Financial Inequities in Maternity Care: Lessons From the Netherlands and US

In the Netherlands—where maternity care is generally accessible—new research revealed that financial barriers persist even in relatively well-structured health care systems.

Published in Health Affairs, a study of high-deductible health plans (HDHPs) in the Netherlands sheds light on the out-of-pocket (OOP) burdens pregnant women face, despite universal access.¹ Coupled with findings from a US study on HDHPs published in The American Journal of Managed Care® (AJMC®), it is clear that financial inequities in maternity care span both public and private systems, raising concerns about the financial vulnerability that pregnant women face.²

Financial Burdens in Maternity Care in the Netherlands

The Netherlands has taken a significant step toward improving maternity care by implementing a bundled payment model.¹ Under this model, providers received a predetermined budget to cover prenatal, natal, and postnatal care, creating financial incentives to coordinate care and reduce unnecessary interventions. This was one of multiple policy interventions made to improve the coordination and quality of maternity care and reduce perinatal mortality, which was relatively high in the Netherlands compared with other European countries.

The Dutch study tested this model between 2016 and 2018 using a quasi-experimental difference-in-differences design and evaluated maternity care practices in 6 regions with bundled payments, including nearly 140,000 total pregnancies.

Compared with maternity care networks not participating in the bundled payment model (controls), those that did saw a 2.74% increase in outpatient, midwife-led births and a –3.52% reduction in in-hospital, obstetrician-led births. The model was also associated with changes in the use of labor inductions, which went down by –1.41%, and a –1.16% decrease in planned and a 1.33% increase in emergency cesarean deliveries.

Pregnant women in the US and in other countries face financial burdens | Image credit: Phushutter – stock.adobe.com

While clinical changes were modest, the financial impact was more significant. Total spending per pregnancy dropped by 5%, translating to a savings of about $328 per pregnancy. Despite these changes, there were no observed differences in key health outcomes for mothers or newborns, such as preterm birth rates or neonatal health scores.

“Total spending on maternity care grew in both the intervention and control groups, but spending growth was slower in the intervention group,” the study authors noted. “To the extent that there was some anticipatory behavior attributable to the intervention in the latter part of 2016 (the beginning of more outpatient deliveries coinciding with less spending), the estimated effect here would be more conservative.”

While the authors referred to these findings as “early and modest” and called for further evaluations of bundled payment models, the study also yielded 3 major lessons for policymakers, payers, and providers considering alternative payment models:

• Bundled payments can influence providers' behavior in the maternity care setting
• Bundled payment incentives vary by context, requiring more understanding of treatment effect heterogeneity
• Clearly defining reform goals and success criteria before implementing payment reform helps assess its effectiveness for policy decisions

The US Perspective: "Deductible Double Jeopardy"

These findings add international context to those of a US study, which highlighted how commercial HDHPs contribute to significant financial burdens for pregnant women.² The authors of the cross-sectional study published in AJMC analyzed over 1.3 million deliveries between 2012 and 2021.

The results revealed that the timing of a woman’s delivery—particularly when pregnancies span 2 insurance plan years—can have a profound impact on OOP costs. This means that for pregnant Americans with HDHPs, delivering in January could mean paying twice as much in OOP costs compared with those delivering in December, as pregnancies that cross calendar years often reset deductibles and OOP limits.

Specifically, delivering in January led to $1310 higher OOP maternity costs than delivering in December. Total OOP spending for the maternity episode, spanning 40 weeks of pregnancy and 12 weeks postpartum, averaged $6308 for January deliveries and $4998 for December deliveries—a difference of $1310 just because of the timing of their pregnancy. Additionally, women whose pregnancies spanned multiple plan years faced an average of $1491 more in OOP costs for delivery hospitalizations alone and $1005 more over a 3-year period.

The phenomenon dubbed “deductible double jeopardy” creates an arbitrary financial burden based on the timing of delivery, often forcing families to deplete savings or accumulate medical debt. For women without sufficient financial cushioning, this can have lasting repercussions on both their economic well-being and their ability to seek needed care.

“These spending differences persist unless enrollees’ out-of-pocket limits are met in each year,” the authors said. “Changing cost-sharing limits to shorter intervals, such as months, may reduce potential arbitrary differences in cost sharing that occur due to pregnancy timing.”

A Shared Global Concern

Both studies highlight similar financial challenges faced by pregnant women despite the stark differences between health care systems in the Netherlands and the US and raise critical questions about the effectiveness of current health care structures in protecting pregnant women from financial harm.

Addressing financial barriers to maternity care requires both systemic changes and targeted interventions. For example, the Dutch study suggests that revising HDHP structures to include maternity care tax exemptions could reduce the financial burden on pregnant women.¹ Policy experts in the Netherlands have also suggested implementing income-based subsidies to reduce OOP costs for families with low incomes and expanding the range of services covered under maternity care, such as home visits and transportation.

In the US, reforming HDHPs to prevent “deductible double jeopardy” has become a focal point for health care advocates.² One proposed solution is to introduce monthly OOP caps instead of annual deductibles. A 2022 study suggested that a monthly cap of $500 could significantly reduce financial strain for about 24% of the commercially insured population.³ For women seeking maternity care, this would mean more manageable medical expenses across a longer care episode, rather than the current system, which can compound costs when pregnancies span multiple years.²

As both the Netherlands and the US grapple with financial inequities in maternity care, it becomes clear that no health care system is immune to the complexities of cost-sharing structures. HDHPs especially place undue financial strain on pregnant individuals and families, especially when pregnancies span more than 1 calendar year. Both studies underscore the need for health care systems to adapt to the realities of maternity care by implementing cost-sharing reforms and offering more comprehensive coverage.

References

1. Scheefhals ZTM, Struijs JN, Wong A, Numans ME, Song Z, de Vries EF. Integrating maternity care through bundled payments in the Netherlands: early results and policy lessons. Health Aff (Millwood). 2024;43(9):1263-1273. doi:10.1377/hlthaff.2023.01637
2. Duffy EL, Randall S, Green S, Trish E. Deductible double jeopardy: patients may pay more out of pocket when pregnancy crosses 2 years. Am J Manag Care. 2024;30(6):285-288. doi:10.37765/ajmc.2024.89562
3. Shafer P, Horný M, Dusetzina SB. Monthly cost-sharing limits and out-of-pocket costs for commercially insured patients in the US. JAMA Netw Open. 2022;5(9):e2233006. doi:10.1001/jamanetworkopen.2022.33006