Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study

Figures & data

Box 1 Recommendations based on study findings

While the abolition of user fees has reduced the provider fees for delivering at a facility, poor, rural Zambian women still face high financial expenditures related to delivery, a problem that may impede Zambia’s efforts to achieve universal health coverage. Understanding the actual OOP delivery expenditure for these remote women is important to target interventions trying to expand facility-based delivery and improve maternal and newborn health outcomes. These interventions can target either the health system, communities, or both.

1) Baby Clothes/Blanket The unofficial requirements or norms for bringing new baby clothes and a baby blanket to a facility delivery in Zambia results in the largest expense for nearly all remote pregnant women in this study, which is likely a widespread phenomenon across the country as it has been found qualitatively in other studies.^Citation11,Citation33,Citation44 Blankets should be recognized as the underlying driving expense for this category. The Zambian Ministry of Health could consider examining the unofficial policy of bringing new baby clothes/blanket to a facility-based delivery and its implications. However, as this expectation has become so associated with social embarrassment, the norm may be hard to change. A way around this norm may be for health staff to advise women to bring clean clothing/blanket, instead of specifically new clothing/blanket, to a facility-based delivery. To address the high cost of baby clothes and baby blankets and mitigate it as a barrier, future programs could strategize on how to make these clothes and blankets more physically and financially accessible such as by promoting social enterprises to bring down their cost and extend the availability of lower priced clothing/blankets to rural areas. Furthermore, village savings groups and birth preparedness interventions^Citation40,Citation45,Citation46,Citation47,Citation48 could assist women in rallying the sufficient resources to more easily purchase these items.

2) Delivery Supplies Though minimal in comparison to total expenditure, the shifted burden for acquiring delivery supplies nonetheless remains a substantial perceived burden to accessing facility-based delivery. The Zambian Ministry of Health should consider health systems strategies to ensure health facilities have adequate financial resources to provide supplies of disinfectant, cord clamps, a razor blade to cut the cord, plastic sheets, and buckets to receive the placenta to every laboring woman free of charge.

3) Transport Lastly, our study suggests that the availability of transport and physical obstacles may be a more important barrier to health facility delivery than the cost of transport itself, though this is difficult to untangle. Interventions to increase physical access to health facilities for delivery could focus on improving planning for transport or providing residential space for women to wait for delivery near health facilities, known internationally as maternity waiting homes.^Citation25,Citation34,Citation36,Citation44,Citation49,Citation50

Figure 1 Distribution of expenditure by total expenditure and all expenditure sub-categories (N=2280).

Figure 2 Distribution of expenditure by delivery location for total expenditure and top three sub-categories.

Table 1 Characteristics of recently delivered women living ≥10km from their assigned primary health center for the total sample and only those who spent money on delivery^‡

		Total sample (n=2280)		Spent money on delivery (n=2223)		p-value
		N	%	N	%
Household-level characteristics
Non-improved water source		1274	55.9	1239	55.8
Non-improved toilet		2051	90.0	1996	89.8	*
No electricity		2270	99.7	2213	99.7	*
House has earth or sand floors		2010	88.2	1956	88.0	*
Charcoal or wood cooking fuel		2271	99.6	2214	99.6	*
Total household members	Median (IQR)	6.0 (4.0, 9.0)		6.0 (4.0, 9.0)
Wealth index	1 (lowest)	519	24.4	498	24.0
	2	547	25.7	535	25.8
	3	536	25.2	523	25.2
	4 (highest)	524	24.6	518	25.0
Distance from village center to health facility (km)	Median (IQR)	12.7 (10.9, 16.2)		12.8 (10.9, 16.2)
	9.5–10	290	12.7	281	12.7
	10–14.9	674	29.6	655	29.5
	15–19.9	599	26.3	586	26.4
	20–24.9	511	22.4	502	22.6
	25+	203	8.9	196	8.8
District	Kalomo	380	16.7	364	16.4
	Choma/Pemba	556	24.4	543	24.4
	Lundazi	572	25.1	564	25.4
	Nyimba	213	9.3	206	9.3
	Mansa/Chembe	559	24.5	546	24.6
Woman-level characteristics
Age, years	Median (IQR)	24.0 (20.0, 31.0)		24.0 (20.0, 31.0)
	15–19	416	18.3	407	18.4
	20–24	732	32.2	713	32.2
	25–29	432	19.0	422	19.0
	30–34	359	15.8	348	15.7
	35+	332	14.6	326	14.7
Education	None	344	15.1	340	15.3
	Any primary	1385	60.9	1345	60.7
	More than primary	545	24.0	532	24.0
Marital Status	Never married	123	5.4	117	5.3
	Divorced/separated or widowed	154	6.8	146	6.6
	Married/cohabitating	1999	87.8	1956	88.1
Gravida	Median (IQR)	3.0 (2.0, 6.0)		3.0 (2.0, 6.0)
Parity	Median (IQR)	3.0 (2.0, 5.0)		3.0 (2.0, 5.0)
Primigravida (first pregnancy)	No	1788	78.5	1743	78.4
	Yes	491	21.5	479	21.6
Four or more ANC visits	No	941	41.3	902	40.6	*
	Yes	1339	58.7	1321	59.4
Delivery location	Home	361	15.8	332	14.9	*
	Primary health center	1659	72.8	1635	73.5
	Hospital	260	11.4	256	11.5
Saved for delivery	No/don’t know	42	17.6	363	16.3	*
		Yes	1878	82.4	1860	83.7
Intended delivery location	Home	20	0.9	18	0.8	*
	Primary health center	2107	92.5	2055	92.5
	Hospital	150	6.6	149	6.7
Went to health facility 24 hrs after delivery^a		94	25.8	93	27.8	*
Mode of transportation to delivery^b	Walking	432	22.6	427	22.6	*
	Bicycle	589	30.8	575	30.5
	Ox cart/wheelbarrow	151	7.9	147	7.8
	Car/Taxi/Bus	617	32.2	613	32.5
	Motorcycle	102	5.3	102	5.4
	Ambulance	24	1.3	23	1.2

Notes: ^‡The following were excluded from the analysis: 77 (3.2%) women who delivered on the way to a health facility, 17 (0.7%) women whose spending behaviors were considered extreme outliers, 6 (0.3%) women who were missing a delivery location, and 1 (0.04%) woman who lived too close to her assigned primary health center. *Chi-square test statistically significant at  p=0.05. ^aOnly asked of those who delivered at home. ^bOnly asked of those who delivered at a primary health center or hospital.

Table 2 Primary transport method used and amount of expenditure on transport among women with a facility-based delivery^‡

Primary Transport Method Used	Primary health center N=1656				Hospital N=260
	Among total sample of primary health center deliveries		Among primary health center deliveries who spent on transportation		Among total sample of hospital deliveries		Among hospital deliveries who spent on transportation
	Transport method used N (%)	Expenditure amount (USD) Mean (SD)	Transport method used N (%)	Expenditure amount (USD) Median (IQR)	Transport method used N (%)	Expenditure amount (USD) Mean (SD)	Transport method used N (%)	Expenditure amount (USD) Median (IQR)
Walking	402 (24.3)	0.81 (3.1)	42 (7.3)	5.73 (3.12, 10.42)	30 (11.6)	2.15 (4.13)	10 (5.4)	6.78 (2.08, 10.42)
Bicycle	552 (33.3)	0.73 (2.85)	70 (12.1)	3.12 (2.08, 7.29)	37 (14.2)	3.21 (6.38)	15 (8.1)	5.21 (2.08, 10.42)
Ox cart/wheelbarrow	150 (9.1)	1.43 (5.45)	22 (3.8)	9.37 (2.08, 10.42)	1 (0.4)	10.42 (.)	1 (0.5)	10.42 (10.42, 10.42)
Car/Taxi/Bus	455 (27.5)	7.33 (7.30)	381 (83.7)	6.25 (4.17, 10.42)	161 (62.3)	9.15 (9.43)	142 (76.8)	7.81, (4.17, 12.50)
Motorcycle	88 (5.3)	4.98 (6.91)	61 (10.5)	5.21 (3.12, 9.37)	14 (5.4)	10.08 (9.24)	11 (5.9)	10.42 (6.25, 20.83)
Ambulance	8 (0.5)	3.25 (6.19)	2 (0.3)	13.02 (10.42, 15.62)	16 (6.2)	3.74 (6.11)	6 (3.2)	9.37 (7.81, 10.42)
Spent on transport regardless of method^a	-	-	589 (35.3)	6.25 (3.12, 10.42)	-	-	185 (71.1)	7.81 (4.17, 12.50)

Notes: ^‡The following were excluded from the analysis: 77 (3.2%) women who delivered on the way to a health facility, 17 (0.7%) women whose spending behaviors were considered extreme outliers, 6 (0.3%) women who were missing a delivery location, and 1 (0.04%) woman who lived too close to her assigned primary health center. ^aProportion of women who delivered at a primary health center or hospital and reported spending on transportation, regardless of the method they used.

Table 3 Predictors of any expenditure (Total Expenditure>0) for delivery and a linear regression of the natural log of total expenditure by women living ≥10 km from their assigned primary health center who also spent money on their delivery^‡

		Odds ratio for any expenditure (total expenditure>0)		Natural log of total expenditure amount
Variable		Adjusted odds ratios^a	p-value	Adjusted coefficent (95% CI)^b	p-value	Adjusted effect (USD) (95% CI)^b	p-value
Women’s Age	15–19	1.77 (0.59, 5.24)	0.305	0.00 (−0.07, 0.08)	0.953	0.00 (−1.14, 1.41)	0.953
	20–24	1.00		1.00		1.00
	25–29	0.83 (0.35, 1.95)	0.660	0.06 (−0.01, 0.13)	0.082	1.05 (−0.17, 2.35)	0.082
	30–34	0.64 (0.23, 1.77)	0.388	0.07 (0.00, 0.13)	0.048	1.23 (0.00, 2.35)	0.048
	35+	0.88 (0.30, 2.59)	0.811	0.05 (−0.03, 0.12)	0.212	0.87 (−0.50, 2.16)	0.212
Education	None	7.04 (2.28, 21.77)	<0.001	−0.09 (−0.17, −0.01)	0.022	−1.46 (- 2.65, - 0.17)	0.022
	Any primary	1.00		1.00		1.00
	More than Primary	1.32 (0.57, 3.15)	0.499	0.12 (0.08, 0.19)	<0.001	2.16 (1.41, 3.54)	<0.001
Marital Status	Never married	0.48 (0.18, 1.30)	0.505	−0.05 (−0.14, 0.05)	0.308	−0.83 (−2.21, 0.87)	0.308
	Divorced/seperated/widowed	0.54 (0.18, 1.62)	0.554	−0.03 (−0.12, 0.05)	0.416	−0.50 (- 1.92, 0.87)	0.416
	Married/cohabiting	1.00		1.00		1.00
Wealth Index	1 (lowest)	0.54 (0.20, 1.45)	0.221	−0.10 (−0.17, −0.03)	0.002	−1.61 (−2.65, −0.50)	0.002
	2	1.00		1.00		1.00
	3	1.07 (0.45, 2.61)	0.887	0.08 (0.02, 0.14)	0.010	1.41 (0.34, 2.55)	0.010
	4 (highest)	1.89 (0.66, 5.41)	0.232	0.17 (0.10, 0.24)	<0.001	3.14 (1.78, 4.60)	<0.001
District	Kalomo	0.44 (0.15, 1.33)	0.145	0.21 (0.12, 0.30)	<0.001	3.96 (2.16, 5.93)	<0.001
	Choma/Pemba	0.68 (0.24, 1.93)	0.465	0.29 (0.21, 0.37)	<0.001	5.70 (3.96, 7.59)	<0.001
	Lundazi	1.00		1.00		1.00
	Nyimba	0.23 (0.07, 0.70)	0.010	0.42 (0.33, 0.52)	<0.001	8.84 (6.62, 11.56)	<0.001
	Mansa/Chembe	0.97 (0.24, 3.87)	0.968	0.58 (0.49, 0.67)	<0.001	13.32 (10.71, 16.17)	<0.001
Primigravida	No	1.00		1.00		1.00
	Yes	0.54 (0.19, 1.53)	0.244	0.07 (0.00, 0.14)	0.048	1.23 (0.00, 2.55)	0.048
Four or more ANC visits	No	0.42 (0.20, 0.87)	0.020	−0.04 (−0.09, 0.01)	0.134	−0.66 (−1.46, 0.17)	0.134
	Yes	1.00		1.00		1.00
Saved for delivery	No	0.11 (0.06, 0.23)	<0.001	−0.22 (−0.29, −0.16)	<0.001	−3.35 (−4.26, −2.50)	<0.001
	Yes	1.00		1.00		1.00
Season of delivery	Rainy	1.00		1.00		1.00
	Dry	0.53 (0.28, 1.01)	0.054	−0.26 (−0.33, −0.19)	<0.001	−3.88 (−4.73, −2.93)	<0.001
Distance from health center	9.5–10	0.55 (0.17, 1.76)	0.315	−0.07 (−0.17, 0.03)	0.194	−1.14 (−2.65, 0.52)	0.194
10–14.9	1.00		1.00		1.00
	15–19.9	1.19 (0.44, 3.27)	0.729	0.00 (−0.08, 0.08)	0.985	0.00 (−1.30, 1.41)	0.985
	20–24.9	1.90 (0.68, 5.27)	0.218	0.00 (−0.08, 0.08)	0.999	0.00 (−1.30, 1.41)	0.999
	25+	1.02 (0.27, 3.80)	0.976	0.02 (−0.07, 0.12)	0.885	0.34 (−1.14, 2.16)	0.885
				Intercept:	2.83
				p-value:	<0.001

Notes: ^‡The following were excluded from the analysis: 77 (3.2%) women who delivered on the way to a health facility, 17 (0.7%) women whose spending behaviors were considered extreme outliers, 6 (0.3%) women who were missing a delivery location, and 1 (0.04%) woman who lived too close to her assigned primary health center. ^aAdjusted for all variables shown in Table 3. ^bAdjusted for all variables shown in Table 3 and delivery location (Table 4)

Table 4 Two-part model of expenditures for recently delivered women living ≥10 km from their assigned primary health center^‡,a

		Total Expenditure for Delivery
		Logistic Regression		Natural Log
		Adjusted odds ratios (95% CI)	p-value	N	Adjusted coefficient (95% CI)	p-value	Adjusted effect (USD) (95% CI)	p-value
Delivery Location	Home	1.0		332	1.0		1.0
	Primary health center	4.13 (2.07, 8.24)	<0.001	1635	0.21 (0.14, 0.28)	<0.001	3.96 (2.55, 5.47)	<0.001
	Hospital	6.14 (1.74, 21.63)	0.005	256	0.37 (0.28, 0.46)	<0.001	7.59 (5.47, 9.90)	<0.001
Intercept					2.83	<0.001
		Expenditure on Baby Clothes/Baby Blanket
		Logistic regression		Natural Log
		Adjusted odds ratios (95% CI)	p-value	N	Adjusted coefficient (95% CI)	p-value	Adjusted effect (USD) (95% CI)	p-value
Delivery Location	Home	1.0		319	1.0		1.0
	Primary health center	3.90 (2.30, 6.64)	<0.001	1616	0.14 (0.08, 0.21)	<0.001	2.02 (1.12, 3.15)	<0.001
	Hospital	3.01 (1.18, 7.69)	0.021	252	0.18 (0.08, 0.27)	<0.001	2.65 (1.12, 4.17)	<0.001
Intercept					2.60	<0.001
		Expenditure on Delivery Supplies
		Logistic Regression		Natural Log
		Adjusted odds ratios (95% CI)	p-value	N	Adjusted coefficient (95% CI)	p-value	Adjusted effect (USD) (95% CI)	p-value
Delivery Location	Home	1.0		235	1.0		1.0
	Primary health center	2.91 (2.16, 3.92)	<0.001	1424	0.02 (−0.11, 0.15)	0.748	1.05 (−0.49, 0.77)	0.748
	Hospital	3.45 (2.12, 5.63)	<0.001	219	0.27 (0.08, 0.46)	0.005	1.47 (0.40, 2.78)	0.005
Intercept					1.56	<0.001
		Expenditure on Transportation
		Logistic Regression		Natural Log
		Adjusted odds ratios (95% CI)	p-value	N	Adjusted coefficient (95% CI)	p-value	Adjusted effect (USD) (95% CI)	p-value
		Expenditure on Transportation
		Logistic Regression		Natural Log
		Adjusted odds ratios (95% CI)	p-value	N	Adjusted coefficient (95% CI)	p-value	Adjusted effect (USD) (95% CI)	p-value
Delivery Location	Home	1.0		43	1.0		1.0
	Primary health center	4.42 (2.94, 6.63)	<0.001	581	−0.14 (−0.36, 0.07)	0.197	−0.86 (−1.98, 0.47)	0.197
	Hospital	16.87 (9.76, 29.16)	<0.001	185	0.02 (−0.18, 0.23)	0.806	0.13 (−1.08, 1.69)	0.806
Intercept					1.88	<0.001

Notes: ^‡The following were excluded from the analysis: 77 (3.2%) women who delivered on the way to a health facility, 17 (0.7%) women whose spending behaviors were considered extreme outliers, 6 (0.3%) women who were missing a delivery location, and 1 (0.04%) woman who lived too close to her assigned primary health center. ^aControlled for the variables in Table 3.

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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].