Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia

Document Type : Original Article


1 Department of Global Health, Boston University School of Public Health, Boston, MA, USA

2 Department of Research, Right to Care Zambia, Lusaka, Zambia

3 Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA

4 National Health Research Authority, Pediatric Centre of Excellence, Lusaka, Zambia

5 Africare Zambia, Lusaka, Zambia

6 Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA

7 Department of Global Health, School of Nursing and Health Professions, University of San Francisco, San Francisco, CA, USA

8 Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA


Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed deliveryrelated expenditure for women who used MWHs and those who did not who delivered at a rural health facility.
During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD).
After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P = .06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery.
Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.


  1. Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284-1299. doi:10.1016/s0140-6736(06)69381-1
  2. World Health Organization (WHO). Postnatal Care of the Mother and Newborn 2013. Geneva, Switzerland; 2013.
  3. World Health Organization (WHO). Guidelines on Maternal, Newborn, Child and Adolescent Health. WHO; 2014.
  4. World Health Organization (WHO). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. WHO; 2016.
  5. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11(1):71. doi:10.1186/1742-4755-11-71
  6. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reprod Health. 2013;10:40. doi:10.1186/1742-4755-10-40
  7. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34. doi:10.1186/1471-2393-9-34
  8. Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review. Syst Rev. 2017;6(1):110. doi:10.1186/s13643-017-0503-x
  9. Kaiser JL, Fong RM, Hamer DH, et al. How a woman's interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: an intersection of the Social Ecological Model with the Three Delays Framework. Soc Sci Med. 2019;220:312-321. doi:10.1016/j.socscimed.2018.11.011
  10. McPake B, Witter S, Ensor T, et al. Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health. Hum Resour Health. 2013;11:46. doi:10.1186/1478-4491-11-46
  11. Masiye F, Kaonga O, Kirigia JM. Does user fee removal policy provide financial protection from catastrophic health care payments? evidence from Zambia. PLoS One. 2016;11(1):e0146508. doi:10.1371/journal.pone.0146508
  12. Lépine A, Lagarde M, Le Nestour A. How effective and fair is user fee removal? evidence from Zambia using a pooled synthetic control. Health Econ. 2018;27(3):493-508. doi:10.1002/hec.3589
  13. Kaiser JL, McGlasson KL, Rockers PC, et al. Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study. Int J Womens Health. 2019;11:411-430. doi:10.2147/ijwh.s214081
  14. Scott NA, Henry EG, Kaiser JL, et al. Factors affecting home delivery among women living in remote areas of rural Zambia: a cross-sectional, mixed-methods analysis. Int J Womens Health. 2018;10:589-601. doi:10.2147/ijwh.s169067
  15. Sialubanje C, Massar K, Hamer DH, Ruiter RA. Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study. BMC Pregnancy Childbirth. 2015;15:216. doi:10.1186/s12884-015-0652-7
  16. Sacks E, Vail D, Austin-Evelyn K, et al. Factors influencing modes of transport and travel time for obstetric care: a mixed methods study in Zambia and Uganda. Health Policy Plan. 2016;31(3):293-301. doi:10.1093/heapol/czv057
  17. Nesbitt RC, Lohela TJ, Soremekun S, et al. The influence of distance and quality of care on place of delivery in rural Ghana. Sci Rep. 2016;6(1):30291. doi:10.1038/srep30291
  18. Sialubanje C, Massar K, Hamer DH, Ruiter RA. Understanding the psychosocial and environmental factors and barriers affecting utilization of maternal healthcare services in Kalomo, Zambia: a qualitative study. Health Educ Res. 2014;29(3):521-532. doi:10.1093/her/cyu011
  19. van Lonkhuijzen L, Stekelenburg J, van Roosmalen J. Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Database Syst Rev. 2012;10(10):CD006759. doi:10.1002/14651858.CD006759.pub3
  20. Chama-Chiliba CM, Koch SF. An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia. BMC Res Notes. 2016;9(1):504. doi:10.1186/s13104-016-2316-8
  21. Gaym A, Pearson L, Soe KW. Maternity waiting homes in Ethiopia--three decades experience. Ethiop Med J. 2012;50(3):209-219.
  22. Henry EG, Semrau K, Hamer DH, et al. The influence of quality maternity waiting homes on utilization of facilities for delivery in rural Zambia. Reprod Health. 2017;14(1):68. doi:10.1186/s12978-017-0328-z
  23. Scott NA, Kaiser JL, Vian T, et al. Impact of maternity waiting homes on facility delivery among remote households in Zambia: protocol for a quasiexperimental, mixed-methods study. BMJ Open. 2018;8(8):e022224. doi:10.1136/bmjopen-2018-022224
  24. Getachew B, Liabsuetrakul T. Health care expenditure for delivery care between maternity waiting home users and nonusers in Ethiopia. Int J Health Plann Manage. 2019;34(2):e1334-e1345. doi:10.1002/hpm.2782
  25. Central Statistical Office (CSO) [Zambia], Ministry of Health (MOH) [Zambia], ICF International. Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: CSO, MOH, ICF International; 2015.
  26. Republic of Zambia Ministry of Health. The 2012 List of Health Facilities in Zambia. Ministry of Health; 2013.
  27. Lori JR, Munro-Kramer ML, Mdluli EA, Musonda Mrs GK, Boyd CJ. Developing a community driven sustainable model of maternity waiting homes for rural Zambia. Midwifery. 2016;41:89-95. doi:10.1016/j.midw.2016.08.005
  28. Scott NA, Vian T, Kaiser JL, et al. Listening to the community: using formative research to strengthen maternity waiting homes in Zambia. PLoS One. 2018;13(3):e0194535. doi:10.1371/journal.pone.0194535
  29. Chibuye PS, Bazant ES, Wallon M, Rao N, Fruhauf T. Experiences with and expectations of maternity waiting homes in Luapula province, Zambia: a mixed-methods, cross-sectional study with women, community groups and stakeholders. BMC Pregnancy Childbirth. 2018;18(1):42. doi:10.1186/s12884-017-1649-1
  30. Kobelt G. Cost Data for Economic Evaluation. In: Health Economics: An Introduction to Economic Evaluation. 3rd ed. Office of Health Economics; 2013.
  31. Bank of Zambia. Historical Average Exchange Rates Series. http://www.boz.zm/average-exchange-rates.htm. Accessed July 18, 2018.
  32. Deb P, Norton EC. Modeling health care expenditures and use. Annu Rev Public Health. 2018;39:489-505. doi:10.1146/annurev-publhealth-040617-013517
  33. Ng'anjo Phiri S, Fylkesnes K, Ruano AL, Moland KM. 'Born before arrival': user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia. BMC Pregnancy Childbirth. 2014;14:323. doi:10.1186/1471-2393-14-323
  34. 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
  35. Vian T, White EE, Biemba G, Mataka K, Scott N. Willingness to pay for a maternity waiting home stay in Zambia. J Midwifery Womens Health. 2017;62(2):155-162. doi:10.1111/jmwh.12528
  36. Sialubanje C, Massar K, van der Pijl MS, Kirch EM, Hamer DH, Ruiter RA. Improving access to skilled facility-based delivery services: Women's beliefs on facilitators and barriers to the utilisation of maternity waiting homes in rural Zambia. Reprod Health. 2015;12:61. doi:10.1186/s12978-015-0051-6
  37. Chiu C, Scott NA, Kaiser JL, et al. Household saving during pregnancy and facility delivery in Zambia: a cross-sectional study. Health Policy Plan. 2019;34(2):102-109. doi:10.1093/heapol/czz005
Volume 11, Issue 8
August 2022
Pages 1542-1549
  • Receive Date: 27 August 2020
  • Revise Date: 12 May 2021
  • Accept Date: 30 May 2021
  • First Publish Date: 23 June 2021