Health Care And Birth In Spain vs. The United States

This is a topic I have wanted to tackle for a long time now, but I also wanted to have all of my information straight before I began. So many Europeans ask me about the health care system in the States and comment on how appalling it is that for being such an advanced country in many ways, the health of our own citizens isn’t a priority. (Agreed!) However, I often find myself rattling off numbers and data that I’m not entirely sure of, so employing the help of a new mom in the US for this post was vital. Luckily, I was recently put in touch with Kelly, an American married to a Spaniard living in Chicago, who just gave birth to her first baby only a few days before we welcomed Enzo. We’ve bonded over our shared views of politics, the general (though not entire) crappy-ness of living in the States compared to Spain, and being kept up all night by sassy newborns. What all great friendships should be made of, really. She agreed to be a part of this interview-style post in order to shed light on what the experience is truly like having a baby in the United States versus in Spain.

Something I should mention before we start is that the average monthly income in the United States vs. Spain. In Spain, the average person will be making between 1,200-2,000 euros per month, after taxes. The Bureau of Labor Statistics says that the median American monthly income is roughly $3,460. That’s not exactly a small difference, and should be kept in mind when we talk about insurance costs as well as maternity and paternity leave. That said, it is no excuse.

How much do you pay for health care?

Kelly (USA): I believe that I pay somewhere around $150-200/month, taken out of my paycheck. My deductible is $2000, I have a $4000 maximum out of pocket yearly spend. I also contribute $2,500/year to an HSA account (pre-tax) and my employer gives $1000. I would say that I have standard insurance for a person working at a large corporation. Middle of the road!

(For anyone who isn’t super familiar with how American health insurance works, (me), let’s break this down. She says she pays 150-200 a month, only for herself, plus a $2000 deductible. That means anything she has to pay for out of pocket because it isn’t covered by insurance like certain visits, medicines, x-rays, etc, go towards this 2,000. Once she reaches that she will pay 20% of any other out of pocket expenses until she reaches $4,000. Then, she is “fully covered”. If you don’t have a calculator out, that means she would pay roughly $5,800-$6,400 before she would be fully covered by insurance. Also, for those wondering, an HSA is a Health Savings Account where she can use that money to put towards her medical expenses not covered by insurance.)

Emily (Spain) : Up until two years ago I never paid a cent towards health insurance. I lived for almost nine years, going for countless blood tests, doctor’s appointments, yearly gyno appointments, an MRI for my knee, x-rays, ultrasounds on my kidneys, and standard yearly check-ups and flu shots, and I was never asked to pay a dime. Nothing comes for free of course, because obviously my taxes go towards that. Based on my income I pay 13% of my income to taxes. But still. Pretty much free.

Like I said, this was up until two years ago. My husband started working for a company which offered some sort of deal, and now we pay 134 euros monthly for my husband and I, plus our infant son to have private health insurance. Why did we do it if we have the public system for free? Most people make this decision based on the sometimes extensive wait times and limited schedule in the public system. The private is very convenient and has a large range of availability during the morning and evening and wait times for surgeries and treatments tends to be far less. In our personal situation, as we started to think about having a baby, we knew we wanted to have access to the private system during pregnancy and birth for conveniency as well as extra ultrasounds and access to a private hospital for birth, so paying something like 70 euros a month for the two of us was worth it. However, we do not pay anything extra towards our insurance such as a deductible or “max out of pocket”. Anything and everything we would require would be covered from the start.

How many appointments did you have during your pregnancy?

Kelly (USA): I had appointments at the following interval:

  1. Blood test to prove pregnancy at 6 weeks,
  2. Ultrasound at appointment to make sure it was in the right place, because I was considered high-risk due to a previous ectopic. I don’t believe you’re eligible with US insurance until 8 weeks otherwise.
  3. Then ultrasound at 8 weeks to make sure it was progressing
  4. 13 weeks (supposed to be 12) because I paid for genetic screening and this is the one where they measure the Nuchal Translucency, but only if you opt into that testing. If you’re under 36 you need to pay out of pocket for the genetic blood tests for abnormalities and also for this ultrasound. I believe it was ~$850.
  5. Then I had the standard 20 week ultrasound where they measure all aspects of the baby at the hospital
  6. Since I was no longer high risk I didn’t have one again until 36 weeks and that was only for them to make sure baby was head down! I would have preferred more visits and attention but I guess I got the “standard of care” as allowed by large insurance carriers. 

Emily (Spain): I had a bit of a weird, “oh I’m pregnant!” experience so I started in the private health system first. I had missed my period and taken a test, but it came back as negative. I waited a bit more, still nothing, so I went to get a check up. The gynecologist did an internal ultrasound and saw nothing. I waited a bit more, STILL nothing happening, and went to be seen again for an internal ultrasound where yes, they finally saw something. Then, I had a blood test to confirm it and another ultrasound shortly thereafter. I paid nothing for any of this, and this was technically before my typical appointments for pregnancy would have started because the pregnancy wasn’t even confirmed yet. After this, I did everything in the public system, and used the private for monthly ultrasounds. In the public system alone I had the following appointments:

  1. Blood test to confirm pregnancy
  2. Appointment with the midwife, (and my husband) where she asked all about my and my husband’s family history, blood types, weight, blood pressure, and go over everything we should and shouldn’t do during your pregnancy. This appointment was long–maybe 45 minutes, when most other appointments usually didn’t even last 10.
  3. Blood test and appointment a few days later with doctor to go over results
  4. Ultrasound and blood test between 12-14 weeks to screen for Down Syndrome and other abnormalities
  5. Appointment with midwife to see how things are going, check baby heart rate, weight and blood pressure
  6. Ultrasound at 20 weeks to check to make sure baby is still looking good!
  7. Glucose test. Barf.
  8. Check up with midwife–weight, blood pressure, baby’s HR, etc.
  9. Dtap vaccine
  10. Another check up with midwife (I had five check ups with her, plus one about a week after the birth)
  11. Ultrasound for the third trimester
  12. Appointment with the midwife after birth to check how I was physically and mentally after the birth.

Obviously these weren’t all appointments with my midwife or ultrasounds–some were simply tests or vaccines, but I felt like the overall standard of care was fantastic. And, again, FREE. I chose not to give birth in the public system simply because I wanted more privacy and, when necessary, new moms have to share a room with another new mom–and her new baby–and I was not up for that. But all of the medication, anesthesia, potential surgical interventions, postnatal care for me as well as baby, including any time he may have needed in the NICU, would have never cost me a cent. (It also didn’t cost me anything in the private hospital, either, but more on that later.)

Were you provided with birthing classes (free or otherwise) by your physician?

Kelly (USA): No, due to Covid we didn’t get anything… if they did offer I’m pretty sure you had to pay out of pocket. 

Emily (Spain): Yes, birthing classes are included in the public health system, and your employer is legally obliged to give you any necessary time off to attend them–without docking your salary– (classes are usually only offered during a certain time frame so it isn’t like you can just go after work). Like Kelly, ours were cancelled but were later offered online, again, free of charge. I believe it was roughly 12 or 15 hours of classes over the course of 5-6 weeks.

How many ultrasounds did you have? 

Kelly (USA): Five total, but one was because I was initially high risk, and another was optional testing done at week 12.

Emily (Spain): Three in the public system, and one every month in the private, except the last month I think I had two. So roughly…12 or 13 total. When I say it out loud it sounds a bit ridiculous, but it was really nice to know we would be checking up on him at least once a month.

How much did your prenatal vitamins cost, and how many were in each pack?

Kelly (USA): In the US you are responsible for getting your own prenatals over the counter. I think mine were $40/50 a bottle (maybe lasted 1-1.5 months??) because I chose organic etc etc. Standard ones were probably cheaper.

Emily (Spain): My packs lasted one month and cost around 2.50 euros.

How long did you spend at the hospital after birth? Was there a maximum number of nights imposed by your insurance?

Kelly (USA): So my insurance only allowed for 24 hours for vaginal and 48 hours for c-section. BUT I was lucky enough (LOL) to get last minute high blood pressure during the birth, so they had to put me on a magnesium drip which gave me an extra night in the hospital because they need to monitor you afterward. Apparently it’s super dangerous? I actually went into early labor (probably due to said last minute blood pressure spike) that sent me to the hospital at 37 weeks 6 days. Well, they SENT ME HOME after 4 hours of monitoring my blood pressure and contractions because I was “on the edge” of it being considered dangerous— and the insurance wouldn’t allow for any inductions or interventions until 38 weeks. The poor nurse felt SO badly for me. So since baby girl was taking my high blood pressure spikes like a champ, we went home. Again, because it was ONE DAY before insurance allowed. I had to go home under the instructions of “don’t come back unless the pain is so bad you cannot breathe / speak a sentence”. I called at 1am that night sobbing and said I couldn’t take it anymore and they said since it was past midnight (aka 38 weeks) I could come back. I got there and my labor had progressed to 4 cm so I got to stay (!!!!!) and get my epidural / induction. America is awesome, best country ever don’t forget.

Emily (Spain): During a standard vaginal birth the typical hospital stay is 2 nights, whether you’re in the private or the public. If you or baby had any complications, this would obviously extend. I think 3 nights is typical for a C-section. That being said, unlike Kelly, I never needed to count hours or withstand unbearable pain because of any protocols imposed on me. My entire stay, as well as baby’s was covered in both public and private hospitals. Again, had baby or I had any complications or needed to stay at the hospital longer, it is all 100% covered. As it should be!

Did you receive any bills for your appointments and/or the birth of your baby?

Kelly (USA): I think without insurance the birth was $45,000 or so. With insurance I paid up to my max but my insurance is July-July at my employer so I’m already starting over again from 0. Fun. Also got a huge bill for Nora but we think it was a mistake because she’s actually a dependent on my husband’s plan so hopefully that gets taken care of. It was for $3,750 for HER hospital stay (aka, being born). 

Emily (Spain): Nope.

What was your maternity leave like?

Kelly (USA): My employer has no official plan – they allow for you to take 6 weeks short term disability (covered 100% by my employer) for vaginal birth. In my case they paid 60% of your weekly pay up to 2,500/week max based on your prior year W2. Luckily I got the max so I actually made money, but most people at my company take a HUGE hit on this and have to financially plan ahead knowing they’ll only be getting 600/week or something during that period. Then I took 6 more weeks unpaid FMLA (government required family medical leave). I felt lucky that I got anything and that my employer is flexible with me. I don’t know anyone who has it better than that. Maybe 4 weeks paid at normal salary plus FMLA? But since I’m sales and not salaried like a normal person, I felt lucky to get the disability payments. 

(Here I’d like to point out the difference in salaries, as in Spain making $2,500 even in one month is almost unheard of, let alone in one week. I think it is worth pointing out because this makes a difference when the government has to cover your salary. It certainly isn’t an excuse, but still a valid point.)

Emily (Spain): Moms are given 16 weeks fully paid maternity leave, plus 120 hours for breastfeeding, which you can take either when you go back to work, making your work days shorter, or altogether which comes out to be 20 days. So all in all its about 5 months of paid leave. As a teacher my vacation is from the last week of July until September 1st, so that didn’t count towards my mat leave and was paid by my employer as well. Enzo was born on July 3rd and I am due back December 23rd. However, due to the holidays that means I won’t be back until January 7th. I swear I didn’t plan it, but it worked out pretty well!

As a side note, in Spain before you give birth, if your doctor determines that you need to go on bed rest or simply should start your leave early for any reason, the government pays (I believe) 60-75% of your salary during that time. Many employers also have insurance who will make up that difference. This does not cut into your maternity leave at all. Maternity leave begins the day your baby is born.

Your employer’s insurance company is also responsible for giving you leave depending on the nature of your job. Certain guidelines determine when you are eligible to go on leave such as working with chemicals, being on your feet for a certain number of hours per day, being exposed to certain levels of noise, having to lift heavy things, etc. Your employer is obligated to either offer you a different position and if they can’t, the insurance company pays your full salary until you give birth. Due to me working with very young children and having to lift, bend over, be on my feet, etc, I was off April 9th (28 weeks). It caught me mid-lockdown so it wasn’t a whole lot of fun but it was fantastic to be able to rest and get ready for baby, and do lots of yoga for back pain!

If you’re keeping track that means once I am back at work I will have been off for almost 10 full months at my full salary. Granted, I don’t make in a month the maximum that Kelly’s employers would pay in a week, but in Spain, its also not necessary as the cost of living is so much lower.

Did your partner receive any paternity leave? If so, how much and was it paid or unpaid? 

Kelly (USA): My husband got 2 weeks paid lol.

(Side note–as lame as 2 weeks off is, I know that not all dads in the US even get this much, and some are forced to take their vacation time in order to spend more time at home with mom and baby.)

Emily (Spain): Paternity leave has improved greatly in recent years. Just five years ago or so dads were only allowed 2 weeks as well. However, governments in recent years have made it a priority and dads now get 12 weeks fully paid by the government. As of January of 2021, if all goes well, dads will receive 16 weeks fully paid, just like moms. I think the first 4 they have to take immediately following the birth and the rest they can take during the first year of baby’s life, which helps for childcare purposes and allows dads a lot more time to be involved with baby. It also makes becoming a dad just as much of a “pain” for employers as becoming a mom.

So what are the key take aways here? That the American system is horrible and Spain’s is perfect? Certainly not. I am sure those moms who have experienced both systems would be able to better tell you which one they truly preferred, or at the very least, tell you the advantages and disadvantages of both. For one thing, I can tell you that even in a private hospital in Spain, it won’t look like your average boujee American hospital. However, on a very basic human level, it is clear that pregnancy and birth in Spain are much more sacred and treated as a respected time during your life. It is engrained in the culture that you should rest and take care of yourself both before and after baby, and that there is no need to become “Supermom” or “Superdad” just weeks after baby is born. Becoming a new parent is one of the most biggest challenges a person can take on, and the very least we can ask of our government is to respect that. Here’s hoping that the US starts doing so soon.


Are you a parent in a different country? Did you give birth to your baby abroad or in the States? What was your experience like? I’d love to read about it in the comments below!

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