Abstract
Background: Cost is a major barrier to maternal health service utilisation for many women in low- and middle-income countries (LMICs). However, comparable evidence of the available cost data in these countries is limited. We conducted a systematic review and comparative analysis of costs of utilising maternal health services in these settings. Methods: We searched peer-reviewed and grey literature databases for articles reporting cost of utilising maternal health services in LMICs published post-2000. All retrieved records were screened and articles meeting the inclusion criteria selected. Quality assessment was performed using the relevant cost-specific criteria of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. To guarantee comparability, disaggregated costs data were inflated to 2019 US dollar equivalents. Total adjusted costs and cost drivers associated with utilising each service were systematically compared. Where heterogeneity in methods or non-disaggregated costs was observed, narrative synthesis was used to summarise findings. Results: Thirty-six studies met our inclusion criteria. Many of the studies costed multiple services. However, the most frequently costed services were utilisation of normal vaginal delivery (22 studies), caesarean delivery (13), and antenatal care (ANC) (10). The least costed services were post-natal care (PNC) and post-abortion care (PAC) (5 each). Studies used varied methods for data collection and analysis and their quality ranged from low to high with most assessed as average or high. Generally, across all included studies, cost of utilisation progressively increased from ANC and PNC to delivery and PAC, and from public to private providers. Medicines and diagnostics were main cost drivers for ANC and PNC while cost drivers were variable for delivery. Women experienced financial burden of utilising maternal health services and also had to pay some unofficial costs to access care, even where formal exemptions existed. Conclusion: Consensus regarding approach for costing maternal health services will help to improve their relevance for supporting policy-making towards achieving universal health coverage. If indeed the post-2015 mission of the global community is to "leave no one behind," then we need to ensure that women and their families are not facing unnecessary and unaffordable costs that could potentially tip them into poverty.
Highlights
Despite significant progress made during the 15-year span of the Millennium Development Goals, the burden of maternal morbidity and mortality remains highest in low- and middle -income countries.[1]
Overview of Studies Ten studies were published between 2000 and 201025,27,28,38,39,41,48,51-53 while the remaining 26 were published post-2010.26,29-37,40,42-47,49,50,54-60 Figure 2 shows the geographical distribution of low- and middle-income countries (LMICs) having at least one published study on the cost of maternal health service utilisation
In terms of cost of service utilisation as it relates to facility type, we found that, for the most part, there was an increment in utilisation cost of maternal health service from public to private facilities for antenatal care (ANC), skilled birth attendance and post-natal care (PNC)
Summary
Despite significant progress made during the 15-year span of the Millennium Development Goals, the burden of maternal morbidity and mortality remains highest in low- and middle -income countries.[1]. As has been well established, maternal health services required to meet the new SDG target include antenatal care (ANC), skilled birth attendance for normal vaginal delivery and emergency obstetric care (EmOC), post-natal care (PNC), family planning and post-abortion care (PAC) (Described in detail in Supplementary file 1).[4] high poverty levels in many low and middle-income countries worsens health disparities such that even when health services are available, they are inaccessible due to high costs. Analysis shows that between 1990 and 2015, the poorest women accounted for the highest proportion of maternal deaths, increasing from 68% to 80%.5. Poor financing mechanisms for health service utilisation have led to an increase in out-of-pocket payments and catastrophic health expenditure, resulting in families shouldering the costs of maternal healthcare beyond Analysis shows that between 1990 and 2015, the poorest women accounted for the highest proportion of maternal deaths, increasing from 68% to 80%.5 poor financing mechanisms for health service utilisation have led to an increase in out-of-pocket payments and catastrophic health expenditure, resulting in families shouldering the costs of maternal healthcare beyond
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