Experts agree that stress, poverty, prenatal care and parental support can affect infant mortality.
But a group of Dane County attorneys believes another factor affects all of the above, and they say it’s largely unrecognized by the public and policymakers: Birth Cost Recovery (BCR).
BCR is state policy intended to support mothers, but ABC for Health, a nonprofit public interest law firm with expertise in health care coverage, says it harms low-income and minority residents in Dane County. They say Dane County should choose not to use BCR.
“In the state when we have infant mortality from communities that rivals the third world … this is just a punitive policy that has long outlived its usefulness,’ said Bobby Peterson, executive director at ABC for Health.
According to a 2012 fetal infant mortality review of Dane County, a baby born to an African-American mother, compared to a white mother, is over twice as likely to die before turning 1.
BCR allows the state to pass on some of the cost of childbirth and pregnancy medical care of unmarried women on Medicaid to fathers. Wisconsin is one of nine states that uses the policy.
According to federal law, a mother can’t be charged for Medicaid pregnancy services, but a father can. The father is summoned to court to determine liability for the expenses, and the money is recovered by the local county child support agency (CSA).
The program lowers Medicaid costs for the state and is intended to make sure noncustodial parents contribute to the costs and take responsibility for their child, said Joe Scialfa, communications director for the Wisconsin Department of Children and Families.
But ABC aruges it can lead to friction between parents over costs, increased poverty by taking the father’s resources, a stressful court process and may even be a deterrent for mothers to receive needed prenatal care. These can all have implications for infant mortality, they say.
“Putting the pieces of this puzzle together leads to strong circumstantial evidence that links birth cost recovery policy as a factor in the rising infant mortality rates for blacks,” Peterson wrote in a letter to Madison Mayor Paul Soglin and Dane County Executive Joe Parisi.
BCR applies only to mothers referred to child support, but there are major differences between BCR and child support, Peterson said. If the woman is on Medicaid, she never sees the BCR money, as it goes directly to the government.
Another key difference is that a mother can waive child support, perhaps because the father is living with her and contributing to the household, but she cannot waive BCR.
BCR is not supposed to apply in cases where the father lives with the child, has too low of an income or has a second child with the mother, but if the father doesn’t show up to court to dispute these facts, he can be charged with the costs, Peterson said.
Costs can be several thousand dollars, and are calculated based on a percentage of the father’s income, the regional average for birth costs or actual birth costs.
Charging a father with these amounts can drive a wedge between parents, Peterson said. Tia Murray, a Madison doula and lactation consultant, found this to be true when she navigated the child support system after she and the father of her coming child had broken up.
“It caused a bit of extra stress for me with my third child, to figure out what co-parenting looks like,” she said. “His argument was, ‘I’m always taking care of all these expenses.'"
Even though they were equally contributing and essentially living together, the father was required to pay the costs. Murray could understand the father’s frustration.
“As far as father involvement, I think there's so much more to it than the monetary piece,” she said.
If a mother does not want the father to have to pay, she can refuse to disclose the name of the father, but with consequences. She will continue to receive Medicaid throughout her pregnancy, but will be “sanctioned. This means that six weeks after birth, her Medicaid benefits will end. In 2008, 543 women were sanctioned statewide across of number of public assistant programs.
A mother can also apply for “good cause,” which means she can be exempt from naming the father if she feels she is in danger of emotional or physical harm.
To avoid costs for the father, other women may choose to delay or go without prenatal care for subsequent pregnancies, Peterson said. As a doula, Murray has seen women choose to forgo prenatal care because of fear of BCR.
Scialfa noted that BCR is required under state law, though ABC for Health noted that the practice varies by county. Counties are allowed to keep 15 percent of recovered BCR recouped from fathers.
Dane County collected $8,310,705 in BCR from 2011 to 2016, retaining $1,246,606.
ABC recommends that Dane County follow the lead of other Wisconsin counties and decide not to use BCR to recoup birth costs from fathers.
“You can look at these situations and say in the vast majority of these cases, they are not in the best interest of the child, and as an office we’re not going to pursue these cases,” Peterson said.
With infant mortality rates among African-American high, he thinks the government should act.
“It’s not the only answer (to infant mortality),” he said. “But it’s big enough that people need to at least discuss it and think about. Why is Wisconsin doing this?”