The birth of an invoice: spoof about charging for childbirth

“… the dumbest thing I ever heard.” That was the reaction of a Norwegian midwife in a new film from Save the Children when she was presented with the idea of women having to pay for childbirth.

In the parody, real-life midwives react to the news that under new cost-control measures, they will now be issuing women with an invoice for the birth of their babies. Of course, credit checks would be performed up front. A birth meter clocks every minute, adding to the bill. A menu of extras is available, including additional costs for pain relief.

The birth meter pauses to check in at the moment of the epidural whether the women has given her consent. “Consent to the procedure?” asks the nurse. “No, consent to the cost,” is the response.

The baby is born, the invoice printed, a bar code attached to the baby’s leg. After all, “It is practical for the patient to know what she has to pay when leaving the hospital.”

The midwives in the film are stunned: “Is this for real?”, “Crazy”, “Not on my watch.” Their reasons follow straight after: “Not everyone has the money to pay,” and “Are you telling me that I should put this to a women giving birth, that a woman in the most critical situation of her life should consider what care to have depending on the size of her wallet?”

No joke

But while in Norway this film is a spoof, in other countries charging women for childbirth is all too real.

The film could go further. What isn’t shown is a life threatening situation needing a caesarean section, an anaesthetic, a blood transfusion, or resuscitation. That birth meter would add these costs from its ‘menu’ of treatments. But it’s not really like a restaurant menu because a woman in labour doesn’t have a choice about what she can pick and choose.

Yes, this is a skit, and these are Norwegian midwives. Norway spends $9,000 a head every year on health, and most of that is government money. But the idea that people should access care, free at the point of use, should not be reserved for the richest in the world. It’s crazy, the dumbest idea ever that women have to pay to give birth.

No sense

Economists used to argue that user fees in health– paying for services – would detract people from using services unnecessarily. That they would keep costs down, while also (in a second, contradictory argument) raising money for health. These arguments have long been shown to be unfounded. Relying on user fees to finance health doesn’t make economic sense . But more importantly, it is inequitable and unjust. Even the World Bank agrees.

The reality is that in some countries, despite global momentum and years of campaigning to abolish user fees for maternal and child care, they still exist.

Attaching a cost to maternity care is particularly problematic. Most maternal deaths are caused by complications during and immediately after delivery, and can only be averted through prompt access to emergency care. These potential complications can rarely be predicted so, in economics jargon, the ‘price of care is uncertain’ – people can’t plan and save ahead. The need for prompt, immediate care means any time spent looking for money to pay for a complicated delivery can be fatal.

Pushed into poverty

The costs attached to maternity care can be expensive, catastrophic in cases, particularly for complicated deliveries, which can cost up to 10 times more than normal deliveries. These costs can push already poor households further into poverty. It is the poorest women who die from maternal health complications, and the poorest women who cannot afford the treatment they need.

When it comes to essential health service, such as maternity care, countries need to move away from relying on private and out-of-pocket spending, and move towards national systems, based on pre-paid funding – that allows healthcare to be available to all, regardless of their income, or whether they are employed.

Should a woman, in the most critical situation of her life consider what care to have depending on the size of her wallet?