Out-of-pocket Expenditure for Antenatal Care Instills amidst Free Health Care Provision: Evidence from a Large Pregnancy Cohort in Rural Sri Lanka

Abstract

Background: Out-of-pocket expenditure (OOPE) considers a barrier to access to healthcare for pregnant women. This study aimed to estimate the magnitude and associated factors of OOPE for antenatal care (ANC) in a rural Sri Lankan setting. Methods: This study was a follow-up of a large pregnancy cohort [Rajarata Pregnancy Cohort (RaPCo)] in all 22 Medical Officers of Health areas in the Anuradhapura District, Sri Lanka. A pre-tested interviewer-administered questionnaire was used to collect data on socio-demographic, economic, and the cost incurred in the first trimester, and self-administered questionnaires were used monthly to collect costs incurred in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics for the magnitude, non-parametric statistical methods for statistically significant difference, and the multiple linear regression model to test the associated factors. Results: The mean (SD)]age of the pregnant women was 28.3 (5.6) years. The mean (SD) monthly household income and expenditure were USD 277.29 (216.04) and USD 190.19 (103.11), respectively. The mean OOPE for per visit ANC was USD 4.18 (52.1% of per day household expenditure). The mean OOPE for total ANC was USD 57.74 (3.4% of annual household expenditure). The direct medical OOPE share (73.8%) was significantly higher than direct non-medical OOPE (26.2%) (p<0.001). Pregnant women who utilized only the government-free health services also spent 28% and 14% of OOPE on medicines and laboratory investigations. Monthly household income (p<0.001), monthly household expenditure (p<0.1), used healthcare mode (p<0.05), having maternal morbidities (p<0.05), and the number of previous pregnancies (p<0.1) were the statistically significant independent predictors of OOPE during ANC.Conclusion: Per visit OOPE for ANC is equivalent to half of the per day household expenditure. Monthly household income, expenditure, used healthcare mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOPE during ANC. Despite having freely available government health facilities, the majority tend to use private health facilities and incur higher OOPE. Government-free healthcare users also incur a direct medical OOPE for medicines and laboratory investigations.

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

“…In this study, the pregnancy expenditure of the pregnant women delivered during the COVID-19 pandemic did not differ from the expenditure incurred for pregnant women delivered before the COVID-19 pandemic. Pregnancy expenditure is identified as an economic burden in the same study setting, since it exceeds more than 10% of household income 25 26. This is problematic for the households whose income was affected, pushed into poverty and the pregnancy and household expenditure remained unchanged during the pandemic.…”

“…The reason was unavailability and the inability to seek work due to pandemics and curfews 35. Daily income earners must spend 70.0% of per day’s income per visit to antenatal care in rural Sri Lanka 26. As reported in Pakistan,36 this could impact pregnant women’s mental health.…”

“…35 Daily income earners must spend 70.0% of per day's income per visit to antenatal care in rural Sri Lanka. 26 As reported in Pakistan, 36 this could impact pregnant women's mental health. Household income reduction and poverty due to the pandemic were common phenomena, as documented by many researchers.…”

“…However, the COVID-19 pandemic caused a higher prevalence of anxiety and depression among pregnant women, requiring additional support from the family and field health officers 24. This could be worse if the household economy were affected, since the income status was associated with the pregnancy expenditure25 26 and pregnancy nutritional status 27. Available evidence indicates that the COVID-19 pandemic created an economic meltdown at the household level and the Sri Lankan economy 28…”