Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California 2009-2011

Abstract

Objective:

To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.

Study design:

We conducted a retrospective analysis of 2009–2011 California in-hospital deliveries at non-Federal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean DRG-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1,265,212.

Results:

Mean maternal costs for all in-hospital deliveries was $8,204, increasing to $13,154 for late preterm (32–36 weeks) and $22,702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6,389: $2,433 for term infants, $22,102 for late preterm, $223,931 for very preterm infants, and $317,982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants these shares were 1.0%/36.5% and 0.4%/20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.

Conclusions:

Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs, and these costs have increased over time.

Pregnancy and delivery are the most common reasons for the hospitalization of women of childbearing age, with almost 4 million deliveries annually in the United States.¹ Peripartum and newborn infant care, particularly for the extremely premature infant, make up a substantial proportion of the costs of medical care for these patients, with estimates of the costs of preterm birth accounting for almost 26 billion dollars annually.² Neonatal and maternal care has continued to evolve over time, including rising rates of Cesarean deliveries and more aggressive management and resuscitation of infants born at periviable gestational ages (GA) <24 weeks.^3–5 However, with reductions in mortality and more aggressive resuscitation come greater use of health care resources. Although preterm rates have been relatively constant ^6,7 the neonatal mortality rate has declined, especially for very preterm infants.^4,8,9 The reduction in very preterm mortality is especially significant, given the very large cost and length of stay differences between survivors and deaths.¹⁰

There currently are little data to quantify the economic impact of these changes in both maternal and neonatal care. The existing studies using data linking mothers to infants and transfers to accurately measure the total costs of delivery are from 2000 or earlier, and thus fail to capture the effects of more recent changes in costs, technologies, and outcomes.^2,10–12 More recent data tend to use hospital charges instead of costs, or use unlinked discharge data that cannot measure the economic impact of mothers or infants across the multiple hospitals where they receive care prior to being discharged home. As these women and infants tend to be the sickest, and most expensive cases, such data may underestimate the impact of certain subgroups of patients. ¹³ Finally, previous data omit physician costs.

The goal of this project is to provide population-based estimates of the costs and lengths of stay for hospitalizations associated with childbirth, including pregnancy-related maternal hospitalization and infant transfers prior to discharge home or death. We include both hospital costs, as performed in prior work, and updated methods to include an estimate of physician costs. Further, to provide policy makers and researchers with in-depth data useful for additional analyses, we provide data stratified by GA, birth weight (BW), and survival status.

Methods

We used the California Office of Statewide Planning and Development (OSHPD) Vital Statistics-Patient Discharge Data to obtain a population-based study cohort of all in-hospital deliveries in that occurred in California non-Federal hospitals between 2009 and 2011. Maternal and infant hospital discharge records were probabilistically linked with birth, infant death, and fetal death certificates to provide linked information for mother/baby pairs. Approximately 96% of in-hospital birth records were successfully linked to maternal and infant hospital discharge abstract data. ¹⁴ Although these linkages are officially probabilistic, the vast majority are unique matches and most of the probabilistic linkages are for uncomplicated term infants for whom the non-exact linkages have minimal effect on the analyses conducted for this study. These data include maternal antepartum records for the nine months prior to delivery. Infant hospital discharge records include the delivery admission and subsequent transfers until the infant was initially discharged to home or died. This study was approved by the Stanford University Institutional Review Board and the California Department of Health Services Committee for the Protection of Human Subjects.

Cases were selected if the birth certificate was successfully linked to both the maternal delivery record and the infant delivery record, or if the fetal death certificate was linked to a maternal hospital record. Maternal prenatal hospitalization records were retained for pregnancyrelated prenatal hospitalizations falling within the gestation period of the current pregnancy based on gestational age at birth (fetal death). Prenatal hospitalizations were considered pregnancy-related if the recorded Major Diagnostic Category value was 14 (Pregnancy, Childbirth, and the Puerperium), or International Classification of Diseases, 9^th edition, Clinical Modification (ICD-9) V-Codes of 22.*, 23.*, 24.*, 26.*, 27.*, 28.* were recorded and no ICD-9 diagnosis codes 633.*−639.* were recorded.

The BW value from the birth certificate was set to missing in cases where the value was >=6,800g or <400g for a live birth. Singleton cases with missing values were replaced with the median BW value for infants of the same GA at birth if there was a valid GA (n=74). For GA, we used the best obstetric estimate of GA when it was available; the LMP GA was used for 2,436 cases. The GA value from the birth certificate (or fetal death certificate) was set to missing in cases indicating a live birth <22 weeks or a GA>45 weeks. For survivors, 3,317 infant records with a GA at discharge <34 weeks were removed as probable data errors.

ICD-9 procedure codes were used to identify infants who underwent surgical procedures using a procedure classification system developed by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project that classifies procedures as “major” or “minor” therapeutic or diagnostic procedures.¹⁷ We performed a further review of major therapeutic surgical procedures to flag procedures likely having major costs associated with them (such as a major heart surgery). Flagging such cases was done to assist in the identification of infant cost outliers – “big” cases with large costs were retained rather than being classified as outliers.

The OSHPD annual hospital financial data for 2009–2011 were utilized to construct costto-charge ratios for each hospital and these were used to convert hospital charges recorded in the maternal and infant hospital discharge records to estimated costs.¹⁸ Data on the mean professional/physicians fees for each Diagnosis Related Group (DRG) and payer source (Medicaid or Private Insurance) were matched to the DRGs of each hospital discharge to incorporate estimated professional fees, with separate adjustment factors for Medicaid and private insurance.¹⁹ Although these physician data are fees, not “costs” we believe that they represent the best available method for adding an estimate of physician costs to our data. For simplicity, we use the term “costs” even when this refers to estimates derived from other sources. The Bureau of Labor Statistics Producer Price Index was used to adjust costs to December 2017 values.^20,21

We excluded cases when the estimated costs were clearly inconsistent with the care that was provided. Maternal costs were flagged as data errors and set to missing if hospital costs-perday were <$500 or >$10,000, or if total hospital costs were <$1,000. Neonatal costs were examined separately for survivors, non-survivors, and major surgical cases. One surgical case with a total hospital cost-per-day of <$125 was flagged as a data error and hospital costs were set to missing. For non-surgical cases, for survivors, hospital costs were set to missing if hospital cost-per-day was less than the 1^st percentile for GA, as this threshold represented the point at which the costs were clearly in error across all gestations. For survivors with a length of stay (LOS) <=5 days, observations with hospital costs-per-day >$10,000 were capped at $10,000. For non-survivors with a LOS of 2–5 days with hospital costs-per-day >$20,000, hospital costsper-day were capped at $20,000.

The Figure (available at www.jpeds.com) outlines how the various criteria above affected the study sample. Of the 1,562,901 in-hospital deliveries, 1,499,769 (96 %) were linked to both maternal and infant discharge abstracts. 6,470 cases were excluded due to missing or excluded BW or GA. The main reason cases were excluded was missing hospital charge data, which dropped 203,096 cases (over 85% of the excluded cases). Of these, 98% were excluded because they included one or more stays at a hospital operated by the Kaiser Permanente health system which does not report hospital charges. An additional 24,991 cases were excluded because either the maternal or infant costs were considered to be outliers relative to their disease state, as described above. Cases were retained only if cost and LOS information were available for both the mother and infant (only maternal costs were required for the fetal deaths). The final sample included 1,265,212 retained cases.

In addition to reporting the estimated costs, lengths of stay and mortality for all infants, we report these by GA and BW groups. For GA, we used the following groups: <25 weeks, 2527 weeks, 28–32 weeks, 32–36 weeks, 37–38 weeks, 39–41 weeks, and >41 weeks. We also provided summary groups for extremely preterm (<28 weeks), very preterm (<32 weeks), and any preterm (<37 weeks). For BW, we report on the following groups: <1000g, <1500g, 10001499g, 1500–2499g, <2500g, and >=2500g. For each of the tables reported in the results, there is a corresponding table available online that reports by week of GA and narrower BW intervals.

Results:

Table 1 reports the number of maternal cases, live births, number of the live births that were multiple births, the number of fetal and infant deaths, and the mean maternal and infant length of stay, for all cases, and for each of the GA and BW groups described above (see Table 2 [available at www.jpeds.com] for more detailed data). For length of stay, we also report the standard deviation, median, and inter-quartile rage. The final sample includes 1,245,622 deliveries (includes fetal deaths), 1,260,457 live births, and 4,755 fetal deaths. 19,280 of the maternal deliveries and 37,649 of the live births were from a multiple delivery. The deaths are predominately preterm (77.7%), with 60.4% of the deaths being very preterm and half (50.1%) being extremely preterm.

Table 1.

Deliveries, Mortality, & Maternal/Newborn Length of Stay by Gestational Age and Birth Weight^a,b

	Maternal Cases	Live Births	Deliveries of Multiples		Newborn Mortality Group						Total Maternal LOS				Total Newborn LOS
					Survivors		In-Hospital Death		Fetal Death
	N	N	N	(%)	N	(%)	N	(%)	N	(%)	Mean	Std Dev	Median	IQR	Mean	Std Dev	Median	IQR
By Gestational Age
<=24	2,695	1,883	258	9.6	754	25. 4	1,12 9	38. 1	1,08 2	36. 5	4.6	5.3	3.0	4.0	54.9	64. 0	9.0	112. 0
25–27	3,366	3,182	379	11. 3	2,695	71. 5	1,12 9	38. 1	590	15. 6	7.6	8.0	5.0	6.0	81.5	40. 0	83.0	36.0
28–31	7,510	8,055	1,121	14. 9	7,719	87. 8	487	12. 9	737	8.4	8.5	10. 1	5.0	6.0	49.8	24. 5	46.0	24.0
32–36	81,012	88,985	8,841	10. 9	88,422	98. 1	1,12 9	38. 1	1,19 1	1.3	4.8	6.9	3.0	3.0	8.7	11. 9	4.0	10.0
37–38	336,080	342,624	7,308	2.2	342,279	99. 7	563	0.6	650	0.2	2.7	2.4	2.0	1.0	2.7	4.1	2.0	1.0
39–41	808,107	808,873	1,360	0.2	808,500	99. 9	1,12 9	38. 1	490	0.1	2.5	1.5	2.0	1.0	2.4	2.8	2.0	1.0
>41	6,852	6,855	13	0.2	6,844	99. 6	373	0.1	15	0.2	2.9	1.4	3.0	2.0	2.6	2.9	2.0	1.0
< 28	6,061	5,065	637	10. 5	3,449	51. 2	1,61 6	24. 0	1,67 2	24. 8	6.3	7.1	4.0	6.0	71.6	51. 9	79.0	95.0
<32	13,571	13,120	1,758	13. 0	11,168	71. 9	1,95 2	12. 6	2,40 9	15. 5	7.5	8.9	5.0	6.0	58.2	39. 0	52.0	44.0
<37	94,583	102,105	10,59 9	11. 2	99,590	94. 2	2,51 5	2.4	3,60 0	3.4	5.2	7.3	3.0	3.0	15.0	24. 4	4.0	15.0
All Deliveries
	1,245,62 2	1,260,45 7	19,28 0	1.6	1,257,21 3	99. 4	3,24 4	0.3	4,75 5	0.4	2.8	2.7	2.0	1.0	3.5	8.3	2.0	1.0
By Birth Weight
<1000g	6,588	5,549	834	12. 7	3,903	52. 0	1,64 6	21. 9	1,96 4	26. 1	6.4	7.3	4.0	6.0	69.7	51. 0	76.0	88.0
<1500g	13,271	13,017	2,035	15. 3	11,037	70. 9	1,98 0	12. 7	2,54 3	16. 3	7.5	9.0	5.0	5.0	56.5	40. 5	51.0	51.0
1000-1499g	6,683	7,468	1,201	18.0	7,134	88.7	334	4.2	579	7.2	8.5	10.2	5.0	6.0	46.7	26.6	44.0	30.0
<2500g	75,920	84,983	12,14 3	16. 0	82,408	93. 1	2,57 5	2.9	3,55 5	4.0	5.4	7.4	3.0	3.0	17.2	26. 1	6.0	17.0
1500-2499g	62,649	71,966	10,108	16. 1	71,371	97. 8	595	0.8	1,01 2	1.4	4.9	7.0	3.0	3.0	10.1	13. 2	4.0	12.0
>=2500g	1,169,70 2	1,175,47 4	7,137	0.6	1,174,80 5	99. 8	669	0.1	1,20 0	0.1	2.6	2.0	2.0	1.0	2.5	3.3	2.0	1.0

Abbreviations: LOS, length of stay; Std Dev, standard deviation; IQR, interquartile range.

^aData Source: 2009–2011 California Linked Vital Statistics – Patient Discharge Data

^bCosts Producer Price Index Adjusted to December 2017

Table 2.

Deliveries, Mortality, and Maternal/Infant Length of Stay^a

	Maternal Cases	Live Births	Deliveries of Multiples		Mortality Group				Total Maternal LOS				Total Newborn LOS
					Survivors		In-Hospital Death
	N	N	N	(%)	N	(%)	N	(%)	Mean	StdDev	Median	IQR	Mean	StdDev	Median	IQR
Gestation al Age in Complete d Weeks	317	351	32	10. 1	26	7.4	325	92. 6	3.7	4.2	2.0	3.0	15.0	46.2	1.0	0.0
22
23	586	649	68	11. 6	208	32.1	441	68. 0	5.2	6.0	3.0	4.0	46.0	62.7	2.0	108. 0
24	798	883	89	11. 2	520	58.9	363	41. 1	6.7	6.2	5.0	6.0	77.2	61.7	94.0	116. 0
25	855	962	105	12. 3	745	77.4	217	22. 6	7.8	7.4	5.0	7.0	87.8	48.2	95.0	41.0
26	928	1,038	108	11. 6	881	84.9	157	15. 1	8.6	7.9	6.0	9.0	82.7	38.4	85.0	32.0
27	1,036	1,182	141	13. 6	1,069	90.4	113	9.6	9.0	8.9	6.0	7.0	75.2	32.5	74.0	27.0
28	1,213	1,435	186	15. 3	1,338	93.2	97	6.8	9.4	10.4	6.0	7.0	66.6	28.4	64.0	25.0
29	1,440	1,681	225	15. 6	1,599	95.1	82	4.9	9.4	9.9	6.0	7.0	56.6	23.7	53.0	20.0
30	1,825	2,149	282	15. 5	2,071	96.4	78	3.6	9.3	11.2	6.0	6.0	48.0	21.2	45.0	17.0
31	2,327	2,790	405	17. 4	2,711	97.2	79	2.8	8.5	10.1	5.0	6.0	38.6	18.2	35.0	16.0
32	3,692	4,388	635	17. 2	4,295	97.9	93	2.1	8.3	10.2	5.0	6.0	29.5	15.1	27.0	13.5
33	5,589	6,601	949	17. 0	6,508	98.6	93	1.4	7.4	9.5	5.0	4.0	20.8	14.1	18.0	11.0
34	11,522	13,266	1,621	14. 1	13,150	99.1	116	0.9	6.4	8.9	4.0	3.0	12.8	12.2	11.0	11.0
35	19,111	21,401	2,255	11. 8	21,296	99.5	105	0.5	4.6	6.4	3.0	2.0	7.1	9.8	4.0	7.0
36	39,957	43,329	3,351	8.4	43,173	99.6	156	0.4	3.8	4.9	3.0	2.0	4.2	7.4	3.0	2.0
37	96,127	100,075	3,957	4.1	99,911	99.8	164	0.2	3.0	3.1	2.0	1.0	3.0	5.2	2.0	1.0
38	239,322	242,549	3,339	1.4	242,368	99.9	181	0.1	2.6	1.9	2.0	1.0	2.5	3.5	2.0	1.0
39	428,873	429,703	977	0.2	429,495	100. 0	208	0.1	2.5	1.5	2.0	1.0	2.4	3.0	2.0	1.0
40	296,857	297,185	313	0.1	297,065	100. 0	120	0.0	2.5	1.4	2.0	1.0	2.3	2.7	2.0	1.0
41	81,887	81,985	70	0.1	81,940	100. 0	45	0.1	2.8	1.7	3.0	1.0	2.4	2.8	2.0	1.0
42	6,169	6,183	9	0.2	6,175	99.9	8	0.1	2.9	1.4	3.0	2.0	2.5	2.9	2.0	1.0
43	473	476	3	0.6	474	99.6	2	0.4	2.7	1.8	2.0	1.0	2.7	3.1	2.0	2.0
44	147	148	1	0.7	147	99.3	1	0.7	2.4	1.0	2.0	1.0	2.9	4.3	2.0	1.0
45	48	48	0	0.0	48	100. 0	.	.	2.3	0.9	2.0	1.0	2.3	1.5	2.0	0.5
All	1,241,09 9	1,260,45 7	19,12 1	1.5	1,257,21 3	99.7	3,24 4	0.3	2.8	2.7	2.0	1.0	3.5	8.3	2.0	1.0
Birth Weight Group	353	397	46	13. 0	82	20.7	315	79. 4	5.5	5.5	4.0	5.0	32.5	58.1	1.0	21.0
<500g
500g-599g	748	831	83	11. 1	323	38.9	508	61. 1	5.9	6.1	4.0	5.0	52.6	63.6	8.0	108. 0
600g-699g	829	939	94	11. 3	573	61.0	366	39. 0	7.2	6.9	5.0	6.0	75.0	58.6	91.0	112. 0
700g-799g	878	978	103	11. 7	775	79.2	203	20. 8	7.8	7.2	6.0	6.0	85.1	47.4	91.0	48.0
800g-899g	843	966	136	16. 1	826	85.5	140	14. 5	8.5	7.8	6.0	7.0	81.8	39.7	85.0	37.0
900g-999g	991	1,116	114	11. 5	1,020	91.4	96	8.6	9.3	9.7	6.0	7.0	72.8	32.6	72.0	31.0
1000g-1099g	955	1,105	132	13. 8	1,022	92.5	83	7.5	8.8	8.8	6.0	6.0	62.6	29.5	62.0	28.0
1100g-1199g	1,067	1,262	186	17. 4	1,183	93.7	79	6.3	9.7	11.4	6.0	6.0	56.8	28.0	54.0	30.0
1200g-1299g	1,076	1,282	174	16. 2	1,216	94.9	66	5.2	9.2	10.4	6.0	6.0	50.7	23.4	50.0	25.0
1300g-1399g	1,417	1,663	223	15. 7	1,602	96.3	61	3.7	8.7	10.3	5.0	6.0	43.1	25.1	41.0	25.0
1400g-1499g	1,386	1,672	232	16. 7	1,613	96.5	59	3.5	8.9	10.9	5.0	5.0	37.7	21.6	35.0	23.0
1500g-1599g	1,800	2,167	347	19. 3	2,119	97.8	48	2.2	8.1	10.3	5.0	5.0	33.4	20.6	31.0	21.0
1600g-1699g	1,839	2,219	360	19. 6	2,163	97.5	56	2.5	7.8	9.8	5.0	5.0	28.2	16.4	25.0	20.0
1700g-1799g	2,462	3,007	466	18. 9	2,957	98.3	50	1.7	7.5	9.7	5.0	4.0	24.0	15.2	21.0	17.0
1800g-1899g	3,263	3,903	675	20. 7	3,846	98.5	57	1.5	6.6	8.6	4.0	3.0	19.2	15.3	16.0	16.0
1900g-1999g	3,548	4,287	715	20. 2	4,233	98.7	54	1.3	6.5	8.9	4.0	3.0	16.4	14.7	14.0	15.0
2000g-2249g	14,836	17,343	2,456	16. 6	17,179	99.1	164	1.0	5.3	7.4	4.0	3.0	10.3	11.7	7.0	11.0
2250g-2499g	32,250	35,680	3,397	10. 5	35,511	99.5	169	0.5	3.9	5.2	3.0	2.0	5.6	8.9	3.0	3.0
2500g-2749g	67,400	70,948	3,426	5.1	70,806	99.8	142	0.2	3.1	3.8	3.0	1.0	3.4	5.6	2.0	1.0
2750g-2999g	150,074	152,824	2,930	2.0	152,684	99.9	140	0.1	2.7	2.6	2.0	1.0	2.6	3.9	2.0	1.0
3000g-3249g	239,748	241,354	1,606	0.7	241,220	99.9	134	0.1	2.6	1.8	2.0	1.0	2.4	3.3	2.0	1.0
3250g-3499g	266,796	267,527	721	0.3	267,424	100. 0	103	0.0	2.5	1.6	2.0	1.0	2.4	3.0	2.0	1.0
3500g-3749g	216,315	216,594	313	0.1	216,521	100. 0	73	0.0	2.6	1.6	2.0	1.0	2.4	2.6	2.0	1.0
3750g-3999g	130,749	130,853	114	0.1	130,821	100. 0	32	0.0	2.6	1.5	2.0	1.0	2.4	2.7	2.0	1.0
>=4000g	99,476	99,540	72	0.1	99,494	100. 0	46	0.1	2.7	1.5	3.0	1.0	2.7	3.3	2.0	1.0

Abbreviations: LOS, length of stay; Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight (Live Births Only)

Table 3 reports the newborn costs until hospital discharge; these data are reported for all infants, including multiple births, by GA and BW (see Table 4 [available at www.jpeds.com] for more detailed data). The mean and median costs per case declined dramatically as GA and BW increase, from a mean total cost of $350,000 for the smallest infants to about $2,500 for term infants. In aggregate, the 8.1% of the live births that are preterm (<37 weeks) incur 60.9% of all newborn costs. Of these, the 1.0 % who are very preterm (<32 weeks) incur 36.5% of all newborn costs, and the 0.4 % who are extremely preterm (<28 weeks) incur 20.0% of newborn costs. This represents a modest increase in the proportion of costs for each of these groups compared with our data in 2000, when preterm infants, very preterm, and extremely preterm infants incurred 54%, 34%, and 19% of costs, respectively.¹² When the overall cost distribution is considered (not shown) the results are even more skewed; the 1.2% of cases with costs of more than $100,000 incur 51.0% of all infant costs. Conversely, 87.2% of the infants with costs under $3,000 incur only 15.8% of all newborn costs. We also provide this for survivors (Table 5; available at www.jpeds.com), deaths (Table 6; available at www.jpeds.com), singletons (Table 7; available at www.jpeds.com), and multiple births (Table 8; available at www.jpeds.com).

Table 3.

Newborn Costs by Gestational Age and Birth Weight^a,b

	Live Births	Total Newborn Costs					Newborn Costs/Day
	N	Total	Mean	Std Dev	Median	IQR	Mean	Median
Gestational Age Group
<=24 Weeks	1883	$494,855,663	$262,802	$339,862	$71,329	$464,280	$4,488	$3,897
25–27 Weeks	3,182	$1,115,722,584	$350,636	$269,326	$296,191	$270,226	$4,680	$3,825
28–31 Weeks	8,055	$1,327,398,922	$164,792	$149,503	$123,595	$114,818	$3,275	$2,698
32–36 Weeks	88,985	$1,966,778,897	$22,102	$54,961	$3,208	$25,088	$1,615	$1,031
37–38 Weeks	342,624	$1,156,140,160	$3,374	$21,571	$1,135	$955	$760	$546
39–41 Weeks	808,873	$1,968,261,372	$2,433	$13,366	$1,097	$894	$729	$554
>41 Weeks	6,855	$23,926,547	$3,490	$14,688	$1,260	$1,205	$875	$619
< 28 Weeks	5,065	$1,610,578,247	$317,982	$300,489	$269,974	$376,964	$4,609	$3,837
<32 Weeks	13,120	$2,937,977,169	$223,931	$232,676	$150,136	$210,179	$3,790	$3,045
<37 Weeks	102,105	$4,904,756,065	$48,036	$118,955	$6,956	$39,639	$1,894	$1,379
All Deliveries	1,260,457	$8,053,084,144	$6,389	$39,263	$1,153	$1,042	$833	$565
Birth Weight Group
Extremely LBW, <1000g	5,549	$1,711,096,197	$308,361	$300,869	$250,711	$366,233	$4,521	$3,769
Very LBW <1500g	13,017	$2,859,433,962	$219,669	$237,120	$145,768	$223,414	$3,756	$3,024
BW 1000–1499g	7,468	$1,148,337,765	$153,768	$143,393	$117,195	$123,514	$3,188	$2,653
All LBW, <2500g	84,983	$4,728,079,717	$55,636	$127,807	$11,818	$49,178	$1,987	$1,551
BW 1500–2499g	71,966	$1,868,645,755	$25,966	$58,075	$4,428	$29,872	$1,667	$1,169
BW >=2500g	1,175,474	$3,325,004,427	$2,829	$16,856	$1,113	$925	$749	$554

Abbreviations: Std Dev, standard deviation; IQR, interquartile range; LBW, low birth weight; BW, birth weight.

^aData Source: 2009–2011 California Linked Vital Statistics – Patient Discharge Data

^bCosts Producer Price Index Adjusted to December 2017

Table 4.

Newborn Costs^a

	Live Births		Total Newborn Costs				Newborn Costs/Day
	N	Total	Mean	StdDev	Median	IQR	Mean	Median
Gestational Age in Completed Weeks	351	$24,652,306	$70,234	$237,359	$559	$1,287	$1,745	$557
22
23	649	$142,556,390	$219,655	$314,534	$22,696	$440,917	$4,520	$3,961
24	883	$327,646,967	$371,061	$351,515	$337,975	$509,178	$5,555	$4,571
25	962	$393,271,216	$408,806	$307,788	$369,184	$323,941	$5,201	$4,326
26	1,038	$372,412,367	$358,779	$262,885	$312,110	$249,395	$4,844	$3,873
27	1,182	$350,039,000	$296,141	$227,641	$242,737	$197,894	$4,112	$3,426
28	1,435	$351,133,715	$244,692	$188,261	$196,463	$167,739	$3,759	$3,119
29	1,681	$325,837,182	$193,835	$143,121	$156,289	$121,957	$3,479	$2,934
30	2,149	$325,229,989	$151,340	$140,769	$116,046	$88,504	$3,165	$2,591
31	2,790	$325,198,036	$116,558	$111,631	$88,868	$72,754	$2,989	$2,450
32	4,388	$381,320,365	$86,901	$92,958	$64,468	$55,777	$2,875	$2,379
33	6,601	$389,116,565	$58,948	$72,843	$41,735	$37,938	$2,754	$2,301
34	13,266	$459,120,137	$34,609	$61,494	$24,018	$30,252	$2,314	$2,036
35	21,401	$376,826,027	$17,608	$47,664	$3,613	$18,746	$1,615	$1,059
36	43,329	$360,395,802	$8,318	$36,887	$1,546	$2,494	$1,099	$639
37	100,075	$465,418,087	$4,651	$27,663	$1,220	$1,144	$846	$568
38	242,549	$690,722,073	$2,848	$18,455	$1,105	$886	$725	$538
39	429,703	$1,045,697,345	$2,434	$14,413	$1,103	$873	$704	$539
40	297,185	$690,522,574	$2,324	$11,490	$1,065	$884	$740	$565
41	81,985	$232,041,453	$2,830	$13,967	$1,190	$1,074	$823	$602
42	6,183	$20,973,517	$3,392	$14,210	$1,251	$1,190	$868	$617
43	476	$1,882,972	$3,956	$12,464	$1,269	$1,297	$911	$609
44	148	$940,707	$6,356	$32,293	$1,333	$1,335	$1,022	$685
45	48	$129,351	$2,695	$6,584	$1,348	$1,292	$897	$764
All	1,260,457	$8,053,084,144	$6,389	$39,263	$1,153	$1,042	$833	$565
Birth Weight Group	397	$66,281,751	$166,957	$335,084	$1,608	$124,975	$3,375	$1,510
<500g
500g-599g	831	$207,867,322	$250,141	$337,161	$63,772	$450,110	$4,522	$3,889
600g-699g	939	$334,348,652	$356,069	$334,340	$326,416	$500,329	$5,228	$4,408
700g-799g	978	$378,904,094	$387,428	$303,918	$341,603	$327,263	$4,953	$4,135
800g-899g	966	$353,997,882	$366,457	$279,308	$316,643	$271,971	$4,791	$4,010
900g-999g	1,116	$309,005,181	$276,886	$219,191	$224,128	$201,403	$3,999	$3,308
1000g-1099g	1,105	$248,588,531	$224,967	$181,474	$182,427	$170,528	$3,642	$3,041
1100g-1199g	1,262	$248,215,139	$196,684	$161,653	$153,732	$145,142	$3,492	$2,873
1200g-1299g	1,282	$219,051,194	$170,867	$139,705	$135,772	$127,617	$3,377	$2,764
1300g-1399g	1,663	$224,088,089	$134,749	$132,908	$103,183	$100,037	$2,962	$2,505
1400g-1499g	1,672	$196,322,490	$117,418	$110,494	$88,552	$89,758	$3,033	$2,506
1500g-1599g	2,167	$214,676,945	$99,066	$105,407	$72,780	$74,826	$2,816	$2,379
1600g-1699g	2,219	$181,948,009	$81,996	$86,181	$60,384	$66,025	$2,809	$2,316
1700g-1799g	3,007	$199,769,094	$66,435	$71,538	$48,352	$53,861	$2,631	$2,233
1800g-1899g	3,903	$208,447,459	$53,407	$78,460	$35,478	$45,892	$2,468	$2,151
1900g-1999g	4,287	$192,286,577	$44,853	$65,946	$29,464	$40,561	$2,398	$2,051
2000g-2249g	17,343	$463,626,397	$26,733	$53,871	$12,773	$31,117	$1,867	$1,592
2250g-2499g	35,680	$444,774,029	$12,466	$42,382	$1,756	$8,516	$1,267	$693
2500g-2749g	70,948	$402,403,751	$5,672	$27,832	$1,268	$1,260	$904	$583
2750g-2999g	152,824	$508,407,478	$3,327	$19,737	$1,124	$942	$767	$553
3000g-3249g	241,354	$640,954,598	$2,656	$18,008	$1,081	$873	$726	$547
3250g-3499g	267,527	$647,809,644	$2,421	$15,928	$1,077	$871	$719	$546
3500g-3749g	216,594	$509,279,986	$2,351	$12,168	$1,093	$893	$724	$549
3750g-3999g	130,853	$320,297,202	$2,448	$10,994	$1,129	$932	$743	$558
>=4000g	99,540	$331,732,650	$3,333	$17,109	$1,248	$1,121	$824	$584

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Table 5.

Newborn Costs, Survivors Only^a

	Live Births		Total Newborn Costs				Newborn Costs/Day
	N	Total	Mean	StdDev	Median	IQR	Mean	Median
Gestational Age in Completed Weeks	26	$18,552,327	$713,551	$278,558	$706,060	$308,858	$4,658	$4,743
22
23	208	$123,854,006	$595,452	$248,527	$534,252	$263,931	$4,607	$4,389
24	520	$290,187,727	$558,053	$301,505	$480,393	$324,295	$4,512	$4,122
25	745	$360,888,863	$484,415	$266,709	$431,438	$274,280	$4,423	$4,096
26	881	$348,743,191	$395,849	$228,087	$336,104	$238,867	$4,117	$3,667
27	1,069	$336,232,339	$314,530	$218,934	$257,120	$188,841	$3,714	$3,307
28	1,338	$340,581,455	$254,545	$170,495	$205,866	$163,097	$3,518	$3,052
29	1,599	$318,276,739	$199,047	$139,444	$161,337	$120,848	$3,265	$2,896
30	2,071	$311,146,889	$150,240	$115,667	$117,426	$87,695	$2,968	$2,566
31	2,711	$316,056,474	$116,583	$105,465	$89,821	$71,993	$2,864	$2,424
32	4,295	$370,284,131	$86,213	$78,838	$65,057	$55,127	$2,777	$2,369
33	6,508	$381,694,131	$58,650	$70,087	$41,832	$37,707	$2,681	$2,292
34	13,150	$447,188,586	$34,007	$56,180	$24,021	$30,094	$2,268	$2,031
35	21,296	$367,096,490	$17,238	$44,018	$3,592	$18,649	$1,586	$1,052
36	43,173	$350,064,172	$8,108	$35,568	$1,544	$2,460	$1,076	$638
37	99,911	$448,177,401	$4,486	$25,308	$1,219	$1,141	$836	$567
38	242,368	$675,921,921	$2,789	$16,591	$1,105	$885	$721	$537
39	429,495	$1,022,439,555	$2,381	$13,297	$1,102	$873	$701	$538
40	297,065	$683,906,492	$2,302	$11,228	$1,065	$883	$738	$565
41	81,940	$228,963,944	$2,794	$13,046	$1,190	$1,073	$821	$602
42	6,175	$20,938,199	$3,391	$14,218	$1,251	$1,187	$866	$617
43	474	$1,880,572	$3,967	$12,489	$1,269	$1,313	$909	$609
44	147	$940,165	$6,396	$32,399	$1,343	$1,328	$1,025	$685
45	48	$129,351	$2,695	$6,584	$1,348	$1,292	$897	$764
All	1,257,213	$7,764,145,121	$6,176	$37,156	$1,151	$1,037	$819	$565
Birth Weight Group	82	$47,348,422	$577,420	$308,092	$550,884	$294,438	$4,512	$4,213
<500g
500g-599g	323	$181,025,844	$560,452	$298,451	$509,316	$325,139	$4,482	$4,206
600g-699g	573	$298,820,780	$521,502	$271,177	$465,939	$319,435	$4,470	$4,144
700g-799g	775	$355,606,680	$458,847	$280,694	$393,403	$285,284	$4,336	$3,949
800g-899g	826	$334,818,993	$405,350	$262,205	$344,024	$258,080	$4,224	$3,798
900g-999g	1,020	$293,451,858	$287,698	$192,408	$236,649	$191,787	$3,564	$3,214
1000g-1099g	1,022	$238,306,452	$233,177	$168,410	$192,502	$169,515	$3,320	$2,970
1100g-1199g	1,183	$240,379,106	$203,195	$155,932	$160,734	$142,917	$3,241	$2,822
1200g-1299g	1,216	$212,255,333	$174,552	$131,409	$139,658	$125,027	$3,165	$2,722
1300g-1399g	1,602	$220,618,073	$137,714	$131,547	$106,272	$99,051	$2,845	$2,491
1400g-1499g	1,613	$192,169,476	$119,138	$108,217	$90,112	$89,101	$2,909	$2,485
1500g-1599g	2,119	$208,864,124	$98,567	$95,368	$73,664	$74,619	$2,749	$2,374
1600g-1699g	2,163	$179,764,805	$83,109	$86,448	$61,246	$65,435	$2,726	$2,310
1700g-1799g	2,957	$195,769,996	$66,206	$65,116	$48,539	$53,602	$2,576	$2,230
1800g-1899g	3,846	$200,638,408	$52,168	$66,561	$35,590	$45,503	$2,392	$2,145
1900g-1999g	4,233	$187,557,523	$44,308	$62,471	$29,506	$40,235	$2,312	$2,040
2000g-2249g	17,179	$454,226,314	$26,441	$53,004	$12,807	$31,000	$1,819	$1,586
2250g-2499g	35,511	$426,760,025	$12,018	$38,453	$1,750	$8,307	$1,239	$691
2500g-2749g	70,806	$388,950,395	$5,493	$25,075	$1,267	$1,253	$894	$583
2750g-2999g	152,684	$492,994,792	$3,229	$17,341	$1,124	$941	$762	$552
3000g-3249g	241,220	$627,702,158	$2,602	$15,906	$1,080	$872	$722	$547
3250g-3499g	267,424	$639,308,656	$2,391	$15,480	$1,077	$871	$717	$546
3500g-3749g	216,521	$504,756,719	$2,331	$11,942	$1,092	$893	$722	$549
3750g-3999g	130,821	$316,781,571	$2,421	$10,435	$1,129	$931	$741	$558
>=4000g	99,494	$325,268,616	$3,269	$15,718	$1,248	$1,120	$821	$584

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Table 6.

Newborn Costs, In-Hospital Deaths^a

	Live Births	Total Newborn Costs					Newborn Costs/Day
	N	Total	Mean	StdDev	Median	IQR	Mean	Median
Gestational Age in Completed Weeks	325	$6,099,979	$18,769	$137,860	$525	$823	$1,512	$516
22
23	441	$18,702,384	$42,409	$135,625	$2,459	$26,507	$4,479	$2,425
24	363	$37,459,240	$103,194	$220,334	$25,112	$88,696	$7,050	$6,957
25	217	$32,382,353	$149,227	$298,415	$36,160	$148,069	$7,871	$7,437
26	157	$23,669,176	$150,759	$338,551	$40,597	$139,758	$8,926	$7,735
27	113	$13,806,662	$122,183	$235,802	$47,622	$123,706	$7,880	$6,587
28	97	$10,552,260	$108,786	$323,364	$18,589	$72,896	$7,071	$6,166
29	82	$7,560,442	$92,201	$173,911	$31,012	$99,620	$7,640	$6,647
30	78	$14,083,100	$180,553	$438,436	$25,343	$62,273	$8,379	$7,655
31	79	$9,141,562	$115,716	$243,163	$25,076	$105,361	$7,256	$6,286
32	93	$11,036,234	$118,669	$347,722	$12,361	$91,220	$7,417	$5,936
33	93	$7,422,434	$79,811	$181,031	$25,922	$66,499	$7,888	$6,385
34	116	$11,931,551	$102,858	$265,658	$21,415	$71,149	$7,504	$6,011
35	105	$9,729,537	$92,662	$255,011	$15,670	$44,849	$7,492	$5,716
36	156	$10,331,630	$66,228	$156,861	$9,957	$49,026	$7,398	$5,037
37	164	$17,240,686	$105,126	$258,963	$16,578	$71,906	$6,868	$5,366
38	181	$14,800,152	$81,769	$286,416	$10,843	$63,434	$6,515	$4,585
39	208	$23,257,791	$111,816	$228,805	$20,948	$75,008	$6,990	$5,681
40	120	$6,616,082	$55,134	$110,404	$8,472	$49,050	$5,678	$2,905
41	45	$3,077,509	$68,389	$205,295	$5,436	$34,184	$5,175	$3,399
42	8	$35,318	$4,415	$4,567	$3,205	$3,647	$3,052	$2,305
43	2	$2,400	$1,200	$1,021	$1,200	$1,444	$1,200	$1,200
44	1	$542	$542	.	$542	$0	$542	$542
All	3,244	$288,939,023	$89,069	$238,988	$11,299	$68,404	$6,319	$5,298
Birth Weight Group	315	$18,933,329	$60,106	$248,325	$910	$3,684	$3,079	$865
<500g
500g-599g	508	$26,841,478	$52,838	$170,811	$2,337	$32,245	$4,547	$2,337
600g-699g	366	$35,527,872	$97,071	$248,591	$18,800	$80,244	$6,416	$6,024
700g-799g	203	$23,297,413	$114,766	$224,863	$29,469	$116,190	$7,307	$7,196
800g-899g	140	$19,178,889	$136,992	$267,432	$39,561	$143,532	$8,134	$7,251
900g-999g	96	$15,553,324	$162,014	$390,135	$40,229	$112,423	$8,622	$6,947
1000g-1099g	83	$10,282,079	$123,880	$281,179	$21,552	$82,864	$7,598	$6,453
1100g-1199g	79	$7,836,033	$99,190	$209,114	$25,159	$96,410	$7,257	$6,229
1200g-1299g	66	$6,795,861	$102,968	$238,589	$30,513	$90,572	$7,294	$6,225
1300g-1399g	61	$3,470,016	$56,886	$145,483	$7,367	$52,702	$6,035	$4,383
1400g-1499g	59	$4,153,014	$70,390	$154,699	$18,419	$50,554	$6,413	$5,858
1500g-1599g	48	$5,812,821	$121,100	$318,855	$11,230	$59,517	$5,743	$6,017
1600g-1699g	56	$2,183,203	$38,986	$61,789	$10,966	$47,563	$6,035	$5,108
1700g-1799g	50	$3,999,098	$79,982	$240,774	$15,813	$67,226	$5,881	$4,072
1800g-1899g	57	$7,809,052	$137,001	$342,824	$15,709	$90,369	$7,649	$5,578
1900g-1999g	54	$4,729,054	$87,575	$195,404	$21,267	$66,882	$9,151	$6,826
2000g-2249g	164	$9,400,083	$57,318	$108,353	$9,556	$70,327	$6,890	$5,143
2250g-2499g	169	$18,014,004	$106,592	$244,921	$15,489	$80,344	$7,114	$5,716
2500g-2749g	142	$13,453,356	$94,742	$256,948	$6,976	$40,801	$5,977	$2,720
2750g-2999g	140	$15,412,686	$110,091	$294,037	$16,435	$89,035	$6,925	$5,635
3000g-3249g	134	$13,252,440	$98,899	$346,795	$15,179	$53,781	$7,181	$6,050
3250g-3499g	103	$8,500,987	$82,534	$175,313	$20,547	$61,945	$8,213	$5,370
3500g-3749g	73	$4,523,267	$61,963	$113,687	$18,284	$55,845	$7,851	$6,794
3750g-3999g	32	$3,515,631	$109,863	$197,001	$20,894	$114,987	$8,642	$6,944
>=4000g	46	$6,464,034	$140,522	$286,332	$13,234	$91,921	$7,485	$7,268

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Table 7.

Newboprn Costs - Singletons^a

	Live Births		Total Newborn Costs				Newborn Costs/Day
	N	Total	Mean	StdDev	Median	IQR	Mean	Median
Gestational age in completed weeks based on OB estimate of GA from BC	288	$21,098,140	$73,257	$244,093	$559	$1,263	$1,652	$557
22
23	520	$107,982,349	$207,658	$300,552	$16,423	$431,851	$4,125	$3,734
24	711	$256,973,677	$361,426	$333,003	$337,807	$503,489	$5,383	$4,462
25	754	$303,065,552	$401,944	$290,428	$364,938	$311,666	$4,995	$4,231
26	824	$286,921,524	$348,206	$263,668	$299,776	$235,878	$4,693	$3,753
27	899	$267,313,419	$297,345	$231,968	$242,853	$198,286	$3,946	$3,369
28	1,032	$247,064,744	$239,404	$187,981	$193,313	$166,346	$3,685	$3,049
29	1,230	$234,958,512	$191,023	$147,076	$152,031	$119,313	$3,475	$2,891
30	1,551	$227,339,105	$146,576	$141,290	$113,521	$81,492	$3,116	$2,564
31	1,938	$218,658,859	$112,827	$113,041	$85,531	$66,790	$2,964	$2,399
32	3,075	$267,660,678	$87,044	$101,104	$62,347	$55,277	$2,898	$2,355
33	4,665	$273,458,653	$58,619	$80,983	$40,204	$36,795	$2,785	$2,293
34	9,954	$330,562,367	$33,209	$66,478	$21,405	$30,095	$2,273	$1,986
35	16,889	$291,288,701	$17,247	$49,361	$2,851	$17,237	$1,597	$987
36	36,658	$301,471,878	$8,224	$38,656	$1,452	$2,250	$1,100	$639
37	92,247	$428,274,356	$4,643	$28,196	$1,181	$1,097	$847	$569
38	236,088	$667,135,409	$2,826	$18,520	$1,095	$870	$725	$538
39	428,050	$1,036,678,986	$2,422	$14,362	$1,101	$872	$703	$539
40	296,712	$686,848,581	$2,315	$11,456	$1,065	$883	$739	$565
41	81,891	$231,384,121	$2,826	$13,966	$1,189	$1,073	$823	$602
42	6,168	$20,862,136	$3,382	$14,206	$1,250	$1,186	$868	$617
43	470	$1,871,184	$3,981	$12,540	$1,269	$1,278	$911	$609
44	146	$935,170	$6,405	$32,512	$1,320	$1,338	$1,023	$678
45	48	$129,351	$2,695	$6,584	$1,348	$1,292	$897	$764
All	1,222,808	$6,709,937,448	$5,487	$35,502	$1,133	$993	$810	$563
Birth Weight Group	312	$57,630,320	$184,713	$355,960	$1,569	$263,803	$3,332	$1,462
<500g
500g-599g	667	$155,093,973	$232,525	$311,599	$47,140	$422,508	$4,188	$3,562
600g-699g	738	$252,511,101	$342,156	$327,716	$316,212	$481,634	$4,931	$4,200
700g-799g	777	$301,183,423	$387,623	$307,310	$342,164	$325,229	$4,796	$4,054
800g-899g	710	$250,802,116	$353,242	$259,890	$307,927	$256,426	$4,675	$3,889
900g-999g	881	$243,848,622	$276,786	$228,122	$223,010	$197,211	$3,880	$3,290
1000g-1099g	825	$182,011,980	$220,621	$176,545	$181,018	$165,513	$3,475	$2,970
1100g-1199g	889	$172,437,556	$193,968	$162,474	$153,008	$142,479	$3,464	$2,868
1200g-1299g	913	$155,442,379	$170,255	$150,279	$131,038	$125,158	$3,398	$2,763
1300g-1399g	1,203	$157,555,575	$130,969	$130,579	$100,827	$98,679	$2,904	$2,469
1400g-1499g	1,159	$134,400,530	$115,962	$109,714	$85,510	$88,674	$3,046	$2,464
1500g-1599g	1,462	$147,795,472	$101,091	$116,201	$71,347	$75,956	$2,787	$2,350
1600g-1699g	1,490	$119,762,773	$80,378	$92,137	$57,038	$64,554	$2,821	$2,269
1700g-1799g	2,010	$134,472,535	$66,902	$77,846	$48,208	$53,591	$2,650	$2,212
1800g-1899g	2,602	$141,198,382	$54,265	$82,874	$34,726	$48,392	$2,468	$2,145
1900g-1999g	2,840	$131,950,734	$46,462	$72,275	$29,516	$41,150	$2,455	$2,058
2000g-2249g	12,411	$343,785,391	$27,700	$59,777	$12,232	$30,803	$1,904	$1,598
2250g-2499g	28,905	$361,013,329	$12,490	$45,283	$1,621	$7,639	$1,266	$692
2500g-2749g	64,027	$354,650,177	$5,539	$28,413	$1,215	$1,172	$896	$583
2750g-2999g	147,232	$483,647,448	$3,285	$19,702	$1,106	$916	$766	$553
3000g-3249g	238,278	$628,425,556	$2,637	$17,888	$1,074	$864	$725	$547
3250g-3499g	266,229	$643,409,834	$2,417	$15,955	$1,074	$868	$719	$546
3500g-3749g	216,098	$507,311,228	$2,348	$12,167	$1,091	$891	$724	$550
3750g-3999g	130,695	$319,264,361	$2,443	$10,971	$1,129	$931	$743	$558
>=4000g	99,455	$330,332,657	$3,321	$17,009	$1,248	$1,121	$823	$584

Abbreviations: OB, Obstetrician; GA, gestational age; BC, birth certificate; Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 CA Linked Data, Matched Good Cost/Length of Stay Cases Only, By Obstetrician Estimate of Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Table 8.

Newborn Costs - Multiples^a

	Live Births		Total Newborn Costs				Newborn Costs/Day
	N	Total	Mean	StdDev	Median	IQR	Mean	Median
Gestational age in completed weeks based on OB estimate of GA from BC	63	$3,554,166	$56,415	$204,945	$577	$1,594	$2,170	$577
22
23	129	$34,574,041	$268,016	$362,815	$55,472	$502,503	$6,112	$5,144
24	172	$70,673,290	$410,891	$418,232	$338,048	$532,251	$6,266	$5,184
25	208	$90,205,664	$433,681	$363,561	$406,116	$398,995	$5,947	$4,688
26	214	$85,490,844	$399,490	$256,404	$348,097	$287,313	$5,426	$4,329
27	283	$82,725,581	$292,317	$213,663	$240,248	$203,482	$4,639	$3,570
28	403	$104,068,970	$258,236	$188,534	$208,565	$185,915	$3,947	$3,235
29	451	$90,878,670	$201,505	$131,584	$168,389	$128,521	$3,489	$3,058
30	598	$97,890,884	$163,697	$138,766	$125,708	$105,386	$3,292	$2,692
31	852	$106,539,177	$125,046	$107,941	$98,806	$79,381	$3,046	$2,566
32	1,313	$113,659,688	$86,565	$70,312	$68,609	$56,823	$2,824	$2,422
33	1,936	$115,657,912	$59,741	$47,852	$45,760	$40,656	$2,681	$2,316
34	3,312	$128,557,770	$38,816	$42,917	$30,302	$29,815	$2,439	$2,156
35	4,512	$85,537,327	$18,958	$40,666	$8,316	$23,391	$1,683	$1,358
36	6,671	$58,923,924	$8,833	$25,031	$2,097	$3,976	$1,097	$637
37	7,828	$37,143,731	$4,745	$20,351	$1,755	$1,527	$829	$544
38	6,461	$23,586,664	$3,651	$15,870	$1,636	$1,290	$746	$535
39	1,653	$9,018,360	$5,456	$24,028	$1,555	$1,350	$803	$539
40	473	$3,673,994	$7,767	$24,449	$1,578	$1,849	$990	$602
41	94	$657,332	$6,993	$14,468	$1,631	$2,552	$1,116	$693
42	15	$111,381	$7,425	$15,725	$2,042	$2,411	$946	$681
43	6	$11,788	$1,965	$1,637	$1,517	$1,691	$860	$594
44	2	$5,537	$2,768	$2	$2,768	$3	$923	$923
All	37,649	$1,343,146,696	$35,675	$98,959	$2,767	$27,841	$1,555	$826
Birth Weight Group	85	$8,651,431	$101,782	$233,957	$1,698	$28,927	$3,533	$1,698
<500g
500g-599g	164	$52,773,350	$321,789	$419,162	$119,114	$510,214	$5,879	$4,988
600g-699g	201	$81,837,552	$407,152	$353,786	$354,812	$567,651	$6,317	$5,121
700g-799g	201	$77,720,670	$386,670	$291,172	$337,975	$346,546	$5,559	$4,358
800g-899g	256	$103,195,766	$403,108	$324,953	$342,513	$321,759	$5,112	$4,311
900g-999g	235	$65,156,559	$277,262	$182,281	$232,340	$201,269	$4,442	$3,423
1000g-1099g	280	$66,576,551	$237,773	$195,043	$193,443	$187,140	$4,131	$3,216
1100g-1199g	373	$75,777,583	$203,157	$159,708	$155,877	$146,259	$3,558	$2,885
1200g-1299g	369	$63,608,815	$172,382	$109,397	$142,517	$127,483	$3,324	$2,765
1300g-1399g	460	$66,532,515	$144,636	$138,472	$113,538	$103,703	$3,113	$2,596
1400g-1499g	513	$61,921,960	$120,706	$112,277	$92,589	$91,062	$3,003	$2,570
1500g-1599g	705	$66,881,473	$94,867	$78,334	$74,481	$73,835	$2,875	$2,485
1600g-1699g	729	$62,185,236	$85,302	$72,447	$65,952	$67,578	$2,785	$2,409
1700g-1799g	997	$65,296,559	$65,493	$56,750	$49,079	$52,240	$2,594	$2,298
1800g-1899g	1,301	$67,249,078	$51,690	$68,786	$36,516	$40,351	$2,468	$2,162
1900g-1999g	1,447	$60,335,843	$41,697	$51,180	$29,323	$38,962	$2,285	$2,031
2000g-2249g	4,932	$119,841,006	$24,299	$34,716	$13,776	$31,800	$1,775	$1,582
2250g-2499g	6,775	$83,760,699	$12,363	$26,671	$2,344	$11,644	$1,270	$699
2500g-2749g	6,921	$47,753,574	$6,900	$21,697	$1,847	$2,178	$973	$583
2750g-2999g	5,592	$24,760,030	$4,428	$20,598	$1,707	$1,473	$809	$547
3000g-3249g	3,076	$12,529,042	$4,073	$25,628	$1,656	$1,336	$785	$539
3250g-3499g	1,298	$4,399,810	$3,390	$8,853	$1,653	$1,409	$793	$547
3500g-3749g	496	$1,968,758	$3,969	$12,690	$1,700	$1,395	$818	$535
3750g-3999g	158	$1,032,841	$6,537	$23,004	$1,487	$1,068	$847	$574
>=4000g	85	$1,399,994	$16,471	$64,580	$1,765	$4,469	$1,271	$771

Abbreviations: OB, Obstetrician; GA, gestational age; BC, birth certificate; Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 CA Linked Data, Matched Good Cost/Length of Stay Cases Only, By Obstetrician Estimate of Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Table 9 reports total maternal costs for all live births, which includes the costs of pregnancy-related prenatal hospitalizations (see Table 10 [available at www.jpeds.com] for more detailed data). The mean maternal costs for term deliveries were $7,600-$7,900. These costs were slightly higher for late preterm deliveries ($9,600), and much higher for very preterm deliveries ($13,200-$23,300). The maternal costs are much less skewed than the infant costs; 76.5% of them were under $10,000 and these cases incurred 53.0% of all maternal costs. There were many fewer expensive cases and these cases had a much smaller share of total maternal costs; the 2.1% of the cases that exceeded $25,000 incurred 11.0% of costs. Table 9 also provides separate information on the frequency and costs of pregnancy-related prenatal hospitalizations. About 5.5 % of the maternal cases had one or more pregnancy-related prenatal hospitalizations and the women who had such admissions averaged 1.2 admissions. These prenatal hospitalizations represent only those cases that were officially classified as a hospital admission, and do not include those cases where a woman was observed on the obstetric ward for a few hours, but not officially admitted to the hospital. Table 11 (available at www.jpeds.com) includes the cases that results in a fetal death. Summary information about the differences in maternal costs by type of delivery are reported in Table 12 (available at www.jpeds.com). As would be expected, maternal costs were markedly higher for cesarean deliveries; the mean cost was $11,006 vs. $6,754 for vaginal deliveries, and these differences were larger for preterm deliveries.

Table 9.

Maternal Costs by Gestational Age and Birth Weight^a,b

	Materna l Cases	Live Births	Visits		Maternal Prenatal Hospitalization Costs ($)					Total Maternal Hospitalization Costs (Prenatal+Delivery) ($)
			Any Prenat al	Total Prenat al
	N	N	N	N	Total	Mean	Std Dev	Median	IQR	Total	Mean	Std Dev	Median	IQR
By Gestation Age
<=24	1,701	1,883	345	397	$2,074,150	$7,03 1	$8,253	$4,46 3	$5,78 8	$27,262,370	$15,83 2	$15,49 3	$10,82 8	$13,03 4
25–27	2,819	3,182	689	864	$4,315,907	$7,24 1	$7,935	$4,22 4	$7,01 2	$66,530,509	$23,31 1	$22,83 2	$16,28 7	$18,99 7
28–31	6,805	8,055	1,883	2,414	$14,007,46 6	$9,09 6	$13,34 8	$4,95 8	$7,54 0	$166,938,852	$24,16 3	$27,15 7	$15,84 0	$18,17 3
32–36	79,871	88,985	14,070	18,518	$112,533,3 73	$9,36 1	$15,68 0	$4,83 4	$6,94 1	$1,055,492,86 0	$13,15 4	$17,66 0	$8,837	$8,238
37–38	335,449	342,624	21,59 7	26,44 4	$142,585,3 39	$6,86 0	$11,69 4	$3,80 9	$5,03 1	$2,658,457,15 7	$7,920	$6,688	$6,534	$4,846
39–41	807,617	808,873	29,66 9	34,12 2	$172,204,6 73	$5,82 9	$8,835	$3,51 6	$4,53 3	$6,150,045,72 1	$7,611	$5,180	$6,456	$4,737
>41	6,837	6,855	375	423	$1,735,356	$4,62 8	$5,473	$3,02 7	$3,85 0	$65,972,605	$9,638	$6,595	$7,868	$6,629
< 28	4,520	5,065	1,034	1,261	$6,390,057	$7,17 2	$8,037	$4,34 7	$6,72 2	$93,792,879	$20,49 7	$20,70 0	$14,10 6	$16,84 5
<32	11,325	13,120	2,917	3,675	$20,397,52 3	$8,39 1	$11,72 0	$4,76 0	$7,10 1	$260,731,731	$22,70 2	$24,85 1	$15,16 3	$17,62 7
<37	91,196	102,105	16,98 7	22,19 3	$132,930,8 96	$9,19 8	$15,09 1	$4,82 0	$6,97 8	$1,316,224,59 1	$14,35 0	$18,97 7	$9,311	$9,394
All Deliveries
	1,241,09 9	1,260,45 7	68,62 8	83,18 2	$449,456,2 63	$6,89 8	$11,46 4	$3,84 3	$5,17 2	$10,190,700,0 74	$8,204	$7,708	$6,626	$5,023
By Birth Weight
<1000g	4,787	5,549	1,170	1,437	$6,991,174	$7,33 6	$8,340	$4,46 1	$6,75 5	$102,658,251	$21,40 1	$22,12 1	$14,81 3	$17,13 9
<1500g	10,921	13,017	2,902	3,682	$20,267,240	$8,793	$13,842	$4,863	$7,442	$253,999,879	$23,036	$25,648	$15,437	$17,460
1000–1499g	6,134	7,468	1,732	2,245	$13,276,06 6	$9,82 0	$16,59 0	$5,14 7	$7,96 9	$151,341,628	$24,29 6	$28,00 1	$15,75 8	$17,80 1
<2500g	72,590	84,983	13,83 9	18,13 7	$106,264,2 47	$9,54 8	$15,74 7	$4,92 2	$7,21 4	$1,097,404,26 8	$15,03 1	$19,53 0	$9,719	$9,910
1500–2499g	61,669	71,966	10,93 7	14,45 5	$85,997,00 7	$9,74 6	$16,20 3	$4,94 4	$7,15 6	$843,404,389	$13,60 7	$17,85 6	$9,131	$8,557
>=2500g	1,168,50 9	1,175,47 4	54,78 9	65,04 5	$343,192,0 16	$6,35 2	$10,28 0	$3,68 1	$4,81 3	$9,093,295,80 6	$7,777	$6,018	$6,504	$4,812

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^aData Source: 2009–2011 California Linked Vital Statistics – Patient Discharge Data

^bCosts Producer Price Index Adjusted to December 2017

Table 10.

Maternal Costs, Does Not Include Fetal Deaths^a

	Maternal Cases	Live Births	Maternal Cases with 1+ Prenatal Hospitaliza tions	Total Prenatal Hospitaliza tions	Maternal Prenatal Hospitalization Costs					Total Maternal Hospitalization Costs (Prenatal+Delivery)
	N	N	N	N	Total	Mean	StdD ev	Median	IQR	Total	Mean	StdD ev	Median	IQR
Gestati onal Age in Completed Weeks	317	351	63	72	$288,148	$5,43 7	$5,31 0	$3,7 97	$5,2 85	$3,591,040	$11,3 28	$10,5 99	$8,06 3	$8,35 7
22
23	586	649	116	135	$745,446	$7,53 0	$8,92 6	$4,7 60	$5,4 21	$8,749,145	$14,8 54	$15,5 77	$10,0 62	$11,1 69
24	798	883	166	190	$1,035,9 28	$7,39 9	$8,68 3	$4,6 81	$6,8 72	$14,730,29 2	$18,3 21	$16,6 16	$13,6 65	$15,6 55
25	855	962	196	239	$1,181,0 36	$6,71 0	$7,86 5	$3,4 74	$6,0 51	$18,498,78 4	$21,3 37	$20,1 03	$15,1 71	$17,2 57
26	928	1,038	241	304	$1,482,4 26	$7,26 7	$7,53 3	$4,6 48	$7,5 36	$23,033,18 1	$24,4 51	$24,3 83	$16,9 27	$20,0 90
27	1,036	1,182	252	321	$1,652,4 46	$7,65 0	$8,36 1	$4,3 26	$7,1 87	$24,972,92 9	$23,9 20	$23,4 35	$16,3 96	$19,2 54
28	1,213	1,435	317	416	$2,339,2 90	$8,69 6	$12,5 72	$4,8 44	$7,6 38	$30,681,91 6	$24,8 24	$26,8 93	$16,7 19	$19,3 19
29	1,440	1,681	380	499	$2,942,6 48	$9,28 3	$12,9 66	$5,0 61	$7,4 00	$37,403,94 2	$25,6 02	$27,1 53	$17,2 94	$20,2 64
30	1,825	2,149	500	630	$3,947,7 01	$9,55 9	$13,1 26	$5,0 76	$8,6 47	$45,310,46 6	$24,4 92	$28,3 71	$15,5 31	$18,8 85
31	2,327	2,790	686	869	$4,777,8 26	$8,83 1	$14,1 13	$4,8 27	$6,9 42	$53,542,52 8	$22,6 68	$26,2 57	$14,7 64	$16,1 83
32	3,692	4,388	1,002	1,294	$8,913,2 66	$10,8 43	$21,3 07	$5,1 93	$8,2 13	$84,208,71 5	$22,4 92	$27,8 63	$14,3 48	$16,2 19
33	5,589	6,601	1,433	1,879	$11,930, 853	$10,2 15	$17,7 49	$5,0 57	$6,9 87	$110,992,8 60	$19,6 94	$24,6 20	$12,9 69	$12,9 98
34	11,522	13,266	2,591	3,420	$21,299, 296	$10,0 61	$16,4 00	$5,0 35	$7,2 17	$194,494,0 88	$16,7 48	$22,0 57	$10,6 33	$11,0 60
35	19,111	21,401	3,424	4,612	$28,238, 707	$9,63 8	$15,0 41	$4,9 18	$7,6 97	$243,313,6 20	$12,6 81	$15,9 99	$8,86 3	$7,77 9
36	39,957	43,329	5,620	7,313	$42,145, 513	$8,45 8	$13,9 91	$4,5 98	$6,2 99	$422,476,3 65	$10,5 47	$13,3 58	$7,77 3	$6,45 2
37	96,127	100,07 5	8,826	11,108	$62,117, 413	$7,48 3	$12,4 12	$4,0 59	$5,5 63	$839,902,0 58	$8,72 9	$8,41 6	$6,91 9	$5,45 9
38	239,32 2	242,54 9	12,771	15,336	$80,467, 926	$6,44 6	$11,1 73	$3,6 74	$4,6 95	$1,818,555,099	$7,59 5	$5,82 0	$6,39 8	$4,62 1
39	428,87 3	429,70 3	16,558	19,248	$99,767, 357	$6,05 5	$9,10 4	$3,6 48	$4,7 15	$3,209,114,673	$7,48 0	$4,98 8	$6,41 9	$4,52 2
40	296,85 7	297,18 5	10,097	11,500	$56,075, 726	$5,57 4	$8,36 6	$3,3 84	$4,3 22	$2,213,906,848	$7,45 4	$4,96 1	$6,28 0	$4,70 7
41	81,887	81,985	3,014	3,374	$16,361, 590	$5,44 1	$8,82 8	$3,2 43	$4,2 38	$727,024,2 00	$8,87 0	$6,58 5	$7,39 3	$5,93 8
42	6,169	6,183	334	369	$1,474,2 00	$4,41 4	$4,49 6	$2,8 81	$3,7 58	$60,514,56 9	$9,79 7	$6,61 2	$8,04 0	$6,79 7
43	473	476	36	49	$236,288	$6,56 4	$11,0 98	$3,8 10	$3,5 36	$4,002,822	$8,46 3	$6,88 9	$6,91 8	$5,18 5
44	147	148	4	4	$20,563	$5,14 1	$1,89 6	$5,7 90	$2,7 19	$1,123,259	$7,64 1	$4,52 1	$6,69 3	$4,35 6
45	48	48	1	1	$4,305	$4,30 5	.	$4,3 05	$0	$331,955	$6,91 6	$3,25 8	$6,65 0	$3,23 5
All	1,241, 099	1,260, 457	68,628	83,182	$449,445,898	$6,89 9	$11,4 64	$3,8 43	$5,1 72	$10,190,47 5,353	$8,20 3	$7,70 8	$6,62 6	$5,02 3
Birth Weight Group	353	397	69	80	$483,424	$7,79 7	$10,4 47	$4,7 02	$5,5 18	$5,940,625	$15,9 69	$13,8 16	$12,1 39	$13,3 32
<500g
500g-599g	748	831	153	179	$950,734	$7,14 8	$8,17 6	$4,3 47	$5,5 48	$12,988,22 4	$17,2 49	$16,8 15	$11,5 03	$14,2 47
600g-699g	829	939	201	245	$1,162,5 77	$6,56 8	$6,42 5	$4,4 24	$6,6 89	$17,842,09 1	$20,6 27	$18,9 67	$14,7 95	$17,3 83
700g-799g	878	978	206	251	$1,399,9 34	$7,69 2	$8,95 7	$4,7 45	$6,7 55	$19,534,03 4	$21,7 29	$20,5 42	$16,2 04	$17,6 89
800g-899g	843	966	214	264	$1,434,4 12	$7,96 9	$8,91 0	$4,5 18	$7,4 91	$20,144,27 7	$23,7 55	$23,0 48	$16,8 14	$18,4 67
900g-	991	1,116	236	300	$1,555,4	$7,20	$8,18	$4,3	$7,4	$25,991,49	$24,8	$29,0	$16,3	$18,7
999g					64	1	7	75	00	2	25	14	62	83
1000g-1099g	955	1,105	239	305	$1,966,1 39	$9,98 0	$18,5 83	$5,3 64	$7,8 35	$23,094,80 1	$23,7 11	$24,6 04	$16,0 32	$18,7 88
1100g-1199g	1,067	1,262	313	397	$2,551,3 42	$9,11 2	$13,8 88	$4,8 48	$7,1 66	$29,471,76 2	$26,0 35	$29,9 32	$16,5 08	$20,2 18
1200g-1299g	1,076	1,282	276	362	$2,216,2 71	$9,47 1	$13,1 73	$4,9 19	$8,1 53	$28,055,77 5	$24,7 41	$27,6 11	$16,1 01	$17,2 64
1300g-1399g	1,417	1,663	358	450	$2,905,6 95	$9,28 3	$15,4 52	$4,7 30	$7,8 19	$34,502,90 3	$23,2 66	$28,4 53	$14,7 53	$16,8 81
1400g-1499g	1,386	1,672	387	522	$3,636,6 20	$11,0 87	$20,2 88	$5,9 77	$7,7 60	$36,216,38 7	$24,0 48	$28,3 74	$15,8 65	$16,8 05
1500g-1599g	1,800	2,167	477	628	$3,918,7 67	$10,1 79	$18,4 11	$4,5 28	$7,1 24	$40,948,62 1	$21,9 45	$28,5 20	$13,9 09	$15,0 48
1600g-1699g	1,839	2,219	497	655	$4,133,8 31	$9,68 1	$14,2 24	$5,4 11	$7,5 41	$40,778,45 4	$20,5 54	$22,6 48	$13,3 26	$14,4 03
1700g-1799g	2,462	3,007	645	841	$5,657,4 54	$10,9 01	$17,1 77	$5,5 51	$8,6 99	$52,468,35 3	$19,9 65	$24,2 42	$12,9 83	$13,7 73
1800g-1899g	3,263	3,903	771	1,010	$6,082,6 25	$9,65 5	$17,1 76	$4,8 93	$7,0 76	$59,253,11 3	$17,4 38	$21,3 07	$11,5 28	$10,6 09
1900g-1999g	3,548	4,287	843	1,100	$7,155,7 02	$10,0 93	$15,2 90	$5,1 28	$7,1 22	$66,879,77 0	$17,4 94	$22,6 76	$11,4 13	$11,5 09
2000g-2249g	14,836	17,343	2,946	3,921	$24,731, 804	$10,0 37	$17,2 19	$5,0 93	$7,4 32	$222,158,5 03	$14,3 62	$18,6 70	$9,66 7	$8,94 1
2250g-2499g	32,250	35,680	4,296	5,719	$34,316, 823	$9,30 0	$15,3 03	$4,7 28	$6,7 71	$360,917,5 76	$10,9 99	$13,6 50	$7,97 0	$6,71 9
2500g-2749g	67,400	70,948	6,161	7,922	$44,351, 955	$8,22 2	$14,6 98	$4,3 30	$5,9 05	$589,675,6 57	$8,89 6	$10,0 81	$6,90 4	$5,41 5
2750g-2999g	150,07 4	152,82 4	9,245	11,413	$64,602, 238	$7,32 9	$12,5 16	$3,9 92	$5,3 88	$1,180,447,513	$7,89 1	$6,85 8	$6,45 5	$4,84 9
3000g-3249g	239,74 8	241,35 4	11,497	13,651	$71,918, 793	$6,35 1	$9,70 9	$3,7 62	$4,8 93	$1,805,036,354	$7,53 0	$5,45 7	$6,31 9	$4,65 8
3250g-3499g	266,79 6	267,52 7	11,206	13,038	$65,101, 241	$5,84 5	$8,74 2	$3,4 92	$4,5 24	$2,005,367,102	$7,51 3	$5,57 7	$6,34 8	$4,63 0
3500g-3749g	216,31 5	216,59 4	8,212	9,432	$47,395, 405	$5,79 2	$9,43 0	$3,5 08	$4,3 69	$1,651,581,939	$7,63 2	$5,37 8	$6,47 3	$4,75 1
3750g-3999g	130,74 9	130,85 3	5,074	5,798	$27,628, 973	$5,44 8	$7,44 5	$3,3 10	$4,4 36	$1,028,146,296	$7,86 0	$5,22 8	$6,64 6	$4,87 0
>=4000g	99,476	99,540	4,106	4,699	$22,187, 674	$5,41 3	$6,90 0	$3,4 33	$4,3 72	$833,033,7 32	$8,37 1	$5,62 2	$7,08 0	$5,19 7

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight, Costs Adjusted to December, 2017

Table 11.

Maternal Costs, Includes Fetal Deaths^a

	Maternal Cases	Live Births + Fetal Death s	Maternal Cases with 1+ Prenatal Hospitaliza tions	Total Prenatal Hospitaliza tions	Maternal Prenatal Hospitalization Costs					Total Maternal Hospitalization Costs (Prenatal+Delivery)
	N	N	N	N	Total	Mean	StdDev	Medi an	IQR	Total	Mean	StdDev	Medi an	IQR
Gestati onal Age in Completed Weeks	731	807	117	136	$650,981	$6,44 5	$6,63 9	$4,1 05	$5,7 72	$8,048,195	$10,8 61	$12,5 27	$7,23 7	$7,50 5
22
23	931	1,023	158	186	$968,237	$7,06 7	$7,86 0	$4,8 41	$5,2 81	$12,692,67 5	$13,4 74	$14,6 21	$9,01 4	$10,0 61
24	1,033	1,135	192	219	$1,180,6 84	$7,19 9	$8,13 0	$4,8 45	$6,4 30	$17,318,80 4	$16,5 73	$16,0 08	$11,4 77	$15,0 51
25	1,028	1,154	212	258	$1,265,7 37	$6,66 2	$8,04 4	$3,3 14	$5,7 20	$20,329,30 0	$19,4 17	$19,4 67	$13,3 91	$15,7 56
26	1,123	1,244	262	327	$1,746,9 25	$7,79 9	$8,89 6	$4,8 88	$7,5 98	$25,781,85 6	$22,6 16	$25,7 77	$14,4 81	$18,2 24
27	1,215	1,374	268	341	$1,790,9 87	$7,75 3	$8,47 4	$4,6 21	$7,3 55	$27,172,46 5	$22,0 73	$22,6 19	$14,5 08	$17,8 06
28	1,419	1,657	336	447	$2,521,6 11	$8,81 7	$12,5 46	$4,9 87	$7,5 70	$32,914,76 3	$22,6 37	$25,6 66	$14,9 63	$17,8 76
29	1,612	1,862	397	518	$3,031,5 36	$9,10 4	$12,7 22	$4,8 82	$7,2 94	$39,243,87 6	$23,9 88	$26,4 00	$15,7 65	$19,0 75
30	1,983	2,312	513	646	$4,053,0 77	$9,51 4	$12,9 85	$5,0 66	$8,5 99	$46,989,96 0	$23,3 43	$27,5 87	$14,7 20	$18,1 85
31	2,496	2,961	699	885	$4,855,4 03	$8,78 0	$13,9 84	$4,8 27	$6,9 15	$55,203,19 9	$21,8 11	$25,6 34	$14,1 66	$16,0 25
32	3,913	4,617	1,030	1,329	$9,123,6 60	$10,7 59	$21,0 63	$5,1 65	$8,0 93	$86,651,98 1	$21,8 21	$27,3 97	$13,8 32	$15,6 70
33	5,773	6,795	1,454	1,904	$12,147, 818	$10,2 17	$17,6 69	$5,0 46	$7,0 02	$113,402,3 04	$19,4 55	$24,9 48	$12,7 59	$12,8 72
34	11,736	13,488	2,603	3,438	$21,388, 565	$10,0 46	$16,3 61	$5,0 35	$7,2 17	$197,041,1 14	$16,6 52	$21,9 49	$10,5 66	$10,9 34
35	19,334	21,636	3,450	4,650	$28,485, 094	$9,64 0	$15,0 09	$4,9 44	$7,6 68	$245,904,7 44	$12,6 62	$15,9 88	$8,84 5	$7,76 5
36	40,256	43,640	5,655	7,358	$43,498, 639	$8,67 0	$18,1 87	$4,6 05	$6,3 11	$426,855,0 49	$10,5 75	$14,0 32	$7,77 1	$6,45 4
37	96,440	100,39 8	8,857	11,151	$62,393, 596	$7,48 8	$12,4 05	$4,0 60	$5,5 65	$843,153,3 05	$8,73 4	$8,42 4	$6,92 0	$5,45 9
38	239,64 0	242,87 6	12,784	15,355	$80,600, 999	$6,45 1	$11,1 75	$3,6 74	$4,6 97	$1,821,511,089	$7,59 7	$5,82 2	$6,39 8	$4,62 3
39	429,14 3	429,97 3	16,571	19,261	$99,833, 337	$6,05 5	$9,10 2	$3,6 48	$4,7 14	$3,211,491,203	$7,48 1	$4,98 9	$6,41 9	$4,52 3
40	297,02 8	297,35 6	10,107	11,520	$56,180, 148	$5,57 9	$8,38 7	$3,3 84	$4,3 23	$2,215,603,156	$7,45 5	$4,96 5	$6,28 1	$4,70 7
41	81,936	82,034	3,016	3,376	$16,366, 010	$5,43 9	$8,82 5	$3,2 39	$4,2 38	$727,551,5 58	$8,87 2	$6,58 7	$7,39 3	$5,94 0
42	6,183	6,197	335	370	$1,475,6 34	$4,40 5	$4,49 2	$2,8 68	$3,7 70	$60,621,57 3	$9,79 2	$6,60 9	$8,03 6	$6,80 0
43	473	476	36	49	$236,288	$6,56 4	$11,0 98	$3,8 10	$3,5 36	$4,002,822	$8,46 3	$6,88 9	$6,91 8	$5,18 5
44	147	148	4	4	$20,563	$5,14 1	$1,89 6	$5,7 90	$2,7 19	$1,123,259	$7,64 1	$4,52 1	$6,69 3	$4,35 6
45	49	49	1	1	$4,305	$4,30 5	.	$4,3 05	$0	$340,036	$6,94 0	$3,22 8	$6,68 5	$3,21 9
All	1,245,622	1,265,212	69,057	83,729	$453,819,834	$6,92 3	$11,902	$3,849	$5,182	$10,240,948,288	$8,21 3	$7,78 5	$6,62 8	$5,02 8
Birth Weight Group	1,102	1,227	163	191	$1,159,701	$7,63 0	$8,62 9	$5,066	$6,618	$14,201,89 7	$12,159	$13,226	$8,109	$9,510
<500g
500g- 599g	1,057	1,173	205	245	$1,348,8 77	$7,57 8	$8,73 7	$4,8 06	$5,8 84	$16,628,80 2	$15,5 85	$16,1 46	$10,5 24	$12,6 67
600g- 699g	1,065	1,189	231	279	$1,400,4 42	$6,83 1	$7,59 9	$4,5 94	$6,4 99	$21,046,48 9	$18,9 95	$21,1 46	$12,8 77	$16,2 46
700g- 799g	1,078	1,188	228	279	$1,574,3 71	$7,71 8	$8,80 3	$4,8 20	$6,8 32	$22,500,60 1	$20,3 44	$24,0 74	$13,8 01	$16,4 56
800g- 899g	985	1,116	226	285	$1,567,5 82	$8,20 7	$9,46 9	$4,5 75	$7,5 11	$21,925,79 4	$22,0 80	$22,5 13	$15,0 84	$17,4 90
900g-	1,155	1,293	243	308	$1,576,5	$7,10	$8,10	$4,3	$7,1	$27,606,29	$22,6	$27,5	$14,4	$17,1
999g					95	2	2	32	71	8	84	61	41	06
1000g- 1099g	1,061	1,220	247	315	$2,020,4 94	$9,85 6	$18,2 60	$5,3 64	$7,7 03	$24,436,48 8	$22,5 43	$24,1 36	$15,0 03	$17,7 79
1100g- 1199g	1,186	1,390	319	403	$2,571,1 11	$9,02 1	$13,7 88	$4,8 44	$6,9 74	$30,835,66 9	$24,5 31	$29,3 02	$15,1 69	$19,3 54
1200g- 1299g	1,156	1,366	281	367	$2,245,1 64	$9,43 3	$13,0 84	$4,9 19	$8,1 53	$28,881,37 8	$23,7 51	$27,0 80	$15,4 27	$16,6 59
1300g- 1399g	1,542	1,793	366	458	$2,944,6 28	$9,23 1	$15,3 21	$4,7 30	$7,8 47	$35,751,73 1	$22,2 06	$27,7 11	$13,9 40	$16,5 44
1400g- 1499g	1,503	1,794	399	535	$3,707,5 14	$10,9 04	$19,9 74	$5,9 29	$7,6 15	$37,414,10 4	$22,9 96	$27,6 83	$14,9 47	$16,3 39
1500g- 1599g	1,900	2,270	486	639	$3,984,6 99	$10,1 13	$18,2 28	$4,5 35	$7,1 30	$41,906,82 1	$21,3 05	$27,9 54	$13,4 98	$14,6 88
1600g- 1699g	1,917	2,300	505	665	$4,308,3 74	$9,90 4	$14,6 41	$5,3 80	$7,7 17	$41,670,02 0	$20,1 79	$22,4 27	$12,9 73	$14,0 65
1700g- 1799g	2,556	3,102	654	852	$5,754,3 71	$10,8 98	$17,1 21	$5,5 48	$8,7 10	$53,567,81 8	$19,6 72	$23,9 86	$12,7 15	$13,5 45
1800g- 1899g	3,372	4,014	780	1,025	$6,150,1 00	$9,62 5	$17,0 68	$4,9 15	$7,0 74	$60,467,51 3	$17,2 42	$21,1 67	$11,3 54	$10,5 60
1900g- 1999g	3,640	4,383	848	1,106	$7,185,2 61	$10,0 63	$15,2 44	$5,1 20	$7,1 22	$67,781,18 6	$17,3 00	$22,5 10	$11,2 71	$11,4 38
2000g- 2249g	15,099	17,612	2,971	3,965	$25,056, 771	$10,0 71	$17,2 20	$5,0 97	$7,4 59	$225,019,9 15	$14,3 00	$18,5 93	$9,61 8	$8,92 1
2250g- 2499g	32,494	35,938	4,309	5,734	$34,363, 653	$9,28 7	$15,2 85	$4,7 28	$6,7 50	$363,305,8 32	$10,9 87	$13,6 14	$7,96 4	$6,71 3
2500g- 2749g	67,631	71,182	6,179	7,944	$44,685, 552	$8,25 7	$14,9 32	$4,3 31	$5,9 19	$591,983,1 11	$8,89 9	$10,1 12	$6,90 6	$5,42 0
2750g- 2999g	150,33 1	153,08 2	9,259	11,435	$65,527, 554	$7,42 2	$15,1 28	$3,9 97	$5,3 91	$1,183,746,193	$7,89 9	$7,19 2	$6,45 7	$4,85 1
3000g- 3249g	239,98 4	241,59 1	11,511	13,666	$71,978, 320	$6,34 9	$9,70 4	$3,7 61	$4,8 92	$1,807,183,062	$7,53 2	$5,45 8	$6,32 0	$4,65 9
3250g- 3499g	266,94 6	267,67 7	11,226	13,066	$65,333, 476	$5,85 5	$8,75 4	$3,4 93	$4,5 30	$2,007,008,205	$7,51 5	$5,58 1	$6,34 9	$4,63 1
3500g- 3749g	216,42 1	216,70 0	8,223	9,445	$47,452, 246	$5,79 1	$9,42 6	$3,5 07	$4,3 71	$1,652,773,720	$7,63 4	$5,38 1	$6,47 4	$4,75 2
3750g- 3999g	130,82 0	130,92 5	5,081	5,809	$27,651, 791	$5,44 6	$7,44 2	$3,3 10	$4,4 36	$1,028,869,522	$7,86 1	$5,22 9	$6,64 7	$4,87 1
>=4000 g	99,621	99,687	4,117	4,713	$22,271, 189	$5,41 9	$6,90 1	$3,4 38	$4,3 86	$834,436,1 18	$8,37 3	$5,62 4	$7,08 2	$5,19 9

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight, Costs Adjusted to December, 2017

Table 12.

Maternal Costs by C-Section Status, Does Not Include Fetal Deaths^a

Gestational Age Group and Delivery Method		Maternal Cases	Live Births	Total Maternal Hospitalization Costs (Prenatal+Delivery)
		N	N	Total	Mean	StdDev	Median	IQR
Gestational Age Group		904	972	$10,977,285	$11,997	$11,950	$8,074	$9,783
<=24 Weeks	Vaginal
	C-section	797	911	$16,285,085	$20,180	$17,747	$14,899	$16,257
25–27 Weeks	Vaginal	858	878	$14,871,903	$17,273	$19,194	$10,423	$15,819
	C-section	1,961	2,304	$51,658,606	$25,920	$23,770	$18,809	$19,676
28–31 Weeks	Vaginal	2,041	2,147	$37,136,368	$18,010	$21,101	$11,159	$15,477
	C-section	4,764	5,908	$129,802,484	$26,780	$28,966	$17,720	$18,960
32–36 Weeks	Vaginal	42,402	43,803	$422,864,617	$9,946	$12,846	$6,816	$6,171
	C-section	37,469	45,182	$632,628,243	$16,770	$21,277	$11,198	$9,612
37–38 Weeks	Vaginal	214,419	215,779	$1,416,586,608	$6,602	$5,354	$5,373	$3,911
	C-section	121,030	126,845	$1,241,870,550	$10,254	$8,041	$8,462	$5,213
39–41 Weeks	Vaginal	558,933	559,420	$3,631,650,864	$6,494	$4,332	$5,491	$3,865
	C-section	248,684	249,453	$2,518,394,857	$10,123	$5,988	$8,619	$5,401
>41 Weeks	Vaginal	4,518	4,522	$35,629,442	$7,879	$5,228	$6,546	$5,046
	C-section	2,319	2,333	$30,343,163	$13,062	$7,565	$11,170	$7,983
< 28 Weeks	Vaginal	1,762	1,850	$25,849,188	$14,555	$16,093	$9,017	$12,014
	C-section	2,758	3,215	$67,943,691	$24,266	$22,351	$17,723	$18,273
<32 Weeks	Vaginal	3,803	3,997	$62,985,556	$16,411	$19,025	$10,062	$13,543
	C-section	7,522	9,123	$197,746,175	$25,859	$26,760	$17,720	$18,691
<37 Weeks	Vaginal	46,205	47,800	$485,850,173	$10,482	$13,583	$6,968	$6,597
	C-section	44,991	54,305	$830,374,417	$18,302	$22,554	$11,972	$11,160
All	Vaginal	824,075	827,521	$5,569,717,087	$6,754	$5,616	$5,524	$3,998
	C-section	417,024	432,936	$4,620,982,987	$11,066	$10,106	$8,817	$5,833
Gestational Age in Completed Weeks		265	296	$2,819,854	$10,405	$8,841	$7,563	$7,830
22	Vaginal
	C-section	52	55	$878,589	$16,270	$15,779	$9,648	$6,907
23	Vaginal	351	381	$4,326,517	$12,187	$12,911	$8,043	$9,640
	C-section	235	268	$4,473,113	$18,954	$18,224	$12,993	$14,635
24	Vaginal	288	295	$3,830,914	$13,256	$13,077	$8,576	$12,384
	C-section	510	588	$10,933,383	$21,148	$17,661	$17,316	$16,366
25	Vaginal	272	280	$4,085,699	$14,911	$14,737	$10,014	$14,108
	C-section	583	682	$14,438,700	$24,308	$21,501	$17,860	$18,897
26	Vaginal	282	286	$5,098,301	$18,015	$18,755	$11,408	$15,640
	C-section	646	752	$17,934,881	$27,215	$25,962	$19,585	$21,523
27	Vaginal	304	312	$5,687,903	$18,710	$22,693	$9,917	$17,701
	C-section	732	870	$19,285,026	$26,061	$23,415	$18,607	$19,395
28	Vaginal	318	333	$5,785,377	$18,079	$22,622	$11,126	$15,701
	C-section	895	1,102	$24,896,539	$27,180	$27,862	$17,973	$19,622
29	Vaginal	424	444	$8,813,981	$20,450	$25,506	$11,501	$16,738
	C-section	1,016	1,237	$28,589,961	$27,757	$27,540	$19,267	$20,762
30	Vaginal	565	593	$9,897,202	$17,394	$20,038	$10,760	$15,009
	C-section	1,260	1,556	$35,413,264	$27,645	$30,858	$17,963	$19,605
31	Vaginal	734	777	$12,639,808	$17,035	$18,115	$11,101	$13,995
	C-section	1,593	2,013	$40,902,720	$25,249	$28,880	$16,548	$16,657
32	Vaginal	1,257	1,327	$21,103,677	$16,670	$19,013	$10,161	$14,447
	C-section	2,435	3,061	$63,105,037	$25,466	$31,022	$16,230	$16,936
33	Vaginal	2,197	2,331	$34,512,965	$15,539	$18,907	$10,023	$11,080
	C-section	3,392	4,270	$76,479,895	$22,395	$27,377	$14,919	$13,838
34	Vaginal	5,564	5,818	$75,220,228	$13,454	$19,251	$8,246	$8,918
	C-section	5,958	7,448	$119,273,860	$19,806	$23,975	$12,754	$12,039
35	Vaginal	10,148	10,514	$98,767,283	$9,715	$11,336	$6,978	$6,089
	C-section	8,963	10,887	$144,546,336	$16,023	$19,458	$10,960	$8,980
36	Vaginal	23,236	23,813	$193,260,464	$8,305	$9,563	$6,214	$5,072
	C-section	16,721	19,516	$229,223,114	$13,654	$16,804	$9,948	$7,286
37	Vaginal	61,651	62,340	$443,839,000	$7,194	$6,739	$5,650	$4,331
	C-section	34,476	37,735	$396,063,058	$11,473	$10,222	$9,118	$6,074
38	Vaginal	152,768	153,439	$972,747,608	$6,364	$4,659	$5,278	$3,757
	C-section	86,554	89,110	$845,807,491	$9,769	$6,924	$8,235	$4,875
39	Vaginal	272,410	272,673	$1,715,455,407	$6,295	$4,172	$5,326	$3,697
	C-section	156,463	157,030	$1,493,659,266	$9,544	$5,583	$8,190	$4,838
40	Vaginal	227,380	227,546	$1,471,321,446	$6,467	$4,018	$5,503	$3,842
	C-section	69,477	69,639	$742,585,403	$10,682	$6,222	$9,151	$5,804
41	Vaginal	59,143	59,201	$444,874,011	$7,516	$5,820	$6,338	$4,794
	C-section	22,744	22,784	$282,150,188	$12,392	$7,132	$10,652	$7,330
42	Vaginal	4,082	4,086	$32,831,543	$8,035	$5,364	$6,694	$5,264
	C-section	2,087	2,097	$27,683,026	$13,239	$7,419	$11,384	$8,136
43	Vaginal	302	302	$1,951,385	$6,462	$3,442	$5,730	$3,610
	C-section	171	174	$2,051,436	$11,997	$9,546	$9,438	$6,661
44	Vaginal	97	97	$617,879	$6,370	$3,432	$5,764	$2,716
	C-section	50	51	$505,381	$10,108	$5,331	$8,552	$5,186
45	Vaginal	37	37	$228,634	$6,179	$2,810	$5,657	$3,136
	C-section	11	11	$103,320	$9,393	$3,565	$8,708	$4,217

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age, Costs Adjusted to December, 2017

Table 13 provides data on how costs are split between hospitals and physicians by GA and BW (see Table 14 [available at www.jpeds.com] for more detailed data). For each cell, we report the number of cases and mean hospital and physician costs, separately for mothers and infants. Overall, physician costs are 31% of total costs for mothers and 18% of the total costs for newborns. The physician’s share of total costs is almost unchanged as GA changes for both mothers and infants; the infant physician share increases to 29% for extremely preterm cases, and the maternal physician share decreases to 29% for these cases.

Table 13.

Mean Maternal and Newborn Hospital and Professional Costs^a,b

	Maternal Count	Total Maternal Hospital Costs	Total Maternal MD Costs	Live Births	Total Newborn Hospital Costs	Total Newborn MD Costs
	N	Mean	Mean	N	Mean	Mean
Obstetrician Estimate of Gestational Age Group	2,695	$9,814	$4,145	1,883	$216,834	$51,332
<=24 Weeks
25–27 Weeks	3,366	$15,332	$6,111	3,182	$286,881	$67,155
28–31 Weeks	7,510	$16,341	$6,498	8,055	$136,201	$30,165
32–36 Weeks	81,012	$9,344	$3,796	88,985	$18,635	$3,704
37–38 Weeks	336,080	$5,459	$2,464	342,624	$2,887	$566
39–41 Weeks	808,107	$5,165	$2,448	808,873	$2,107	$397
>41 Weeks	6,852	$6,584	$3,049	6,855	$2,995	$589
< 28 Weeks	6,061	$12,877	$5,236	5,065	$260,840	$61,273
<32 Weeks	13,571	$14,794	$5,934	13,120	$184,318	$42,174
<37 Weeks	94,583	$10,134	$4,106	102,105	$39,924	$8,647
All	1,245,622	$5,631	$2,582	1,260,457	$5,387	$1,113
Birth Weight Group	1,239,034	$5,590	$2,567	1,254,908	$4,293	$854
Extremely LBW, <1000g	6,588	$13,242	$5,362	5,549	$252,851	$59,667
Very LBW <1500g	13,271	$14,951	$5,949	13,017	$180,644	$41,387
BW 1000–1499g	6,683	$16,630	$6,526	7,468	$126,992	$27,805
All LBW, <2500g	75,920	$10,569	$4,280	84,983	$46,230	$10,058
BW 1500–2499g	62,649	$9,632	$3,923	71,966	$21,917	$4,392
BW >=2500g	1,169,702	$5,309	$2,471	1,175,474	$2,435	$466

Abbreviations: LBW, low birth weight; BW, birth weight.

^aData Source: 2009–2011 California Linked Vital Statistics – Patient Discharge Data

^bCosts Producer Price Index Adjusted to December 2017

Table 14.

Mean Maternal and Newborn Hospital and Professional Costs^a

	Maternal Count	Total Maternal Hospital Costs	Total Maternal MD Costs	Live Births	Total Newborn Hospital Costs	Total Newborn MD Costs
	N	Mean	Mean	N	Mean	Mean
Gestational age in completed weeks based on OB estimate of GA from BC	731	$7,467	$,3,395	351	$58,748	$,13,784
22
23	931	$9,361	$,4,113	649	$181,247	$,43,280
24	1,033	$11,882	$,4,691	883	$305,830	$,72,176
25	1,028	$13,908	$,5,509	962	$332,811	$,79,837
26	1,123	$16,168	$,6,448	1,038	$292,539	$,68,720
27	1,215	$15,761	$,6,313	1,182	$244,532	$,55,459
28	1,419	$16,129	$,6,508	1,435	$203,292	$,45,820
29	1,612	$17,142	$,6,846	1,681	$158,925	$,35,993
30	1,983	$16,776	$,6,567	2,149	$125,150	$,27,390
31	2,496	$15,600	$,6,211	2,790	$96,513	$,20,739
32	3,913	$15,684	$,6,137	4,388	$72,253	$,15,229
33	5,773	$13,955	$,5,500	6,601	$49,540	$,9,880
34	11,736	$11,849	$,4,803	13,266	$29,139	$,5,768
35	19,334	$9,033	$,3,630	21,401	$14,911	$,2,883
36	40,256	$7,470	$,3,105	43,329	$7,120	$,1,370
37	96,440	$6,084	$,2,649	100,075	$3,955	$,783
38	239,640	$5,207	$,2,390	242,549	$2,447	$,476
39	429,143	$5,095	$,2,386	429,703	$2,116	$,396
40	297,028	$5,031	$,2,424	297,185	$2,004	$,380
41	81,936	$6,011	$,2,861	81,985	$2,436	$,469
42	6,183	$6,675	$,3,117	6,183	$2,883	$,572
43	473	$5,969	$,2,494	476	$3,854	$,658
44	147	$5,309	$,2,332	148	$5,153	$,1,203
45	49	$4,899	$,2,041	48	$2,359	$,336
Birth Weight Group	1,102	$8,464	$,3,695	397	$134,405	$,34,863
<500g
500g-599g	1,057	$11,028	$,4,556	831	$206,411	$,50,078
600g-699g	1,065	$13,554	$,5,441	939	$294,631	$,69,027
700g-799g	1,078	$14,561	$,5,783	978	$317,414	$,74,946
800g-899g	985	$15,910	$,6,170	966	$297,750	$,70,940
900g-999g	1,155	$16,126	$,6,557	1,116	$227,682	$,51,326
1000g-1099g	1,061	$16,271	$,6,272	1,105	$184,311	$,41,441
1100g-1199g	1,186	$17,603	$,6,928	1,262	$163,181	$,35,909
1200g-1299g	1,156	$17,080	$,6,671	1,282	$140,672	$,31,032
1300g-1399g	1,542	$15,881	$,6,325	1,663	$111,823	$,24,278
1400g-1499g	1,503	$16,520	$,6,476	1,672	$96,929	$,20,774
1500g-1599g	1,900	$15,288	$,6,017	2,167	$82,277	$,17,409
1600g-1699g	1,917	$14,525	$,5,654	2,219	$68,256	$,14,372
1700g-1799g	2,556	$14,156	$,5,516	3,007	$55,625	$,11,377
1800g-1899g	3,372	$12,303	$,4,939	3,903	$44,636	$,9,211
1900g-1999g	3,640	$12,376	$,4,924	4,287	$37,870	$,7,520
2000g-2249g	15,099	$10,185	$,4,114	17,343	$22,546	$,4,439
2250g-2499g	32,494	$7,746	$,3,241	35,680	$10,728	$,2,077
2500g-2749g	67,631	$6,186	$,2,713	70,948	$4,858	$,946
2750g-2999g	150,331	$5,428	$,2,471	152,824	$2,896	$,550
3000g-3249g	239,984	$5,135	$,2,396	241,354	$2,296	$,435
3250g-3499g	266,946	$5,105	$,2,410	267,527	$2,081	$,397
3500g-3749g	216,421	$5,181	$,2,453	216,594	$2,022	$,383
3750g-3999g	130,820	$5,339	$,2,522	130,853	$2,096	$,404
>=4000g	99,621	$5,742	$,2,631	99,540	$2,825	$,558

Abbreviations: OB, Obstetrician; GA, gestational age; BC, birth certificate.

^a2009–2011 CA Linked Data, Matched Good Cost/Length of Stay Cases Only, By Obstetrician Estimate of Gesational Age and Birth Weight, Costs Adjusted to December, 2017

Table 15 (available at www.jpeds.com) reports the combined maternal and infant costs.

Table 15.

Total Pregnancy Costs (Maternal + Newborn)^a

	Live Births	Total Costs (Maternal + Newborn)
	N	Total	Mean	StdDev	Median	IQR
Gestational Age in Completed Weeks	351	$28,270,704	$80,543	$238,350	$10,128	$12,898
22
23	649	$151,210,671	$232,990	$316,976	$43,511	$441,914
24	883	$342,453,921	$387,830	$354,636	$353,556	$504,124
25	962	$411,824,474	$428,092	$310,320	$387,711	$330,098
26	1,038	$395,339,464	$380,867	$266,779	$330,467	$253,300
27	1,182	$375,136,762	$317,375	$231,074	$266,695	$206,008
28	1,435	$381,863,108	$266,107	$192,807	$216,351	$176,597
29	1,681	$363,328,476	$216,138	$148,320	$177,472	$130,816
30	2,149	$370,625,057	$172,464	$146,545	$136,881	$99,641
31	2,790	$378,787,426	$135,766	$116,382	$106,492	$82,230
32	4,388	$465,565,715	$106,100	$98,854	$81,481	$64,939
33	6,601	$500,238,703	$75,782	$77,840	$56,434	$46,964
34	13,266	$653,782,062	$49,283	$66,335	$36,287	$37,556
35	21,401	$620,431,558	$28,991	$51,019	$16,193	$24,732
36	43,329	$783,044,396	$18,072	$39,874	$9,936	$11,307
37	100,075	$1,305,534,317	$13,046	$29,523	$8,285	$7,084
38	242,549	$2,509,261,741	$10,345	$19,775	$7,654	$5,638
39	429,703	$4,254,893,585	$9,902	$15,653	$7,715	$5,526
40	297,185	$2,904,457,464	$9,773	$12,957	$7,559	$5,813
41	81,985	$959,076,569	$11,698	$15,966	$8,907	$7,374
42	6,183	$81,492,457	$13,180	$16,332	$9,640	$8,515
43	476	$5,885,793	$12,365	$14,953	$8,556	$7,024
44	148	$2,063,966	$13,946	$32,959	$8,345	$5,909
45	48	$461,306	$9,611	$8,627	$7,937	$3,977
All	1,260,457	$18,245,029,694	$14,475	$41,306	$8,050	$6,581
Birth Weight Group	397	$71,776,226	$180,797	$337,756	$17,909	$145,007
<500g
500g-599g	831	$220,747,000	$265,640	$341,601	$81,115	$451,815
600g-699g	939	$351,327,906	$374,151	$337,276	$347,349	$492,734
700g-799g	978	$397,890,972	$406,841	$307,160	$364,003	$336,124
800g-899g	966	$373,912,800	$387,073	$281,942	$335,030	$277,589
900g-999g	1,116	$333,066,156	$298,446	$222,638	$248,839	$204,913
1000g-1099g	1,105	$271,926,548	$246,087	$186,113	$205,357	$179,340
1100g-1199g	1,262	$275,913,566	$218,632	$167,668	$174,707	$149,311
1200g-1299g	1,282	$246,188,847	$192,035	$145,441	$154,249	$135,230
1300g-1399g	1,663	$257,218,328	$154,671	$137,757	$124,255	$110,778
1400g-1499g	1,672	$230,108,926	$137,625	$116,592	$107,186	$97,424
1500g-1599g	2,167	$254,345,914	$117,372	$110,864	$90,431	$82,518
1600g-1699g	2,219	$220,236,716	$99,250	$90,608	$76,403	$72,662
1700g-1799g	3,007	$251,002,784	$83,473	$78,488	$63,911	$59,784
1800g-1899g	3,903	$266,708,444	$68,334	$82,948	$48,666	$54,046
1900g-1999g	4,287	$254,401,864	$59,343	$70,628	$42,210	$47,824
2000g-2249g	17,343	$679,768,621	$39,196	$58,506	$23,711	$36,530
2250g-2499g	35,680	$803,355,521	$22,516	$45,739	$10,902	$16,189
2500g-2749g	70,948	$1,011,619,403	$14,259	$30,325	$8,471	$7,684
2750g-2999g	152,824	$1,696,699,996	$11,102	$21,411	$7,755	$6,077
3000g-3249g	241,354	$2,448,615,286	$10,145	$19,301	$7,571	$5,688
3250g-3499g	267,527	$2,653,852,767	$9,920	$17,313	$7,618	$5,661
3500g-3749g	216,594	$2,160,972,107	$9,977	$13,754	$7,767	$5,808
3750g-3999g	130,853	$1,348,446,455	$10,305	$12,747	$7,992	$5,988
>=4000g	99,540	$1,164,926,540	$11,703	$18,553	$8,681	$6,804

Abbreviations: Std Dev, standard deviation; IQR, interquartile range.

^a2009–2011 California Linked Data, Matched Good Cost/Length of Stay Cases Only, By Gestational Age and Birth Weight (Live Births Only), Costs Adjusted to December, 2017

Discussion:

These data provide a population-based update to the birth hospitalization costs and days of care for mothers and neonates. These cost estimates also include physician costs, which have been lacking in most previous studies. Both maternal and especially newborn costs are sensitive to GA and BW, with the highest average costs accruing for infants born with a GA<28 weeks, and for mothers delivering between 28 and 36 weeks gestation. Newborn costs, especially those for the most preterm infants, are also sensitive to changes in survival. Compared with prior work,¹² the increase in survival among premature infants is the driver behind the 7% increase in the share of infant costs incurred by preterm infants.

Our data show how the costs for maternity and neonatal care have increased in the 10 years since we previously reported these population-based costs for California.¹² The mean maternal cost increased from $3,641 to $8,204, and the mean infant cost increased from $3,567 to $6,389. Our previous estimates did not include estimated physician reimbursement; if physician fees are excluded, the mean maternal cost is $5660 (55% increase) and the mean newborn cost is $5,239 (47% increase). Adjusting for inflation, these cost increases are modest; 10.3% for maternal delivery hospitalizations and 4.3% for neonatal hospitalization costs.²⁰ Some of the increase in maternal costs is likely associated with the increased rate of cesarean deliveries (mean difference of $4,550 (Table 12), which has reversed in more recent years.²² These differences help highlight why it is important to periodically update the estimates of the costs of maternal and infant care to account for changes in survival and clinical practice.

Although the overall newborn costs have been essentially constant, those for the smallest infants have increased; after adjustment for physician fees and inflation, the costs for very preterm infants increased by 92.4%. Some of this can be attributed to the fact the survival roughly doubled for these smallest infants, and the difference is sensitive to GA, at the lowest GA the average cost for a survivor is hundreds of thousands more than for non-survivors (Table 5 and Table 6). But because the mean LOS for these infants only increased by about 10 days, the increased survival does not account for the all, or even most of the 90% increase in costs for these infants. Although our analyses are not designed to identify the causes, this implies that these infants have become significantly more expensive to treat, both overall, and in cost/day. Additional analyses are needed to understand why very preterm infants have become so much more expensive to treat.

The maternal data highlight some important public health trends in maternal child health. First, operative mode of delivery increases the costs of childbirth by 63%, with even greater increases seen in women who deliver prematurely. These costs are secondary to both physician fees, which are increased for operative deliveries, and for the longer lengths of stay typically seen in women who deliver via Cesarean delivery. With growing evidence that many of these deliveries may be occurring in low-risk women,^5,23 the baseline added costs of these deliveries are a concerning trend in maternity care. Second, we found significant economic impact of the women who deliver moderately and late preterm, with similar lengths of stay for women who deliver 32–36 weeks gestation to those who deliver at 24 weeks or less and greater overall costs of care.

Neonatal data differ from maternal data in the importance of the outlier patients: for neonates, the 1.2% of infants whose costs were >$100,000 made up 51% of the economic impact of newborn care, whereas the 2.1% of women whose costs were >$25,000 only made up 11% of the maternal costs. These infants are the sickest, smallest infants whose lengths of stay, medical requirements, and transfers of care within the medical system are the greatest, and provide an area of intervention to reduce the economic costs of neonatal care.

There are limitations to our data. They are from California, where hospital costs are higher than the US average. Care patterns and costs could be different in other parts of the country. In 2014, average US hospital costs were 69% of those in California,²⁴ which can be used as the basis of adjusting our results to obtain estimates of the national average costs for delivery care.²⁴ When considering aggregate costs, one also needs to consider that preterm rates in California are lower than the national average. Thus, using these data to project national costs would require adjustments for the differences in the GA distribution.

There are some limitations to the estimated costs in our study as we did not directly observe either physician or hospital costs. First, the hospital and physician costs are not fully equivalent. The hospital costs are estimated by converting hospital charges to estimated costs using hospital-level cost to charge ratios, and physician costs are estimated by the average payments to physicians, measured separately for privately insurance and Medicaid. In addition to not being equivalent, each of these methods of estimating costs has limitations. For hospital costs, it is possible that these ratios do not reflect the actual difference between costs and charges for care provided in neonatal and obstetric units. However, these methods have been used for estimating neonatal and obstetric unit hospital costs in prior work. There is no way to know the extent that this may bias the estimates, but we expect that any bias will be moderate. For physician costs, we are making the assumption that the actual physician revenue is a reasonable proxy for costs.

Our results are also sensitive to the choice of index to adjust for inflation, but there is no “perfect” index to adjust hospital costs for inflation.²¹ It has been demonstrated that the medical component of the consumer price index (MCPI) significantly overstates actual medical care inflation. Because the results of our analysis are the production costs of care for mothers and neonates, a producer price index (PPI) is more consistent with our intent. Producer price indices also have limitations as they are based on revenue to producers and there are significant disconnects between revenue and production costs for hospitals, which vary greatly across different types of insurance. Although the Bureau of Labor Statistics recently started reporting separate hospital PPIs for different types of insurance, these don’t extend back to 2000, which would preclude the comparisons that we make to our previous work. Table 16 (available at www.jpeds.com) shows how the different measures would affect the inflation adjustments for 2010 to 2017 and 1999 to 2017. In general, with the exception of the MCPI, the effect of the choice of index on the inflation adjustment is small. Of note, there is no consistency over which measure has the higher inflation adjustment; for example the overall PPI has a larger inflation adjustment than the Hospital Services PPI for 1999 to 2017, but a lower adjustment for 2010 to 2017.

Table 16.

Different Measures of Inflation

	Inflation Index
	December, 1999	December, 2010	December, 2017	Change 2010 to 2017	Change 1999 to 2017
Overall Consumer Price Index for All Urban Consumers (CPI-U)	168.3	219.2	246.5	27.3	78.2
Medical Component of CPI, or MCPI	254.2	391.9	509.0	117.1	254.8
Producer Price Index (PPI)	128.0	189.9	196.4	6.5	68.4
Hospital Services PPI	69.1	103	118.5	15.5	49.4
PPI for General and Surgical Hospitals - Medicare Patients		160.6	168.4	7.8
PPI for General and Surgical Hospitals - Medicaid Patients		137.0	140.1	3.1
PPI for General and Surgical Hospitals - All Other Patients		202.1	253.1	51.0

The exclusion of all Kaiser cases due to a lack of cost information is also a potential source of bias, as these cases are predominantly patients with private insurance. However, the share of patients with private insurance is still large (48%) and the net effect of this exclusion is modest; if all of the Kaiser cases had been included, privately insured patients would make up 54% of the sample.

Our exclusion of infant readmissions does result in the exclusion of some costs that could be considered related to delivery. Although the highest volume of these cases is probably related to neonatal jaundice, the impact of excluding the jaundice cases should be moderate, given their relatively low cost.²⁵ Conversely, there are cases of readmission incurring much higher costs; such as infants readmitted for major cardiac surgery. Also, the sickest infants born at the youngest gestational ages have the highest risk of a hospital readmission, which adds to the economic burden of these high severity patients.²⁶

In conclusion, our data demonstrate that maternal and infant costs are sensitive to both the timing of delivery; the mode of delivery; and changes in survival especially for the sickest of infants. Even with these increasing costs, neonatal intensive care remains a highly cost-effective intervention when compared with other interventions.^27–29 Such data highlight the persistent economic impact of childbirth in the United States and areas for further intervention in the face of ongoing changes in survival and technology.

Figure 1:

Derivation of the Study Sample

Abbreviations

BW

birth weight

GA

gestational age

IQR

interquartile range

LBW

low birth weight

LOS

length of stay

Std

Dev standard deviation