanted to know what it is really like having a baby in the States. Now clearly, one woman can’t represent a huge nation of diverse women, of all social and financial circumstances, different ethnicities, religions and cultures. But Season Holland tells us how it is for her, a married, college-educated working mum, enjoying a middle income. She has one daughter, with another baby on the way. Her husband works part-time to care for their daughter and while she would describe their lifstyle as secure, with the costs of childcare, health insurance etc, they don't enjoy much disposable income.

(Some of the American terms may be unfamiliar so I have tried to translate where relevant!)

Health Insurance

Access to healthcare is a complicated issue in the States. Unlike in the UK where we have the NHS which is free at the point of delivery, an American woman’s access to prenatal care and birth support depends upon her financial circumstances. A big problem seems to relate to access to care in low income families who earn too much to qualify for Medicaid but not enough to qualify for tax credits. Health insurance is usually paid through your employer, so depending on the plan your employer offers as part of your salary package, you could have nothing to pay at the hospital or a hefty "co-pay" fee.

American prenatal care also seems to be highly medicalised – whereas in the UK you will see your midwife or GP 7-10 times during your pregnancy, seeing a consultant only if you are deemed high-risk, American women routinely see an obstetrician for their antenatal appointments which is presumably more expensive than midwife-led care. I asked Season about the costs of prenatal and labour care.

"Our family currently has health insurance coverage through my employer. I have had much better at another employer and also plans that were worse. In terms of prenatal care, all the plans I've been a part of consider basic care "preventative" and, thus, you don't pay a co-pay (extra fee) for any of your regular OB (obstetrician) visits. For both pregnancies, I saw my obsetrician monthly from about 8-32 weeks, then every other week for about a month and then weekly thereafter. These visits and all of the bloodwork, ultrasounds, and additional testing were 100% covered under my current plan. There weren't really any tests that I wanted that I couldn't get."

"However, when I was pregnant with my first child I was at a different job and under a different type of plan. It was a combination of a High Deductible Insurance Plan and a Health Savings Account. The gist of how it works is that the monthly out of pocket for the plan is relatively low and you also deposit pre-tax money into a special savings account that can be only used for qualified medical expenses. But the caveat is that when you do get medical services, you are paying more than a typical co-pay. So, with her, I did have to pay a few hundred dollars for one of my tests (maybe one of the ultrasounds) and the hospital bill was several thousand dollars. I don't know for sure but I anticipate only paying about $200 out of pocket for the hospital visit with my second child, given my current plan.”

A medical birth

  • American women may be more accustomed to a medically-managed birth than women in the UK. According to one study, 69% of women having a singleton vaginal birth in 2008 had an epidural (Osterman & Martin 2011). In the UK, more like 30% of women have an epidural. 
  • Caesarean rates sit at one in three births in the USA, a major surgical procedure that carries additional risks. In the UK, the caesarean level is close to 25% (so one in four births); any level of caesareans over 15%  is thought to indicate "overuse of surgery".
  • Home birth rates in the UK are at 2.5% versus less than 1% in the US where the American College of Obstetricians and Gynaecologists continues to condemn home births (Guardian).

From Season's account below, if you have a good insurance plan, you may well get more attention from healthcare staff and more privacy than you would get routinely in a UK hospital. Epidurals do demand one to one care, which may be hard to come by in shortstaffed NHS wards. Clearly if you don't have comprehensive insurance, you may receive less attention and be in a shared room. The fear of a large hospital bill if things get complicated must be overwhelming for people with a less comprehensive insurance plan.

Season says "I have a primary GYN (gynaecologist) who I see for annual check ups but then once I became pregnant they basically put you on a rotation to be seen by all of the doctors during your prenatal visits. When I was pregnant with my daughter there were three obstetricians in the practice and now there are five. They rotate on call at the hospital so basically whoever is delivering that day is the one who will deliver your baby. I like the practice a lot and was always comfortable going with a hospital birth, with epidural. I haven't worked with a midwife for either pregnancy.

"I was very happy with the care I received during labor and delivery. Throughout the day I was probably cared for by 3-4 nurses with the doctor checking in periodically. When I was actually pushing it was just my husband and one nurse in the room and she was great. Once the baby was about to be delivered, the doctor came in for the actual delivery. I did get the epidural and, although I have heard horror stories otherwise, I thought it was great. I still had feeling in my abdomen and legs, I could feel my contractions and I was able to push. It was not a pain-free experience but the intensity of the contractions was definitely lessened by the drugs. I hope to have a similar experience this time around. We went in on Friday morning, she was born Friday evening and I went home on Sunday. The hospital was really nice and I had a private recovery room where my baby roomed in with us. I have visited friends at other local hospitals where the recovery room is sometimes shared and I think that would be really awkward." 

"I think hospital births with doctors are, by far, the most common. Since I do read quite a few mommy blogs, it seems like the natural birth movement is pretty popular but I think that skews more upper class and white. Of all the other women I know who have had kids around the same time I have, I can't think of any who really had an "alternative" birth. Everyone was in a hospital and all delivered without a midwife or doula, as far as I can remember. One friend didn't get the epidural but that was because she progressed too quickly, not because she didn't want it."

Maternity leave

While many men still do not take their 2 weeks paternity leave due to pressure at work, women in the UK enjoy 39 weeks statutory maternity pay if they have worked for their employer for 26 weeks up to the 15th week before their due date (NI Direct). The US is the only high income country that does not have a statutory right to paid maternity leave for employees. Season tells us she is lucky to live in one of only two states that offer women a financial allowance during a brief maternity leave which they deem "disability pay".

"This is definitely one of those areas where socioeconomic status and even the state you live in plays a huge role in the type of maternity leave you can take. When I had my daughter I took 10 weeks of leave. I received two thirds of my pay for the first 6 weeks and then a lesser portion of that for the remaining four weeks. The 6 week paid leave came in part from a short term disability allowance paid out by the state of New Jersey and partly from disability insurance through my employer. New Jersey and California are the only two states in the US that actually pay any sort of disability for maternity leave and, at least here, there is a cap on how much you get. It's two thirds of your salary up to a certain amount. Then, my employer-provided disability insurance picked up the remainder to get me to the full 2/3. If you have a c-section, both benefits extend from 6 weeks to 8 weeks. I took the additional 4 weeks under the Family Medical Leave Act which states that my employer can't fire me but they don't have to pay me for that extra time off. Again, since I'm lucky and live in NJ, the state benefits continue during this time but I did not receive the extra money from my employer. So, it was definitely a financial burden to take even that amount of time off.

The financial situation for each family will vary greatly, even in the same state, based on what the employer offers. Some of my friends got full pay during maternity, others were pretty much high and dry and had to go back to work ASAP. With baby number 2, I plan to take 12 weeks and the situation will be pretty much the same...2/3 pay for 6 weeks then a smaller amount for the remaining 6 weeks. My husband was a student at the time so paternity leave didn't apply to him. Since he is working part time, he could get some pay through the state FMLA insurance I was referencing above but it would be really minimal based on what he makes.

If money wasn't an issue, I would really prefer to take at least 6 months off and possibly up to a year. Before I had a baby, 12 weeks of leave sounded like a long time but, after having a baby, leaving a 3 month old in any kind of childcare is very difficult (much less a 6 week old!!). The baby is still so young! I was lucky that, even though I went back to work, we were able to keep my daughter home by splitting time between my husband watching her and a nanny until she was almost two years old, at which point she went into part-time daycare. I also have an awesome schedule where I work from home three days a week so that made it easier for me emotionally since I wasn't away from her all day and nursing wasn't such a hassle because I only had to pump at the office two days a week.

The future

I asked Season whether there were any planned changes to maternity rights in the US. With a Democratic President in power I was hopeful but there do seem to be a lot of deeply right-wing conservative campaigns against women's rights at the moment.

"I think that our maternity rights in this country are very sad. Personally, I think all new moms should be able to take at least 6 months off, with pay, and that fathers should also receive some sort of legally-binding paternity leave. Same thing for adoptive parents...I don't know much about their rights but I believe they are guaranteed even less under the law, which is deplorable. Another related issue is the cost of childcare. There should be some subsidy for childcare or some way to help struggling families afford to put their kids in safe childcare facilities without causing financial hardships. It feels like the laws here still operate under the assumption that most families have a stay at home mom taking care of the kids when that just isn't the reality for most American families anymore."

"I have read about the "baby box" that Finland gives all new babies and think that is such an amazing program. What a way for the government to welcome a new citizen and help mothers who might not have a lot of money get started. Other than that, I don't know too much about maternity leave in other countries besides the fact that I've heard women in France get a year off (no idea if that's true), but honestly any sort of federally mandated leave/pay/support has to be better than here. In general, the legal situation in the US seems to be on a downward slide for women with the equal pay bill not making it through Congress, the countless measures around the country trying to roll back our abortion rights and letting corporations decide not to cover birth control for employees. So, it doesn't feel like any major maternity/childcare reform is on the horizon any time soon."


CQC. 2010. National NHS patient survey programme: survey of women's experiences of maternity services 2010. London: Care Quality Commission [pdf file, accessed July 2012]

Osterman, M. & Martin, J. (2011). Epidural and Spinal Anesthesia Use During Labor: 27-state Reporting Area, 2008. National Vital Statistics Reports, 59 (5).

What do you think of the American system? Do you like the idea of a more medically controlled birth, attended by doctors you know well? What do you think of the US health insurance system? Did you find anything in this piece surprising? Would be great to hear your views.

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