Cost of Utilising Maternal Health Services in Low- and Middle-Income Countries: A Systematic Review

Document Type : Review Article

Authors

1 Department of Health Policy, London School of Economics and Political Science, London, UK

2 Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, ON, Canada

3 Health Education West Midlands, Birmingham, UK

4 Department of Medicine, University of Alberta, Edmonton, AB, Canada

5 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK

Abstract

Background
Cost is a major barrier to maternal health service utilisation for many women in low- and middle-income countries (LMICs). However, comparable evidence of the available cost data in these countries is limited. We conducted a systematic review and comparative analysis of costs of utilising maternal health services in these settings.
 
Methods
We searched peer-reviewed and grey literature databases for articles reporting cost of utilising maternal health services in LMICs published post-2000. All retrieved records were screened and articles meeting the inclusion criteria selected. Quality assessment was performed using the relevant cost-specific criteria of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. To guarantee comparability, disaggregated costs data were inflated to 2019 US dollar equivalents. Total adjusted costs and cost drivers associated with utilising each service were systematically compared. Where heterogeneity in methods or non-disaggregated costs was observed, narrative synthesis was used to summarise findings.
 
Results
Thirty-six studies met our inclusion criteria. Many of the studies costed multiple services. However, the most frequently costed services were utilisation of normal vaginal delivery (22 studies), caesarean delivery (13), and antenatal care (ANC) (10). The least costed services were post-natal care (PNC) and post-abortion care (PAC) (5 each). Studies used varied methods for data collection and analysis and their quality ranged from low to high with most assessed as average or high. Generally, across all included studies, cost of utilisation progressively increased from ANC and PNC to delivery and PAC, and from public to private providers. Medicines and diagnostics were main cost drivers for ANC and PNC while cost drivers were variable for delivery. Women experienced financial burden of utilising maternal health services and also had to pay some unofficial costs to access care, even where formal exemptions existed.
 
Conclusion
Consensus regarding approach for costing maternal health services will help to improve their relevance for supporting policy-making towards achieving universal health coverage. If indeed the post-2015 mission of the global community is to “leave no one behind,” then we need to ensure that women and their families are not facing unnecessary and unaffordable costs that could potentially tip them into poverty.
 
Prospero Registration Number
CRD42019150058

Highlights

 

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Keywords


  1. Alkema L, Chou D, Hogan D, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387(10017):462-474. doi:10.1016/S0140-6736(15)00838-7
  2. United Nations. Sustainable Development Goals: 17 goals to transform our world. Sustainable Development Goals. http://www.un.org/sustainabledevelopment/sustainable-development-goals/.   Published 2016. Accessed March 29, 2020.
  3. World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Population Division. Trends in Maternal Mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2019. https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf.
  4. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370(9595):1358-1369. doi:10.1016/S0140-6736(07)61578-5
  5. GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775-1812. doi:10.1016/S0140-6736(16)31470-2
  6. Miller S, Belizán JM. The true cost of maternal death: individual tragedy impacts family, community and nations. Reprod Health. 2015;12:56. doi:10.1186/s12978-015-0046-3
  7. Vargas V, Ahmed S, Adams AM. Factors enabling comprehensive maternal health services in the benefits package of emerging financing schemes: a cross-sectional analysis from 1990 to 2014. PLoS One. 2018;13(9):e0201398. doi:10.1371/journal.pone.0201398
  8. World Health Organization. Universal health coverage. Health systems. https://www.who.int/healthsystems/universal_health_coverage/en/.  Published 2019. Accessed October 17, 2019.
  9. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
  10. Nixon J, Khan KS, Kleijnen J. Summarising economic evaluations in systematic reviews: a new approach. BMJ. 2001;322(7302):1596-1598.
  11. Carande-Kulis VG, Maciosek M V, Briss PA, et al. Methods for systematic reviews of economic evaluations for the guide to community preventive services. Am J Prev Med. 2000;18(1):75-91. doi:10.1016/S0749-3797(99)00120-8
  12. Gomersall JS, Jadotte YT, Xue Y, Lockwood S, Riddle D, Preda A. Conducting systematic reviews of economic evaluations. Int J Evid Based Healthc. 2015;13(3):170-178. doi:10.1097/XEB.0000000000000063
  13. Wilczynski NL, Haynes RB, Lavis JN, Ramkissoonsingh R, Arnold-Oatley AE. Optimal search strategies for detecting health services research studies in MEDLINE. CMAJ. 2004;171(10):1179-1185. doi:10.1503/cmaj.1040512
  14. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press; 2015.
  15. World Bank. World Bank Country and Lending Groups. Data. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519.  Published 2019. Accessed March 29, 2020.
  16. Husereau D, Drummond M, Petrou S, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BJOG. 2013;120(6):765-770. doi:10.1111/1471-0528.12241
  17. Banke-Thomas A, Wilson-Jones M, Madaj B, van den Broek N. Economic evaluation of emergency obstetric care training: a systematic review. BMC Pregnancy Childbirth. 2017;17:403. doi:10.1186/s12884-017-1586-z
  18. Mangham-Jefferies L, Pitt C, Cousens S, Mills A, Schellenberg J. Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2014;14:243. doi:10.1186/1471-2393-14-243
  19. Stone G, Hutchinson A, Corso P, Teutsch S, Feilding J, Carande-Kulis V. Understanding and Using the Economic Evidence. In: Zaza S, Briss PA, Harris KW, eds. The Guide to Community Preventive Services. New York: Oxford University Press; 2005:449-463. doi:10.1093/acprof:oso/9780195151091.003.0011
  20. Borghi J. What is the cost of maternal health care and how can it be financed? In: De Brouwere V, Van Lerberghe W, eds. Safe Motherhood Strategies: A Review of the Evidence. Antwerp, Belgium: ITGPress; 2001:243-292.
  21. Mogyorosy Z, Smith P. The Main Methodological Issues in Costing Health Care Services. York; 2005. https://www.york.ac.uk/media/che/documents/papers/researchpapers/rp7_Methodological_issues_in_costing_health_care_services.pdf.
  22. OANDA. Currency Converter. Currency Tools. https://www.oanda.com/currency/converter/.   Accessed November 4, 2018. Published 2019.
  23. Turner HC, Lauer JA, Tran BX, Teerawattananon Y, Jit M. Adjusting for Inflation and Currency Changes Within Health Economic Studies. Value Health. 2019;22(9):1026-1032. doi:10.1016/j.jval.2019.03.021
  24. International Monetary Fund. World Economic Outlook database. Data and statistics. https://www.imf.org/external/pubs/ft/weo/2019/01/weodata/download.aspx.  Accessed October 2, 2019. Published 2019.
  25. Dhar RSG, Nagpal J, Sinha S, Bhargava VL, Sachdeva A, Bhartia A. Direct cost of maternity-care services in South Delhi: a community survey. J Health Popul Nutr. 2009;27(3):368-378.
  26. Lince-Deroche N, Fetters T, Sinanovic E, Devjee J, Moodley J, Blanchard K. The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa. PLoS One. 2017;12(4):e0174615. doi:10.1371/journal.pone.0174615
  27. Henshaw SK, Adewole I, Singh S, Bankole A, Oye-Adeniran B, Hussain R. Severity and cost of unsafe abortion complications treated in Nigerian hospitals. Int Fam Plan Perspect. 2008;34(1):40-50. doi:10.1363/ifpp.34.140.08.
  28. Bonu S, Bhushan I, Rani M, Anderson I. Incidence and correlates of “catastrophic” maternal health care expenditure in India. Health Policy Plan. 2009;24(6):445-456. doi:10.1093/heapol/czp032
  29. Mohanty SK, Srivastava A. Out-of-pocket expenditure on institutional delivery in India. Health Policy Plan. 2013;28(3):247-262. doi:10.1093/heapol/czs057
  30. Skordis-Worrall J, Pace N, Bapat U, et al. Maternal and neonatal health expenditure in Mumbai slums (India): a cross sectional study. BMC Public Health. 2011;11:150. doi:10.1186/1471-2458-11-150
  31. Rahman MM, Rob U, Noor FR, Bellows B. Out-of-Pocket Expenses for Maternity Care in Rural Bangladesh: A Public-Private Comparison. Int Q Community Health Educ. 2013;33(2):143-157. doi:10.2190/IQ.33.2.d
  32. Pearson L, Gandhi M, Admasu K, Keyes EB. User fees and maternity services in Ethiopia. Int J Gynecol Obstet. 2011;115(3):310-315. doi:10.1016/j.ijgo.2011.09.007
  33. Tellis SB, Rent PD, Dmello MK. Utilization of antenatal care and out of pocket expenditure on delivery care in Dakshina Kannada. Int J Community Med Public Health. 2018;5(8):3553. doi:10.18203/2394-6040.ijcmph20183097
  34. Tripathy JP, Shewade HD, Mishra S, Kumar AM V., Harries AD. Cost of hospitalization for childbirth in India: how equitable it is in the post-NRHM era? BMC Res Notes. 2017;10(1):409. doi:10.1186/s13104-017-2729-z
  35. Anafi P, Mprah WK, Jackson AM, et al. Implementation of fee-free maternal health-care policy in Ghana: perspectives of users of antenatal and delivery care services from public health-care facilities in Accra. Int Q Community Health Educ. 2018;38(4):259-267. doi:10.1177/0272684X18763378
  36. Khan A, Zaman S. Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth. 2010;10(1):2.  doi:10.1186/1471-2393-10-2
  37. Neke N, Reifferscheid A, Buchberger B, Wasem J. Time and cost associated with utilization of services at mobile health clinics among pregnant women. BMC Health Serv Res. 2018;18(1):920. doi:10.1186/s12913-018-3736-z
  38. Storeng KT, Baggaley RF, Ouattara F, et al. Paying the price: The cost and consequences of emergency obstetric care in Burkina Faso. Soc Sci Med. 2008;66:545-557. doi:10.1016/j.socscimed.2007.10.001
  39. Afsana K. The Tremendous Cost of Seeking Hospital Obstetric Care in Bangladesh. Reprod Health Matters. 2004;12(24):171-180. doi:10.1016/S0968-8080(04)24142-8
  40. Arsenault C, Fournier P, Philibert A, et al. Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households. Bull World Health Organ. 2013;91(3):207-216. doi:10.2471/BLT.12.108969
  41. Perkins M, Brazier E, Themmen E, et al. Out-of-pocket costs for facility-based maternity care in three African countries. Health Policy Plan. 2009;24(4):289-300. doi:10.1093/heapol/czp013
  42. Acharya J. Are free maternity services completely free of costs? Osong Public Health Res Perspect. 2016;7(1):26-31. doi:10.1016/J.PHRP.2015.11.002
  43. Honda A, Randaoharison PG, Matsui M. Affordability of emergency obstetric and neonatal care at public hospitals in Madagascar. Reprod Health Matters. 2011;19(37):10-20. doi:10.1016/S0968-8080(11)37559-3
  44. Douangvichit D, Liabsuetrakul T, McNeil E. Health care expenditure for hospital-based delivery care in Lao PDR. BMC Res Notes. 2012;5(1):30. doi:10.1186/1756-0500-5-30
  45. Adamu AN, Adamu H, Isa A., Zubairu S. Expenditure on Emergency Obstetric Care in a Federal Tertiary Institution in Nigeria. J Womens Health Care. 2013;2(4):1000134. doi:10.4172/2167-0420.1000134
  46. Acharya J, Kaehler N, Marahatta SB, Mishra SR, Subedi S, Adhikari B. Hidden Costs of Hospital Based Delivery from Two Tertiary Hospitals in Western Nepal. PLoS One. 2016;11(6):e0157746. doi:10.1371/journal.pone.0157746
  47. Govil D, Purohit N, Gupta SD, Mohanty SK. Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India. J Health Popul Nutr. 2016;35:15. doi:10.1186/s41043-016-0051-3
  48. Satapathy DM, Panda R, Das BC. Cost Factors Related with Normal Vaginal Delivery and Caesarean Section in Government and Non-Government Settings. Vol 30. 2005. http://iapsm.org/.  Accessed June 22, 2020.
  49. Kalu-Umeh NN, Sambo MN, Idris SH, Kurfi AM. Costs and patterns of financing maternal health care services in rural communities in Northern Nigeria: evidence for designing national fee exemption policy. Int J MCH AIDS. 2013;2(1):163-172.
  50. Hitimana R, Lindholm L, Krantz G, Nzayirambaho M, Pulkki-Brännström A-M. Cost of antenatal care for the health sector and for households in Rwanda. BMC Health Serv Res. 2018;18(1):262. doi:10.1186/s12913-018-3013-1
  51. Borghi J, Hanson K, Acquah CA, et al. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy Plan. 2003;18(4):383-390.
  52. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out-of-pocket payments for ‘free’ delivery services in rural Tanzania. Trop Med Int Health. 2008;13(12):1442-1451. doi:10.1111/j.1365-3156.2008.02173.x
  53. Borghi J, Ensor T, Neupane BD, Tiwari S. Financial implications of skilled attendance at delivery in Nepal. Trop Med Int Health. 2006;11(2):228-237. doi:10.1111/j.1365-3156.2005.01546.x
  54. Bennis I, De Brouwere V. Fee exemption for caesarean section in Morocco. Arch Public Health. 2012;70(1):3. doi:10.1186/0778-7367-70-3
  55. Vlassoff M, Fetters T, Kumbi S, Singh S. The Health System Cost of Postabortion Care in Ethiopia. Int J Gynaecol Obstet. 2012;118 Suppl 2:S127-S133. doi:10.1016/S0020-7292(12)60011-3
  56. Vyas S, Bhatt GS, Gupta KI, Tiwari H. A cost analysis of deliveries conducted in various health care settings in a city of India. Health J Indian Assoc Prev Soc Med. 2011;2(1):61-64.
  57. Ravit M, Philibert A, Tourigny C, et al. The Hidden Costs of a Free Caesarean Section Policy in West Africa (Kayes Region, Mali). Matern Child Health J. 2015;19(8):1734-1743. doi:10.1007/s10995-015-1687-0
  58. Moore AM, Dennis M, Anderson R, et al. Comparing women’s financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia. Reprod Health Matters. 2018;26(52):138-150. doi:10.1080/09688080.2018.1522195
  59. Sambo MN, Shamang A, Abdulrazaq G, Ibrahim A. Household cost of antenatal care and delivery services in a rural community of Kaduna state, northwestern Nigeria. Niger Med J. 2013;54(2):87. doi:10.4103/0300-1652.110034
  60. Leone T, Coast E, Parmar D, Vwalika B. The individual level cost of pregnancy termination in Zambia: a comparison of safe and unsafe abortion. Health Policy Plan. 2016;31(7):825-833. doi:10.1093/heapol/czv138
  61. Conteh L, Walker D. Cost and unit cost calculations using step-down accounting. Health Policy Plan. 2004;19(2):127-135. doi:10.1093/heapol/czh015
  62. Borghi J, Sabina N, Blum LS, Hoque ME, Ronsmans C. Household costs of healthcare during pregnancy, delivery, and the postpartum period: a case study from Matlab, Bangladesh. J Health Popul Nutr. 2006;24(4):446-455.
  63. Levin A, Dmytraczenko T, McEuen M, Ssengooba F, Mangani R, Van Dyck G. Costs of maternal health care services in three anglophone African countries. Int J Health Plann Manage. 2003;18(1):3-22. doi:10.1002/hpm.690
  64. Banke-Thomas OE, Banke-Thomas AO, Ameh CA. Factors influencing utilisation of maternal health services by adolescent mothers in Low-and middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2017;17(1):65. doi:10.1186/s12884-017-1246-3
  65. Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review. BMJ Open. 2019;9(10):e031890. doi:10.1136/bmjopen-2019-031890
  66. Dennis ML, Benova L, Owolabi OO, Campbell OMR. Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa. BMC Health Serv Res. 2018;18(1):699. doi:10.1186/s12913-018-3514-y
  67. Wright K, Banke-Thomas A, Sonoiki O, Ajayi B, Ilozumba O, Akinola O. Opinion of women on provision of emergency obstetric care in public facilities in Lagos, Nigeria: a qualitative study. Health Care Women Int. 2017;38(6):527-543. doi:10.1080/07399332.2016.1234482
  68. Olivier de Sardan J-P, Ridde V. L’exemption de paiement des soins au Burkina Faso, Mali et Niger. Les contradictions des politiques publiques. Afr Contemp. 2012;243(3):11-32. doi:10.3917/afco.243.0011
  69. Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan. 2010;25(5):384-392. doi:10.1093/heapol/czq013
  70. Dzakpasu S, Powell-Jackson T, Campbell OMR. Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Policy Plan. 2014;29(2):137-150. doi:10.1093/heapol/czs142
  71. Lagarde M, Palmer N. The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev. 2011;(4):CD009094. doi:10.1002/14651858.CD009094
  72. Gilson L, McIntyre D. Removing user fees for primary care in Africa: the need for careful action. BMJ. 2005;331(7519):762-765. doi:10.1136/bmj.331.7519.762
  73. Parkhurst JO, Ssengooba F. Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda. Health Policy Plan. 2009;24(5):377-384. doi:10.1093/heapol/czp023
  74. Belaid L, Ridde V. An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso. BMC Pregnancy Childbirth. 2012;12(1):143. doi:10.1186/1471-2393-12-143
  75. Gaitonde R, Oxman AD, Okebukola PO, Rada G. Interventions to reduce corruption in the health sector. Cochrane database Syst Rev. 2016;(8):CD008856. doi:10.1002/14651858.CD008856.pub2
  76. Villar J, Ba’aqeel H, Piaggio G, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357(9268):1551-1564.    doi:10.1016/s0140-6736(00)04722-x
Volume 10, Issue 9
September 2021
Pages 564-577
  • Receive Date: 30 October 2019
  • Revise Date: 01 May 2020
  • Accept Date: 14 June 2020
  • First Publish Date: 01 September 2021