Abstract
Purpose
Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home).
Methods
We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis.
Results
Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery.
Conclusion
These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.
Acknowledgments
The authors would like to thank the Zambian Ministry of Health at the National, Provincial, and District levels, as well as the Chiefs overseeing the study areas, for their approval and support for the study. We appreciate the assistance provided by the staff and volunteers at the health facility study sites in sampling the most remote households. We are deeply thankful for the study respondents who shared their experiences, time, and perspectives. We would also like to thank the data collectors, transcribers, and study staff, without whose tireless efforts during the weeks of preparation, data collection, and transcription, this study could never have happened. We recognize the contributions of Meghan Guptill who assisted in developing the qualitative codebook and coded the IDIs. We greatly appreciate the contributions of Elizabeth G. Henry, who supervised the coding of the IDIs, and who cleaned and managed the household survey data as it was collected. Lastly, the authors would like to thank the funders of this work. This program was developed and implemented in collaboration with Merck Sharp Dohme (MSD) for Mothers, MSD’s 10-year, USD500 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, N.J., USA (MRK 1846-06500.COL). The development of this article was additionally supported in part by the Bill & Melinda Gates Foundation (OPP1130329) and The ELMA Foundation (ELMA-15-F0017). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not reflect positions or policies of MSD, the Bill & Melinda Gates Foundation, or The ELMA Foundation.
Ethical approval and informed consent
Ethical approval for the study was obtained from the Institutional Review Boards (IRBs) of the authors’ institutions (Boston University IRB, Ref No. H-34526; University of Michigan IRB for de-identified data only), in addition to the ERES Converge IRB in Zambia (Ref. No. 2015-Dec-012). Permission to conduct the study was granted from the Ministry of Health and from traditional leaders overseeing the data collection areas. Written informed consent was obtained from all household heads and recently delivered women through signature or a thumbprint.
Data availability
The authors will provide the de-identified household survey and in-depth interview demographic data upon reasonable request to the Principle Investigator, Dr. Nancy A Scott, at [email protected]. The in-depth interview transcripts are not publicly available due to ethical restrictions on publicly sharing data which are of sensitive nature and contain potentially identifiable information instituted by the Boston University IRB and the ERES Converge IRB in Zambia. Qualitative data requests may be sent to the Boston University IRB at [email protected].
Abbreviations list
ANC, antenatal care; BEmONC, basic emergency obstetric and neonatal care; CI, confidence interval; IDI, In-depth interview; IRB, institutional review board; KM, kilometer; MWK, Malawian kwacha; OOP, Out-of-pocket; USD, United States dollar; ZMW, Zambian kwacha.
Author contributions
NAS acquired the study funding. NAS, PCR, DHH, TV, JRL, and GB conceptualized the overarching evaluation. NAS, PCR, and JLK designed the cross-sectional study discussed in the article. JLK, TN, and RMF acquired the data. PCR and KLM conducted the quantitative data analysis. RMF conducted the qualitative data analysis. JLK, PCR, KLM, and NAS contributed to data visualization. JLK drafted and edited the article. NAS, PCR, KLM, RMF, TN, DHH, TV, GB, and JRL provided critical review and edits to the article. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.
Disclosure
Ms Jeanette L Kaiser, Ms Kathleen L McGlasson, Dr Peter C Rockers, Ms Rachel M Fong, Ms Thandiwe Ngoma, Dr Davidson H Hamer, Dr Godfrey Biemba, Dr Jody R Lori, and Dr Nancy A Scott report grants from MSD for Mothers, the Bill & Melinda Gates Foundation, and The ELMA Foundation, during the conduct of the study. The authors report no other conflicts of interest in this work.