Costs and Patterns of Financing Maternal Health Care Services in Rural Communities in Northern Nigeria: Evidence for Designing National Fee Exemption Policy

Introduction

More than two decades after the launch of the Safe Motherhood Campaign in 1987, over half a million women most of whom live in developing countries continue to die of maternal causes each year.^[1] Nigeria accounts for approximately 2% of the world population; yet with an estimated 59,000 annual maternal deaths and a maternal mortality of 545 per 100,000, Nigeria is a leading contributor to the high maternal mortality rate in Sub-Saharan Africa.^[2] Nigeria also accounts for almost 10% of the world's maternal deaths.^[3] There are several reasons advanced for this high level of maternal mortality. According to the 2008 National Demographic Health Survey, only 35% of Nigerian women deliver in hospitals and the leading barrier to access is lack of finances for treatment. One in three women mentioned distance and transportation difficulties as the major problem while 41% of the respondents were concerned about lack of drugs.^[4] Some other factors that prevent women from accessing maternal health services include indirect costs, women's lack of authority for decision-making and multiple demands on their time, as well as the attitude of healthcare workers.^[5]

Many of the common causes of maternal mortality in Nigeria such as post-partum hemorrhage, sepsis and anemia are readily preventable, detectable and manageable. Key interventions such as ensuring antenatal care attendance and having a skilled attendant at delivery have also been identified and used to improve maternal health care in many countries. However, the use of such interventions has been found to be limited in developing countries like Nigeria.^[6] One of the reasons for this is the level of health care financing, especially by the government. The introduction of user fees has been widely implemented in government health programs as a means of alleviating pressure on constrained budgets as demands for services increase. However, this has proved to be a significant barrier to access. As more people realize that health systems should not only be concerned with improving peoples' health but also protect them against the financial costs of illness, there has been growing calls world-wide for the removal of user fees (especially for basic health services at the primary health care level). This is important in view of the fact that currently, out-of-pocket expenditure represents 70% of health expenditure in Nigeria.^[7] Apart from increasing access, it will also reduce morbidity and mortality, especially for the vulnerable groups such as young children and pregnant women. These exemptions may however not ensure universal access because informal fees and other costs associated with accessing healthcare are not affected; furthermore, exemption mechanisms may be poorly implemented.

Many sub-Saharan African countries have introduced “free” maternity services in a bid to eliminate poverty as an important barrier to maternal health service access and utilization. Some states in Northern Nigeria such as Kano, Katsina, Kaduna and the Federal Capital Territory, Abuja have also introduced similar schemes in public hospitals. One of the visible positive effects of such schemes has been the recorded increase in the number of women attending formal antenatal and delivery services. However, without adequate planning and financing, “free” maternity services could result in overstretched facilities, overworked staff and dissatisfied clients.

Objectives

This study was conducted in a community where ‘free’ maternal health services had been instituted in government owned health facilities, in order to assess the actual financial implications for the women and their families. Overall, we sought to provide evidence for proper planning and equitable allocation of resources, thereby increasing access to maternal health services. In general, the objectives of the study were to determine the cost of maternal health care in the designated community; and determine the pattern of financing of maternal healthcare in the community. Specifically, we sought to (1) identify the commonest maternal health problems in the community; and (2) identify the sources of maternal healthcare in the community.

Methods

Sample size determination

The sample size for the study was determined using the formula n = z² pq/d² where

• z = 1.96 at 95% confidence interval

• p = 0.2 (this was the proportion of women who had been pregnant and delivered within the preceding one year estimated from a pilot study in the same area)

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Results

Discussion

In this study, 53 of the women did not have any formal education. This finding is not unusual in the North Western part of Nigeria although there is increasing focus on girl child education. Female education is also a critical factor in maternal and child mortality reduction because the woman's income is more likely to be used for household needs such as food, education, medicine and other family needs.^[8] Educated women are also more likely to make important family decisions about nutrition, healthcare and the use of resources.

The average monthly income for the respondents in this study was N2,196. At the rate of N150 to a dollar, this equals US$14.6 per month or about US$0.5 per day. These findings highlight the socioeconomic status of women living in the area. Seventy-one households consisted of 10 to 14 people. The more individuals who need to be cared for may mean less money is available for women's maternal healthcare needs.

Fever, which could be characteristic of malaria or other infections, was the commonest health problem; it was followed by hemorrhage. This is worth noting in view of the fact that antimalarial and antibiotics are part of the essential drug list in Nigeria; misoprostol has also been recently added. Similar studies done in Maiduguri in Northern Nigeria and the Ejisu district in Ghana found hemorrhage, obstructed labour, hypertensive diseases in pregnancy and sepsis to be important contributors to maternal morbidity and mortality.^[2,10]

Many factors limit the utilization of maternal health services in the rural areas in developing countries including Nigeria. These factors include the availability, accessibility and quality of services as well as the social characteristics of the users and their communities. In this study, the majority of the women who did not receive ante-natal care cited financial difficulty as the main reason. In another study in Bangladesh which reviewed findings from a national survey, almost half of the women were found to have had complications during pregnancy however only one in three sought treatment from a trained provider, the principal reason being the cost of care.^[8]

While most respondents who received ante-natal care considered distance to be the major factor that influenced their choice of source of care, only 16 mentioned financial costs or affordability. This was most likely due to the state government's free maternal and child health package was offered at both public facilities in the community-the primary health center and the general hospital-which catered for the needs of over 90% of the women in this study. The package was not offered at private health facilities and accordingly, affordability was not a factor in the choice of private hospitals. Other studies have also shown that the cost of seeking institutionalized care can act as a deterrent in the case of poor households.^[9] Additionally, there is evidence that medical expenses can push even non-poor households below the poverty line.^[11]

Health workers in the general hospital were considered to be most experienced; in addition to being the most geographically accessible, primary health centers were considered to have the least waiting times to service. It must be noted that despite the high rates of antenatal care attendance (only 31 did not attend at all), 101 women-nearly half-delivered their babies at home. This supports the 2008 National Demographic Health Survey findings that states that of the 70% of births that occur in rural areas only 27% are assisted by skilled birth attendants. ^[4]

Nearly every woman who attended antenatal care at the general hospital delivered at those hospitals whereas of the 104 women who utilized the primary health center, only 31 deliveries were taken. The reasons are not farfetched. Culturally, many women in the area prefer to deliver at home and usually have a female relative/ neighbor/ friend who double as a local midwife or traditional birth attendant to assist them. Indeed, some studies show that Nigerian women rate the services of traditional birth attendants as being better than that of medical healthcare practitioners especially with regards to interpersonal relationships and flexibility of payment options.

Some of the health workers, especially from public health facilities, were also said to assist at home deliveries. Apart from this, the primary health facility in the study area lacked adequate facilities to effectively manage obstetric emergencies. For example, there was no electricity or running water in the facility. It was manned by Community Health Extension Workers and a few nurses who gave health talks, routine antenatal services, immunization and the treatment of common diseases such as malaria. Cases that appeared difficult to handle or occurred at night were usually referred to the general hospital. Many women were aware of the need for specialized care during the antenatal and delivery periods but not during postnatal period. For many of them, the essence of being pregnant and cared for during that period is to have a safe delivery.

Several studies on out-of-pocket costs of maternity care in low income countries in sub-Saharan Africa and Asia have consistently shown that out-of-pocket costs of maternity care vary considerably depending on the type of delivery (normal or complicated), as well as the type of health facility (public vs. private) and the level of the health system.^[11] In Uganda, Malawi and Ghana, for example, out-of-pocket costs for normal delivery (including user fees, travel costs and accommodation costs) ranged from US$2.30-22.80 in Uganda, US$0.40-7.90 in Malawi, and US$12.60-20.70 in Ghana. Fees for complicated deliveries were higher, ranging from US$13-59 in Uganda to US$68-140 in Ghana.^[12] With respect to the mean cost of delivery by place of delivery, it is by far much cheaper for the women to deliver at home N332.92 or (USD2.12) than in the private health facilities N12,638.57 or (USD84.25) in the community.

In other studies in Kenya and Tanzania, costs of normal delivery were significantly higher at private facilities than at government facilities. In Kenya, costs at private/mission facilities were twice as high as those incurred at government facilities, and in Tanzania, these costs were almost four times as high. In contrast, mean costs at mission health centers in Burkina Faso (US$3.1) were lower than those incurred at government health centers because such sites subsidized the costs of drugs and supplies.^[11] Although only 18 of the respondents in this study paid unofficial or extra fees, these fees have been found to be quite substantial in some studies. For instance, in a study in Bangladesh, unofficial fees were on average 12 times higher than official fees. ^[13] Another study in India reported that such fees were five times the formal fees, and represented 80% of total out-of-pocket expenses.^[14] A Tanzanian study also found that 73.3% of spending was actually out of pocket which is in line with the over 70% estimated for Sub-Saharan Africa.^[15] Notably, none of the respondents was covered by any form of health insurance whatsoever. Considering the fact that there is a National Health Insurance Scheme in place, which can help to prevent the catastrophic effects of healthcare financing and efforts, are being made to expand the scheme to rural areas, opportunities exist for intervention in the community. It might also be interesting to compare the pattern of maternal healthcare financing in the study area prior to the commencement of the free maternal health scheme and after.

It is worthy of note that treatment was only delayed in less than half of the cases that reported difficulties in paying for maternal health services. This was due mostly to familiarity with the health workers and in some instances, compassion. This brings to the fore the importance of the attitudes of health workers in maternal healthcare. However, six women still ended up with miscarriages.

Most women in the study felt it was improper for them to recommend for the government or that things should be left as they were as far as maternal healthcare financing and services were concerned. Interestingly, this highlights the social status of many women who cannot picture themselves as voices to be heard or as agents of change. Many of them were among the 60 who did not pay for the services. Others were concerned about the extension of the programmer to more rural areas, private hospitals and the less privileged. Adequate free drugs and the financial empowerment of women were also mentioned; the latter they said could be done through loans and setting up of small scale industries and government-assisted local cooperative groups. Very few women felt that more awareness needed to be created among the husbands and household heads on the importance of maternal healthcare for women. They felt the men could be reached at social gatherings and places of worship in the community.

Conclusion and Public Health Implications

From the research findings, the commonest maternal health problems identified by the women were fever, hemorrhage and anemia. The sources of maternal healthcare available to the women in the community were the traditional birth attendants, the private hospitals, the primary health center and the general hospital. A lot of women in the community still delivered in their homes as opposed to health facilities where there was a higher chance of having a skilled attendant at delivery and thus preventing maternal and infant mortality. The problems encountered in seeking maternal healthcareinclude financial difficulties, socio-cultural factors and distance. Most of the spending was still out of pocket. On the average, the women lived in households of 5-9 individuals and the majority (n=117) had no income; but average earnings were less than half a dollar a day which translates to N2190 or (US$14.6) a month or N26280 or (US$175.2) annually. On the other hand, the average total cost of maternal care was NI, 323 or (US$9) for normal delivery which is almost month's earnings. Where Caesarean sections were involved, the average total cost of maternal care was NI4,873 or (US$99), almost equivalent to seven months (untouched) earnings.