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Managing hospital bills after giving birth isn’t much different than having a baby again. If that sounds far-fetched, consider the parallels: Despite careful planning, you can’t possibly predict how things will turn out. You’ll be confused by the jargon. You’ll encounter deeply troubling aspects of our health care system. You’ll be overwhelmed. You’ll hear that they “do it better in Europe.” And you’ll wonder how the hell the majority of American women somehow manage it.

I don’t know any mother (including myself) who really understood the flood of bills that arrived in the mail after giving birth. Many new parents don’t bother to analyze the individual items – they have their hands full, after all. But it’s worth checking the costs. A friend of mine saw a bill for $5,000 for “room and board” for the day. after She left the hospital and when she brought it to attention, she was told it was a “mistake” – oops! Another friend had to pay an $11,000 “nursery fee” that her health insurance refused to cover because they considered it an “optional” expense. She had no idea what the fee was for until she realized one of the nurses had taken her newborn son out of the room for about 20 minutes to check his hearing, which was done in said “nursery” and definitely not offered as an “option.” She disputed the fee and after months of back and forth, the hospital dropped it.

Most pregnancies are considered low-risk and result in “uncomplicated” births. Nevertheless, the average cost of health care during pregnancy, birth and postpartum care is $2,854 – that is after Insurance, according to a recent analysis by KFF, an organization that researches health policy. That’s likely why one in five women have medical debt after giving birth, including those with private health insurance (which accounts for more than half of all births in the U.S.; Medicaid funds about 40 percent).

Also, don’t forget that your baby will have their own hospital bill too. This is for standard newborn tests (checking hearing, heartbeat, lung function, genetic disorders, etc.) and the average cost is usually between $400 and $1,000.

Here’s how these bills work: Hospitals have a list of fixed prices for their services called a “chargemaster.” The numbers on this list are almost arbitrary, sometimes more than three times the actual cost of the procedure (to maximize the hospital’s revenue, of course). Regardless, they’re for your insurance (or Medicaid), not for you directly. But the total amount will scare you when you see your first bill.

Then your health insurance company steps in, works its black magic, and conjures up the “allowable cost” – an adjusted amount negotiated for its policyholders. Your insurer then covers a large portion, leaving you with only out-of-pocket costs that are a fraction of the original cost – but usually still not to be sniffed at.

The point is, don’t freak out if you get five-figure bills right away. “These commercial fees are basically a ruse,” says Carol Sakala, the director of Childbirth Connection programs for the National Partnership for Women & Families. “Our research shows that hospitals charge an average of over $32,000 for a vaginal birth, but the actual amount paid by the insurance company, the mother and any other third parties is about $18,000. The cost you have to cover yourself is much, much less.”

So how can you predict what your bill might actually look like? It’s hard to estimate in advance. Of course, a major factor is what type of birth you’re having and where you live. A cesarean section is major surgery and costs about 50 percent more than a typical vaginal delivery. However, a vaginal birth with complications can quickly exceed the cost of a routine cesarean section. If your baby needs to go to the NICU, that can add thousands to your bill as well. In short, a lot of expensive things can happen during labor, delivery, and the aftermath. And like everything else, costs are higher in certain cities and states.

One way to prepare is to talk to your doctor beforehand, says John Hargraves, senior researcher at the Health Care Cost Institute. “Women are often embarrassed to bring up the cost of care, but it’s an important conversation,” he explains. “When choosing a hospital, ask your doctor if other patients have had problems with costs or if he or she can recommend someone you can talk to about it.”

Also, don’t be afraid to consult your insurer, as annoying as that may sound. Most insurance companies now offer relatively user-friendly portals that allow you to research approximate prices for services in your area without having to pick up the phone and wait half a day on hold. “Many people don’t know about their insurance’s transparency tools, and therefore don’t use them enough,” says Hargraves. “They’re a good resource when it comes to procedures with a big price difference, and childbirth definitely falls into that category.” Some health insurance companies even have apps that let you find local providers and see what co-payments to expect.

If you’re medically low risk, consider a birth center, a non-clinical health facility staffed by midwives. “We strongly recommend that healthy women choose a birth center over a hospital ward because costs are much lower, there are fewer interventions, and patient satisfaction is high,” says Sakala. Under the Affordable Care Act, insurance companies are required to cover government-licensed birth centers. Some birth centers are even attached to or located within hospitals, making it easy to transfer you if needed. However, they’re still quite rare and difficult to access. And if you’re thinking a home birth might be cheaper, guess again: Most insurance doesn’t cover it, so you’ll have to pay for midwife services and other related costs—which average $4,650—out of pocket.

Ultimately, over 98 percent of American parents deliver their babies in the most expensive way possible: in an American hospital. If you plan to be one of them, here’s a roundup of information, advice, and resources. (Please note that these numbers are taken from a 2022 KFF analysis and are based on health claims filed between 2018 and 2020; they are for parents with private health insurance, not Medicaid.)

Average total costs for prenatal, intranatal and postnatal care: 14,768 USD

Average cost price: $2,655

What you pay for: With a vaginal birth, you may still pay high fees for anesthesia and professional services, but your facility fees will be much lower because you are not in an operating room.

What you should pay attention to: Interventions to speed up labor, such as induction, that aren’t medically necessary. One way to reduce your chances of having a cesarean section is to hire a doula, a trained professional who acts as your advocate during labor. Research shows that women who hire a doula have significantly fewer cesarean sections—between 28 and 56 percent. Depending on where you live and the services you want, doulas can cost anywhere from $500 to $3,500. Some insurance companies will reimburse you for the cost; if your insurance doesn’t, hiring a doula may not save you any money, but it will likely make the birth process go more smoothly.

Average total costs for prenatal, intranatal and postnatal care: $26,280

Average cost price: 3,214 USD

What you pay for: Higher facility fees (hospital equipment, operating rooms, etc.) and anesthesia.

What you should pay attention to: The anesthesiologist. Sometimes different doctors, even those at the same hospital, accept different types of insurance, and the anesthesiologist on call may not be in your network. “This adds additional costs that you may not find out about until you get a surprise on your bill,” says Sakala. “Be sure to ask.” The best time to do this is before you’re admitted—your doctor should be able to tell you or at least point you in the right direction. However, you can also ask the anesthesiologist in person when they arrive—which is what I did in the delivery room!

All of your bills should be listed individually. The tedious task of going through them line by line is best outsourced to a partner or close friend. (I personally texted photos of all of my hospital bills to a nurse friend to make sure they looked right.) If you notice anything suspicious, call the number on the bill or have someone else do it. The error rate for medical bills is alarmingly high—as high as 80 percent, by some estimates.

If you can’t afford your bill, you’re welcome to a very big club. Most hospitals are open to “talking” about your payment options, which could mean anything from an outright reduction in your bill to an interest-free payment plan. So reach out if you need help—you’re not the only one.