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.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

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.

The Rajarata Pregnancy Cohort (RaPCo): study protocol.

BACKGROUND: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. METHODS: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. DISCUSSION: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

Serum creatinine and estimated glomerular filtration rate (eGFR) in early pregnancy and changes during the pregnancy.

Renal functions in pregnancy undergo rapid changes, and the thresholds for normal values are a major research gap and are still debatable. The lack of prospective population-based studies with early pregnancy recruitment hampered the decision-making process on the best thresholds to be used in clinical practice. We present the serum creatinine (sCr) and sCr-based estimated glomerular filtration rates (eGFR) in early pregnancy with changes over the gestational period in a large prospective, community-based cohort, the Rajarata Pregnancy Cohort (RaPCo). We carried out a community-based prospective cohort study with 2,259 healthy pregnant women with a gestation period of less than 13 weeks and without pre-existing medical conditions. Gestational period-specific sCr and sCr-based eGFR were calculated for different age strata, and the participants were followed up until the second trimester. Renal functions of pregnant women were compared with 2.012 nonpregnant women from the same geographical area. The mean (SD) sCr of the 2,012 nonpregnant women was 62.8(12.4) µmol/L, with the 97.5th percentile of 89.0 µmol/L. Among the pregnant women, mean (SD) sCr was 55.1(8.3), 52.7(8.1), 51.1(9.1), 47.1(7.2), and 49.3 (9.9), while the 97.5th percentile for sCr was 72.4, 69.1, 70.0, 63.6, and 66.0 µmol/L respectively during the 4-7, 8-9, 10-12, 24-27 and 28-30 weeks of gestation. The average sCr value was 84.7% and 76.4% of the nonpregnant group, respectively, in the first and second trimesters. The mean eGFR was 123.4 (10.7) mL/min/1.73 m2 in the first trimester and increased up to 129.5 mL/min/1.73 m2 in the 24th week of gestation. The analysis of cohort data confirmed a significant reduction in sCr with advancing pregnancy (p<0 .001). This study provides thresholds for renal functions in pregnancy to be used in clinical practice. Clinical validation of the proposed thresholds needs to be evaluated with pregnancy and newborn outcomes.

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.