Racial disparities in out-of-pocket maternity costs reported

Racial disparities in out-of-pocket maternity costs reported | Image Credit: © DisobeyArt - © DisobeyArt - stock.adobe.com.

Introduction

The out-of-pocket cost paid for maternity care is often increased among Black, Asian, and Hispanic patients with private insurance vs their White counterparts, according to a recent study published in JAMA Health Forum.¹

Significant differences were reported during pregnancy, with Black patients on average paying 74% more than White patients for recommended prenatal care services. In comparison, Hispanic patients paid 51% more and Asian patients 4% more.¹

“We found that out-of-pocket costs were highest for Black people overall through pregnancy, delivery, and postpartum,” said lead study author Rebecca Gourevitch, PhD, professor at the University of Maryland School of Public Health. “The study shows yet another way that people from different racial and ethnic groups are having different experiences of maternity care.”¹

Study design

The retrospective cross-sectional study included health plan enrollment and medical claim data from 2018 to 2022.² The US Census American Community Survey was assessed for median household income per year based on census block.

Comparisons with commercially insured births were conducted using data from the Centers for Disease Control and Prevention’s natality records. Data directly reported to the Blue Cross Blue Shield of Massachusetts (BCBSMA) allowed the self-reported race and ethnicity data of some patients to be determined.²

Race and ethnicity data from the remaining study population was obtained from the Bayesian Improved First Name Surname and Geocoding method. Afterward, race and ethnicity were combined into a single variable.²

Birthing patients enrolled in a BCBSMA health plan for the prenatal and delivery periods as well as the first 42 days postpartum were included in the analysis. Only patients with a self-reported Black, Asian, White, or Hispanic race and ethnicity were evaluated, as sample sizes were too small for assessment among other race and ethnicity groups.²

Out-of-pocket spending was reported as the primary outcome, measured by summing the deductible, coinsurance, and copayments linked to medical services. This cost was measured for the prenatal period, delivery, and the first 42 days postpartum. Covariates included age at delivery and Census of residence during the year of delivery.²

There were 87,253 deliveries from 76,826 patients aged a mean 32.4 years included in the analysis. Of patients, 9.8% were Asian, 3.8% Black, 7.9% Hispanic, and 78.5% White. Being aged 30 to 34 years was reported in 44%, cesarean delivery in 32.3%, and residing in census blocks with a median household income of $75,000 or less in 26.9%.²

Key findings

A mean out-of-pocket spending during the maternity period of $2398 was reported among Black patients vs $2300 among Hispanic patients. These costs were higher than those among Asian and White patients, at $2202 and $2036, respectively.²

Based on these results, Black patients spent 17.7% more on out-of-pocket maternity costs than White patients, while Hispanic patients spent 12.9% more and Asian patients 8.1% more. During the prenatal period, these rates were 32.6% more, 16.9% more, and 6.3% less, respectively.²

Black birthing people spent 74.4% more on recommended prenatal care services than White birthing people, while Hispanic birthing people spent 51.2% more and Asian 4.2% more. However, reduced differences were reported in costs of delivery and during the postpartum period.²

Associations of race and ethnicity with out-of-pocket spending remained when adjusting for covariates. In adjusted analyses, Black, Hispanic, and Asian patients spent $251.88, $91.95, and $122.34, respectively, more for deliveries than White patients. Coinsurance payments showed the largest differences, at $772, $779, and $669 more, respectively.²

“Our results reveal that health insurance companies, employers and policymakers have an opportunity to lower out-of-pocket costs for all pregnant and postpartum people and to reduce disparities in costs by changing how health insurance plans are designed,” said Gourevitch.¹

References

1. Study reveals racial and ethnic disparities in maternity care spending. University of Maryland. February 28, 2025. Accessed March 6, 2025. https://www.eurekalert.org/news-releases/1075066
2. Gourevitch RA, Cohen JL, Shakley T, et al. Racial and ethnic differences in out-of-pocket spending for maternity care. JAMA Health Forum. 2025;6(2):e245565. doi:10.1001/jamahealthforum.2024.5565