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

Abstract

Purpose Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home). Methods We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis. Results Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery. Conclusion These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.

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

“…Costs of baby clothes or chitenge (Zambian fabric) for delivery had previously been reported as a large contributor to OOP spending. [13][14][15] Specifically, we had previously found that the expectation that women will bring their own baby clothes represents an additional barrier to facility-based delivery. 13 In this analysis, baby clothes continued to make up the majority of OOP expenditure in both groups.…”

“…[13][14][15] Specifically, we had previously found that the expectation that women will bring their own baby clothes represents an additional barrier to facility-based delivery. 13 In this analysis, baby clothes continued to make up the majority of OOP expenditure in both groups. The cost of baby clothes may remain a financial barrier to facility-based delivery, but does not differ between MWH users and nonusers and is therefore unlikely to have influenced a pregnant woman's decision to use a MWH.…”

“…While finding reliable transportation might remain a barrier to access to a health facility, transportation cost may not be as important as previous qualitative studies have suggested. 13,14,16 Further research should explore the availability and the cost of transportation as barriers to facility-based delivery. Additionally, we found that women utilizing the MWHs expend significantly more on accommodation than those who do not.…”

“…Women across Zambia, Tanzania, and Ethiopia continue to face other financial roadblocks including OOP expenditure for transportation to health facilities, delivery supplies, and baby clothes. 5,[7][8][9][13][14][15][16] Distance to health facilities is also a well-documented barrier to maternal health service utilization. 6,7,[16][17][18] This is especially true for women in remote areas, who have trouble finding reliable and affordable transportation to get to a heath facility.…”

The predictive power of health system environments: a novel approach for explaining inequalities in access to maternal healthcare

“…However, households in the two lowest wealth quintiles are more likely to struggle to afford the cost of a facility delivery. This cost was recently estimated by a study on rural Zambia as US$29 for primary-level facilities and US$36 for hospitals, despite the absence of formal user fees, relative to an average monthly income of US$105 for the poorest rural residents 31. Recent qualitative research shows that facility-level expectations that mothers will bring materials for the delivery constitute a social exclusion mechanism for women without sufficient access to financial resources 11…”