The magnitude of out-of-pocket expenditure for antenatal care in low and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Owing to the lack of compiled global evidence on out-of-pocket expenditure (OOPE) for antenatal care (ANC), this systematic review and meta-analysis estimated the magnitude of OOPE for ANC in low and middle-income countries (LMICs). METHODS: An electronic search was conducted using 10 databases and a hand search of the eligible studies' reference lists. Studies on OOPE for ANC in LMICs, published in English without time restriction, were included. The comparability of OOPE values was improved using inflation and exchange rate adjustment to the year 2019. Random-effects meta-analysis was performed to generate pooled estimates. RESULTS: Among the 9766 articles retrieved, 32 were selected. Only 13/137 (9.5%) countries reported evidence of OOPE during pregnancy in LMICs. The majority of the studies (n = 2779.4%) were from lower-middle-income settings. Ten (31.3%) studies from African region, 21 (65.6%) studies from South-East-Asian region, 1 (3.1%) study from region of Americas and none from the other regions were included. The average OOPE for ANC and single ANC visit ranged from United States Dollar (USD) 2.41 to USD 654.32 in LMICs, the lowest in Tanzania and the highest in India. The pooled OOPEs were USD 63.29 (95% confidence interval [CI] = 51.93-74.65) and USD 12.93 (95%CI = 4.54-21.31) for ANC and single ANC visit in LMICs, respectively. CONCLUSION: The study revealed that the pooled estimates of OOPE for ANC throughout pregnancy and per visit were high in some countries, with a wide variability observed across countries. There was a lack of evidence on OOPE for ANC from many LMICs, and filling the evidence gap in LMICs is highlighted.

Social determinants of health pave the path to maternal deaths in rural Sri Lanka: reflections from social autopsies.

BACKGROUND: Ending preventable maternal deaths remains a challenge in low- and middle-income countries (LMICs). Society perceived causes and real-life observations can reveal the intangible causes of maternal deaths irrespective of formal maternal death investigations. This study reports complex patterns in which social determinants act towards paving the path to maternal deaths in a rural Sri Lankan setting. METHODS: We conducted social autopsies for 15/18 maternal deaths (in two consecutive years during the past decade) in district A (pseudonymized). In-depth interviews of 43 respondents and observations were recorded in the same field sites. During thematic analysis, identified themes were further classified according to the World Health Organization framework for social determinants of health (SDH). The patterns between themes and clustering of social determinants based on the type of maternal deaths were analyzed using mixed methods. RESULTS: Discernable social causes underpinned 12 out of 15 maternal deaths. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were the characteristic structural determinants of most deceased families. Social isolation was the commonest leading cause manifesting as a reason for many other social factors and resulted in poor social support paving the path to most maternal deaths. A core set of poverty, social isolation, and poor social support acted together with alcohol usage, and violence leading to suicides. These core determinants mediating through neglected self-health care led to delay in health-seeking. Deficits in quality of care and neglect were noted at health institutions and the field. CONCLUSION: Social autopsies of maternal deaths revealed complex social issues and social determinants of health leading to maternal deaths in Sri Lanka, indicating the need for a socially sensitive health system.

How costly is the first prenatal clinic visit? Analysis of out-of-pocket expenditure in rural Sri Lanka - a country with free maternal health care.

BACKGROUND: This study aimed to determine the magnitude of and factors associated with out-of-pocket expenditure (OOPE) during the first prenatal clinic visit among pregnant women in Anuradhapura district, Sri Lanka, which provides free maternal healthcare. METHODS: The study design was a cross-sectional study, and the study setting was 22 Medical Officers of Health (MOOH) areas in Anuradhapura District, Sri Lanka. Data of 1389 pregnant women were analyzed using descriptive statistics and non-parametric tests. RESULTS: The mean OOPE of the first prenatal clinic visit was USD 8.12, which accounted for 2.9 and 4.5% of the household income and expenditure, respectively. Pregnant women who used only government-free health services (which are free of charge at the point of service delivery) had an OOPE of USD 3.49. A significant correlation was recorded between household expenditure (rs = 0.095, p = 0.002) and the number of pregnancies (rs = - 0.155, p < 0.001) with OOPE. Education level less than primary education is positively contributed to OOPE (p < 0.05), and utilizing government-free maternal health services lead to a decrease in the OOPE for the first prenatal clinic visit (p < 0.05). CONCLUSION: Despite having free maternal services, the OOPE of the first prenatal clinic visit is high in rural Sri Lanka. One-fifth of pregnant women utilize private health services, and pregnant women who used only government-free maternal health services also spend a direct medical cost for medicines/micronutrient supplements.

Out-of-Pocket Expenditure for Antenatal Care Amid Free Health Care Provision: Evidence From a Large Pregnancy Cohort in Rural Sri Lanka.

INTRODUCTION: Global evidence suggests that high out-of-pocket (OOP) expenditure negatively affects health service utilization and creates an economic burden on households during pregnancy. This study aimed to estimate the magnitude and associated factors of OOP expenditure for antenatal care (ANC) in a rural Sri Lankan setting by following up with a large pregnancy cohort (The Rajarata Pregnancy Cohort [RaPCo]) in Anuradhapura District, Sri Lanka. METHODS: Data were collected from July 2019 to May 2020. An interviewer-administered questionnaire was used to collect socioeconomic data and OOP expenditures in the first trimester. Self-administered questionnaires were used monthly to collect OOP expenditures in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics, nonparametric statistics, and a multiple linear regression model. RESULTS: The majority of participants used both government and private health facilities for ANC. The mean (standard deviation [SD]) OOP expenditure per ANC visit was US$4.18 (US$4.19), and the mean (SD) OOP expenditure for total ANC was US$57.74 (US$80.96). Pregnant women who used only free government health services also spent 28% and 14% of OOP expenditure on medicines and laboratory investigations. Household income (P<.001), household expenditure (P<.1), used health care mode (P<.05), maternal morbidities (P<.05), and the number of previous pregnancies (P<.1) were the statistically significant independent predictors of OOP expenditure. OOP expenditure per visit for ANC equals half of the daily household expenditure. CONCLUSION: Despite having freely available government health facilities, most pregnant women tend to use both government and private health facilities and incur higher OOP expenditure. Free government health care users also incur a direct medical OOP expenditure for medicines and laboratory investigations. Monthly household income, expenditure, used health care mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOP expenditure.

Impact of COVID-19 pandemic on health service utilisation and household economy of pregnant and postpartum women: a cross-sectional study from rural Sri Lanka.

OBJECTIVES: This study aims to describe how household economies and health service utilisation of pregnant and postpartum women were affected during the pandemic. DESIGN: A cross-sectional study. SETTING: This study was conducted in the Anuradhapura district, Sri Lanka. PARTICIPANTS: The study participants were 1460 pregnant and postpartum women recruited for the Rajarata Pregnancy Cohort during the initial stage of the COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: Household economic (income, poverty, nutritional and health expenditures) and health service utilisation details during the COVID-19 pandemic were gathered through telephone interviews. Sociodemographic and economic data were obtained from the cohort baseline and analysed with descriptive and non-parametric analysis. RESULTS: Out of the 1460 women in the sample, 55.3% (n=807) were pregnant and 44.7% (n=653) were postpartum women. Of the total sample, 1172 (80.3%) women participated in the economic component. The monthly household income (median (IQR)=212.39 (159.29-265.49)) reduced (median (IQR)=159.29 (106.20-212.39)) in 50.5% (n=592) families during the pandemic (Z=-8.555, p<0.001). Only 10.3% (n=61) of affected families had received financial assistance from the government, which was only 46.4% of the affected income. The nutritional expenditure of pregnant women was reduced (Z=-2.023, p=0.043) by 6.7%. During the pandemic, 103 (8.8%) families with pregnant or postpartum women were pushed into poverty, and families who were pushed into poverty did not receive any financial assistance. The majority of women (n=1096, 83.3%) were satisfied with the free public health services provided by the public health midwife during the pandemic. CONCLUSION: During the early stages of the pandemic, healthcare utilisation of pregnant women was minimally affected. Even before the country's current economic crisis, the household economies of pregnant women in rural Sri Lanka were severely affected, pushing families into poverty due to the pandemic. The impact of COVID-19 and the aftermath on pregnant women will have many consequences if the policies and strategies are not revised to address this issue.

Economic burden of out-of-pocket expenditure, productivity cost during pregnancy and COVID-19 impact on household economy in a cohort of pregnant women in Anuradhapura District, Sri Lanka; A study protocol.

Background: Investigating the out-of-pocket expenditure (OOPE) associated with maternal health is important since OOPE directly affects the affordability of health services. Global evidence suggests the importance of capturing the productivity cost during pregnancy in terms of absenteeism and presenteeism. Furthermore, the impact of the ongoing COVID-19 pandemic on the household economy needs to be further evaluated as pregnant women are one of the most vulnerable groups. This study aims at determining the economic burden of OOPE, productivity cost, and COVID-19 impact on pregnant women's household economy in a cohort of pregnant women in Anuradhapura District, Sri Lanka. Methods: The study setting is all 22 Medical Officer of Health (MOH) areas in Anuradhapura district, Sri Lanka. The study has three components; a follow-up study of a cohort of pregnant women to assess the magnitude and associated factors of OOPE and to assess the productivity cost (Component 1), a qualitative case study to explore the impact and causes of the OOPE under free health services (Component 2) and a cross-sectional study to describe the effects of COVID-19 outbreak on household economy (Component 3). The study samples consist of 1,393 and 1,460 participants for components one and three, respectively, and 25 pregnant women will be recruited for component two. The data will be analyzed using descriptive, parametric, and non-parametric statistics for the first and third components and thematic analysis for the second component. Discussion: With the lack of evidence on OOPE, productivity loss/cost in terms of maternal health, and COVID-19 impact on household economy in Sri Lanka, the evidence generated from this study would be valuable for policymakers, health care administrators, and health care practitioners globally, regionally, and locally to plan for future measures for reducing the OOPE, productivity loss/cost, and minimizing the economic hardship of the COVID-19 outbreak during pregnancy.