What Are the Costs of a Multiple Pregnancy and Birth?

People often joke with Angela Roeber that she lucked out with a two-for-one deal by having twins. But for Roeber, this assumption "couldn't be further from the truth." For seven years, Roeber and her husband tried nearly everything to conceive—intrauterine inseminations (IUIs), multiple infertility clinics, blood draws, consultations with doctors out of state and out of network, and natural healing practices. Despite having a successful pregnancy in 2010, Roeber experienced multiple miscarriages over the next decade, and no one was able to tell her why it was very difficult to conceive again. After spending approximately $15,000 to $20,000 a year for seven years, a doctor finally told her that "an egg donor or adoption were our only two options." The cost for an egg donor was around $30,000, and as far too many parents have learned, there is often "no such thing as payment plans in the world of infertility."

Roeber, who serves as the senior communications director for Project Harmony, a child advocacy center in Nebraska, finally welcomed her twins in 2020. Though elated, she tells Parents that the costs were significant—financially, physically, and emotionally. She estimates that the total out-of-pocket costs for the birth of her boys were $55,000, which included medications, two transfers, testing, delivery, the hospital stay, and the NICU stays.

Roeber's pregnancy highlights the exorbitant costs that families pay to welcome multiples—and goes to show that when it comes to pregnancy and birth, there's never a true two-for-one deal.

Costs Increase Exponentially With Multiples

Kaylan Sharp, RN, BSN, BS, and her twin sister Keira Davis, BSN, BA, are acutely aware of the expenses for families of multiples. As twins, registered nurses, doulas, and co-founders of Baby Mama, an online resource for expectant and new parents based out of Colorado, they spend a lot of time poring over pregnancy and birth data. "A 2013 study published in the American Journal of Obstetrics and Gynecology (AJOG) showed the adjusted total health care cost for a twin pregnancy, birth, and care of babies in their first year of life was $105,000; comparatively, the cost of a single baby was $21,000," they tell Parents. These figures appear to be the most recent available, indicating that the data on the costs of twin and higher-order multiple pregnancies and births is under-reported.

The average costs in this study take into account all of the health care expenses for the birthing parent from 27 weeks before the delivery date to 30 days postpartum and a year of medical expenses for the baby and reflect the total cost of care paid by patients and insurers.

According to the study, birthing parents "with twins had significantly higher co-existing conditions" than singleton parents, all of which increased costs. Co-existing conditions can include hypertension, gestational diabetes, anemia, and cardiovascular disease. Additionally, parents of multiples experience "increased maternal complications, increased rate of cesarean births, longer hospital stays, increased admissions, and longer NICU stays for the babies," Sharp adds. And for parents of triplets? That number could skyrocket to more than $400,000, in combined out-of-pocket and insurance-covered costs.

Even without the first year of life costs, the expenses are drastic. A study from the Urban Institute found that the average cost for Medicaid-covered births of twins in four states from 2014 to 2015 "was $48,479, over two and a half times as high as for singleton births." These costs accounted for both the birthing parent and the babies during the "prenatal, delivery, and post-natal period."

How are these figures possible when the average cost of giving birth is $4,500? Risk factors, increased testing and ultrasounds, and a higher likelihood of hospital-monitored bed rest and cesarean births all make multiple births more expensive.

Higher-risk Often Means Higher Costs

Multiple birth pregnancies are often considered at higher risk for a multitude of factors. More than 60 percent of twins are born preterm, and almost all "higher-order multiples are premature," according to Johns Hopkins Medicine. Pregnancy conditions such as gestational hypertension, gestational diabetes, cervical incompetence, hemorrhaging, twin-to-twin transfusion, and birth defects are also more common with multiple births than with singleton ones. In its 2013 study, the AJOG found that birthing parents of multiples had longer hospital stays compared to parents of singletons; similarly, infant multiples "were more likely to be admitted to NICU and had a higher mortality rate than infants of singletons."

Twin parents will often see a high-risk specialist in addition to their primary clinician, and they will attend more frequent visits closer to their delivery dates. Ashley Ostoff, the chief surrogate officer at The Biggest Ask and a gestational carrier who carried twins in Wisconsin, received more ultrasounds than she did with her singleton pregnancies. And unlike her other pregnancies, she required "an iron transfusion once a week from 20 weeks on" because the twins were what her OB jokingly called "little vampires." Such transfusions can cost thousands of dollars per visit.

Conz Preti, parenting and health editor at Insider and author of Too Pregnant to Move, also noticed differences between her singleton and twin pregnancies in New York City. Though her twin pregnancy was relatively complication-free, her clinician recommended that she undergo genetic testing because she was over the age of 35. She also had more ultrasounds and "was checked more regularly for preeclampsia, which is a higher risk when you're carrying multiples," she says. Additionally, her OB ordered a specific ultrasound with a neonatal cardiologist "because the girls were identical and there's a higher risk of heart deformities or heart issues."

Rebecca Lund, a mother of triplets in Washington state, also says that she had to work with her insurance to cover necessary testing. Because she had undergone IVF, her triplets were at a higher risk of heart defects and required fetal echocardiograms. However, her insurance only covered the cost of one of the three fetal echocardiograms, and she wound up paying $2,140 out of pocket.

As a carrier of triplets, Lund also underwent much more intensive monitoring than many twin parents. Her primary clinician referred her to a maternal-fetal specialist about 30 minutes out of town who performed three-hour ultrasounds at every appointment in which "they measured anything and everything you could think of because they wanted to keep the babies in as long as possible, so long as it was safe," she says.

In addition to the ultrasounds, Lund says she was put on short-term disability and told not to work at 19 weeks. Because of the weight of the babies, she developed some cervical funneling at 25 weeks and was hospitalized for four days as doctors "put in a collar over the cervix to reinforce what was left." At 31 weeks, she was admitted into the hospital for full-time monitoring as Baby C had developed fetal growth restriction, a condition in which the fetus was not hitting standardized developmental milestones.

Her babies also required monitoring in the NICU after they were born for 12-, 17-, and 18-day stays. In total, Lund says the hospital bill was nearly $700,000; however, with her insurance, she paid just $7,200 out of pocket.

Cesareans are more common with multiple births because they are considered higher risk than singleton births. Approximately 40 percent of all twins and nearly all triplets are born via C-section. Nationally, a C-section could cost between $7,500 and $14,500 out of pocket. Like Lund, Ostoff had a C-section and the twins each had NICU stays ranging from two to four weeks; her total hospital bill was $100,000. Preti, who had a C-section and no NICU stays for her twins, says the bill was $150,000.

How to Handle the Costs of Multiples

Look into insurance costs

Like hospital bills, insurance costs vary depending on the type of coverage (individual or employer-sponsored plans), plan type (PPO, HMO, Bronze, Silver, Gold, etc.), medical history, city, and state. Under the Affordable Care Act, pregnancies are no longer considered pre-existing conditions, and both employers and ACA-compliant insurers are required to pay for preventative care, such as prenatal visits, lactation services, and well-baby visits.

Lund, the mother of triplets, tells Parents she had great insurance coverage through United Healthcare. Her PPO plan covered the vast majority of her infertility treatments (all but $8,000 for a year-and-a-half), and hundreds of thousands of dollars for her hospital stay, treatments, C-section, and NICU stays. She acknowledges her experience was rare, but encourages all expectant parents to "call [their] insurance and find out what is covered and what to expect upfront." By creating a relationship with her provider, she said that she was able to set her expectations and budget accordingly.

Sean Fletcher, a father of twins and a health insurance broker with The JWS Group, says expectant parents should "weigh the cost between [their] employer's costs and the marketplace plans" because it's not guaranteed that employers will cover spouses and children. "You could hop on a marketplace plan and get a child-only plan once the child is born for $300 to $400," Fletcher says. "But if it's got an $8,750 maximum out-of-pocket and the employer plan costs $400 but has a $4,000 maximum out-of-pocket, you're going to do better with the employer plan." Additionally, families should ask questions about their tax credits and eligibility under the recently enacted American Rescue Act.

Those deductible fees are really where you should focus, he says. "If you're looking at having any children, but specifically multiples, you need to look at what your maximum out-of-pocket is for both you and the kids…because you're going to hit it," Fletcher adds. He experienced this first-hand after one of his twins had multiple hospital stays, including time in the NICU and on oxygen, during his first year of life. He and his wife had a $5,000 deductible through her employer-sponsored insurance plan, which they quickly maxed out. Fletcher says that the total bill for the birth, which included a C-section, was about $90,000. Then there was another $30,000 to $40,000 bill for the NICU stay. Add the subsequent hospital stays, and Fletcher says "we probably spent $150,000 of the insurance's money that first year on one child."

But what if you don't have insurance or if your provider options are limited? "Be familiar with the evidence" surrounding medical decisions and be your own best advocate during pregnancy and the birthing process, says Kaylan Sharp, a registered nurse and doula. Ask questions about recommended care and insist on participating in non-life-threatening medical decisions, such as whether it's necessary to induce pregnancy, have additional ultrasounds, or undergo a C-section, as these can add costs. "If you're not informed and not prepared, that can be a detriment to your health and your babies' health," Sharp says.

Parents without insurance should also check to see if they're eligible for Medicaid or the Children's Health Insurance Program (CHIP) through their state.

Hire a doula or midwife

Some parents of multiples might find that a birth doula and/or a postpartum doula can be helpful as an additional source of knowledge and support through their pregnancies and into their fourth trimesters.

"Birth doulas really have a relationship with a pregnant mom, creating [an understanding of] the family dynamic, and are there for the actual birth," Sharp says. "Those range depending on years of experience, but you're probably looking at $800 to $1,200 for that type of service." Parents can save a few hundred dollars, she adds, by hiring a student doula.

Sharp and her sister, Kiera Davis, are both postpartum doulas. They too create a relationship with an expectant family throughout the pregnancy, but the majority of their work is done in the first six weeks postpartum; however, they often offer support for the first 12 weeks. Postpartum doulas typically assist families during the postpartum transition, helping with everything from feedings, diaper changes, errands and meal prep, and parenting education. Sharp and Davis' postpartum doula services run at about $2,000, though they say the increased cost is because they also "have the added component of clinical experience" as registered nurses. Nationally, their pricing tracks, as many postpartum doulas charge between $1,500 and $2,000, they say.

"Finding someone who has experience with multiples is very important," Sharp says, adding that those services will often be more expensive because of the additional expertise. "You want somebody who has done night-nanny services for multiples because they will understand how the scheduling will go with feedings and changes."

Look into child care options

Parents with older children will also need to consider the costs of child care throughout the pregnancy and delivery. Preti, who had a toddler while pregnant with her twins, said that hiring an in-home nanny was essential to allow her to work and rest throughout her pregnancy. "My only goal was to keep those babies inside for as long as my OB would allow me to," Preti says. "I also took it way more easy on myself. With my [singleton] son, I was commuting to work on the subway every single day and doing all these things. With the twins, I was like, 'If I need to take a nap, I'm going to take a nap. If I need to log off at four, I'm going to do it.'"

Having a nanny and working remotely allowed her the opportunity to rest, but it also helped with other riskier activities, like carrying or chasing after her toddler when she was far along in her pregnancy. The service didn't come without a cost, though. According to the International Nanny Association, the average hourly rate for nannies around the globe was $19 in 2017. Preti paid around that cost for her son's care and one-and-a-half times the rate if the nanny worked more than 40 hours. Because her family is out of the country and she needed her husband as a support person, she paid a premium to have her nanny spend overnights with her son during her birth.

Keep in mind that daycares can cost over $1,300 per month for one child, according to the Center for American Progress.

Know surrogacy costs are always higher with multiples

Families who opt to hire surrogates also need to be mindful that multiple pregnancies will cost more. According to New Beginnings Surrogacy, the average cost of a surrogate twin pregnancy costs $90,000 to $175,000. Surrogates are paid an additional $5,000 on top of their base; nationally, the average compensation for first-time surrogates is between $35,000 and $45,000.

Ostoff, who was a gestational carrier for twins, says that these numbers align with her experience. "My intended parents told us their entire surrogacy journey was around $175,000," she says. "My compensation was $35,000 plus $5,000 for carrying twins and $2,500 for having a C-section."

The intended parents did benefit from her "surro-friendly" insurance, she says. Her total out-of-pocket cost for the delivery was $13,000.

And home births are more complicated with multiples

Though not as common, some parents of twins opt to have a home birth and hire a midwife. Nationally, home birth with a midwife costs between $3,000 and $9,000, but as Sharp and Davis noted with doulas, parents of multiples can expect to pay more due to the higher level of risk.

It should be noted that not every state permits home deliveries of multiples and that the American Academy of Pediatrics advocates for hospital deliveries for all births.

Don't forget about pregnancy and parenting classes

Pregnancy and parenting classes can be a great tool for expectant parents who want to feel more prepared, Sharp and Davis say. Their company, Baby Mama, offers multiple virtual courses for parents: Preparing for Birth, which covers everything from the stages of labor to how to best advocate for the birth experience parents want; Postpartum Care, which explores milk production, perineal care, C-section incision care, and postpartum bleeding; and Newborn Care, which dives into soothing techniques, diapering, feeding, sleep and hunger cues, and umbilical care. The courses range from one-and-a-half hours to four hours and cost between $150 to $175 per couple.

Local hospitals sometimes offer preparedness courses, as well—and some even offer classes specifically for parents of multiples. VeryWell Family reports the average course runs between $20 to 200, though some courses can cost upwards of $1,000.

The Bottom Line

Preparing for multiples can be overwhelming, and with so many variables, it's hard to give an average cost estimate. Researching, asking questions, and advocating for your best interests can help save money and stress in the long run.