Association of Childbirth With Medical Debt

Abstract

We evaluated the association between childbirth and having medical debt in collections and examined differences by neighborhood socioeconomic status. Among a statewide cohort of commercially insured pregnant (n=14,560) and postpartum (n=12,157) adults, having medical debt in collections was more likely among postpartum individuals compared with pregnant individuals (adjusted odds ratio [aOR] 1.36, 95% CI 1.27-1.46) and those in lowest-income neighborhoods compared with all others (aOR 2.18, 95% CI 2.02-2.35). Postpartum individuals in lowest-income neighborhoods had the highest predicted probabilities of having medical debt in collections (28.9%, 95% CI 27.5-30.3%), followed by pregnant individuals in lowest-income neighborhoods (23.2%, 95% CI 22.0-24.4%), followed by all other postpartum and pregnant people (16.1%, 95% CI 15.4-16.8% and 12.5%, 95% CI 11.9-13.0%, respectively). Our findings suggest that current peripartum out-of-pocket costs are objectively more than many commercially insured families can afford, leading to medical debt. Policies to reduce maternal-infant health care spending among commercially insured individuals may mitigate financial hardship and improve birth equity.

Figure 1.

Increased adjusted probability of medical debt in collections among postpartum compared with pregnant individuals, especially for individuals in lowest-income neighborhoods. This figure displays adjusted proportions of individuals with medical debt in collections in January 2021, by cohort (pregnancy compared with postpartum) and neighborhood income (assessed by ZIP code in month of childbirth, with lowest quintile neighborhood income defined as being in the cohort’s lowest quintile of per capita income [≤$25,417.60]). The pregnancy cohort includes individuals undergoing childbirth in February to July 2021 (with credit outcomes observed 1–6 months before childbirth), and the postpartum cohort includes individuals undergoing childbirth in January to June 2020 (with credit outcomes observed 7–12 months after childbirth). Error bars indicate 95% CI.