Cost to households in treating maternal complications in northern Ghana: A cross sectional study

BMC Health Services Research, Volume 15, No. 1, Year 2015

Interpretation

Background: The cost of treating maternal complications has serious economic consequences to households and can hinder the utilization of maternal health care services at the health facilities. This study estimated the cost of maternal complications to women and their households in the Kassena-Nankana district of northern Ghana. Methods: We carried out a cross-sectional study between February and April 2014 in the Kassena-Nankana district. Out of a total of 296 women who were referred to the hospital for maternal complications from the health centre level, sixty of them were involved in the study. Socio-demographic data of respondents as well as direct and indirect costs involved in the management of the complications at the hospital were collected from the patient’s perspective. Analysis was performed using STATA 11. Results: Out of the 60 respondents, 60% (36) of them suffered complications due to prolonged labour, 17% (10) due to severe abdominal pain, 10% (6) due to anaemia/malaria and 7% (4) due to pre-eclampsia. Most of the women who had complications were primiparous and were between 21-25 years old. Transportation cost accounted for the largest cost, representing 32% of total cost of treatment. The median direct medical cost was US$8.68 per treatment, representing 44% of the total cost of treatment. Indirect costs accounted for the largest proportion of total cost (79%). Overall, the median expenditure by households on both direct and indirect costs per complication was US$32.03. Disaggregating costs by type of complication, costs ranged from a median of US$58.33 for pre-eclampsia to US$6.84 for haemorrrhage. The median number of days spent in the hospital was 2 days – five days for pre-eclampsia. About 33% (6) of households spent more than 5% of annual household expenditure and therefore faced catastrophic payments. Conclusion: Although maternal health services are free in Ghana, women still incur substantial costs when complications occur and face the risk of incurring catastrophic health expenditure. The study was conducted in the Kassena-Nankana Districts (East and West) located in northern Ghana. For the purposes of this study, the two districts shall be referred to by their former name – the Kassena-Nankana District (KND). The KND has an area of about 1,675 square kilometres with a population of about 152,000 people [21]. Subsistence agriculture is the mainstay of the people. The district is characterized by a high poverty and mortality burden. The district is in one of the poorest regions in Ghana with poverty incidence of 88% [22,23]. Maternal mortality ratio for the period 1995–1996 was estimated at 637/100,000 live births but it declined to 373 maternal deaths per 100,000 live births based on an estimate for the period 2002–2004, representing a 40% reduction in the ratio [24]. With regards to health care, the KND has a district hospital located in the capital town (Navrongo) that serves as a referral point for all health facilities in the district. The hospital is the only health facility equipped to offer comprehensive emergency obstetric care in the district [11]. There are six health centres, one private clinic and twenty seven Community-based Health Planning and Services (CHPS) compounds. The CHPS initiative started in 1999 by the government of Ghana with the aim of increasing access to primary health care in the entire country. In this initiative, midwives and community health nurses are trained and sent to rural communities to provide basic preventive and curative services as well as doorstep services. These include antenatal care, delivery and postnatal services [25]. A cross sectional quantitative survey design was employed in data collection. Data was collected between February and April 2014 from the patient’s perspective. Two graduate research officers conducted all the interviews after two weeks of training on the study tools. Women with pregnancy-related complications were defined as women who were diagnosed by health staff during pregnancy or delivery to have a maternal complication and were referred from the health centre to the hospital for treatment. Data on all women who had pregnancy-related complications at the six main health centres in the district between April 2012 and March 2013 (12 month period) were obtained from the six health centres. A total of 296 women with maternal complications were referred from the health centres to the hospital within the period. However, contact information for 145 cases were never recorded by the health centre and therefore could not be traced in the community. In addition, 91 women had migrated from the district when their homes were visited. Thus only 60 women who were met during our visits were interviewed. Information on socio-demographic characteristics, direct and indirect costs of treating the complications were obtained. The reasons for referral reported by the women were also obtained. Since the aim was to capture official and unofficial payments made by women, all expenditures incurred within the hospital and outside the hospital were included. This study was part of a larger project (QUALMAT project) which aimed to improve quality of maternal and prenatal care in Ghana, Tanzania and Burkina Faso by testing two interventions: a computer-assisted clinical decision support system and performance-based incentives for improvement of the quality of maternal health services provided [26,27]. Ethical approval was obtained from the ethics committee of the University of Heidelberg (S-173/2008) and the Institutional Review Board of the Navrongo Health Research Centre in Ghana (NHRCIRB 085) before the study was conducted. In addition, individual oral informed consent was obtained from respondents before being interviewed. Data were entered into Epidata 3.1 and exported into STATA 11.0© for analysis. Descriptive analysis on background characteristics of respondents was done. The direct out-of-pocket costs for each pregnancy-related complication were estimated. Direct and non-direct medical costs were estimated by summing the costs and means calculated. The direct medical costs covered out-of-pocket payments for drugs, laboratory tests and medical supplies. Direct non-medical costs included all expenditure made on food during the health seeking process and transportation to the hospital and back home. The transportation cost included both the woman and the person who accompanied her to the hospital. Indirect costs associated with productivity lost were estimated by multiplying the number of days spent at the hospital by the daily minimum wage for the year 2013 (GH¢5.24/US$2.8). This was calculated for both the patient and the caretaker. Pre-referral costs were not collected and for that matter are not part of the analysis. Given that health centres are generally closer to the people, indirect cost such as transportation will be negligible. Also health centres do not have in-patient services hence costs related to in-patient care will be marginal. To determine the financial impact of maternal complications for households, actual cost incurred by the household was measured in relation to average annual household expenditure obtained from the Ghana Living Standards Survey Report of the fifth round (GLSS 5)_ Gh¢1,918 (US$1009) [28]. Catastrophic Health Expenditure (CHE) was also assessed. CHE is when a household’s out-of-pocket (OOP) payments are so high relative to its available resources which would require the household to forego the consumption of other essential goods and services [29]. Thus total OOP health care payments in excess of a certain threshold of household resources (household income, expenditure or consumption) are catastrophic. There is no consensus regarding the threshold for defining catastrophic health expenditures. Most authors have used threshold levels of 2.5%, 5%, 10% 15% and 20% of total household income. All costs were collected in Ghana Cedis (GH¢) and results presented in US$. The US$ conversion was based on the average exchange rate for 2013 (1US$ = 1.9GH¢). Given that the numbers interviewed were small, results on expenditures are presented in median.

AI Digest

Study Justification:

This study aimed to estimate the cost of treating maternal complications to women and their households in the Kassena-Nankana district of northern Ghana. The cost of treating maternal complications can have serious economic consequences for households and may hinder the utilization of maternal health care services. By understanding the financial burden faced by households, policymakers can develop strategies to reduce these costs and improve access to maternal health care services.

Study Highlights:

– The study found that transportation costs accounted for the largest cost, representing 32% of the total cost of treatment.
– The median direct medical cost per treatment was US$8.68, representing 44% of the total cost of treatment.
– Indirect costs, such as productivity lost, accounted for the largest proportion of the total cost (79%).
– The median expenditure by households on both direct and indirect costs per complication was US$32.03.
– About 33% of households spent more than 5% of their annual expenditure on treating maternal complications, facing catastrophic payments.

Study Recommendations:

– Policymakers should consider strategies to reduce transportation costs, such as improving transportation infrastructure or providing subsidies for transportation to health facilities.
– Efforts should be made to reduce direct medical costs by improving the availability and affordability of drugs, laboratory tests, and medical supplies.
– Measures should be taken to address the indirect costs associated with productivity lost, such as providing financial support or income replacement for women and their caretakers during hospital stays.
– Policies should be implemented to protect households from catastrophic health expenditures, such as expanding health insurance coverage or providing financial assistance for households facing high medical costs.

Key Role Players:

– Ministry of Health: Responsible for developing and implementing policies to improve maternal health care services and reduce costs.
– District Health Directorate: Coordinates health services in the Kassena-Nankana district and can implement local strategies to address the study recommendations.
– Health Facilities: Including the district hospital, health centers, and community-based health planning and services (CHPS) compounds, these facilities play a crucial role in providing maternal health care services and can contribute to reducing costs.
– Non-Governmental Organizations (NGOs): NGOs working in the health sector can collaborate with the government to implement interventions aimed at reducing costs and improving access to maternal health care services.

Cost Items for Planning Recommendations:

– Transportation infrastructure improvement: Includes costs for road construction, maintenance, and public transportation services.
– Subsidies for transportation: Budget allocation for providing financial support to women and their caretakers for transportation to health facilities.
– Availability and affordability of drugs, laboratory tests, and medical supplies: Budget allocation for ensuring the availability and affordability of these essential items.
– Financial support or income replacement: Budget allocation for providing financial assistance to women and their caretakers during hospital stays.
– Health insurance coverage expansion: Budget allocation for expanding health insurance coverage to include maternal health care services.
– Financial assistance for households: Budget allocation for providing financial support to households facing high medical costs.
Please note that the cost items provided are general categories and not actual cost estimates. Actual cost estimates would require a detailed analysis and planning process.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides detailed information on the cost of treating maternal complications in the Kassena-Nankana district of northern Ghana. The study design is cross-sectional, which limits the ability to establish causality. To improve the strength of the evidence, future studies could consider using a longitudinal design to track the costs over time and include a larger sample size to increase generalizability.

Abstract

The study was conducted in the Kassena-Nankana Districts (East and West) located in northern Ghana. For the purposes of this study, the two districts shall be referred to by their former name – the Kassena-Nankana District (KND). The KND has an area of about 1,675 square kilometres with a population of about 152,000 people [21]. Subsistence agriculture is the mainstay of the people. The district is characterized by a high poverty and mortality burden. The district is in one of the poorest regions in Ghana with poverty incidence of 88% [22,23]. Maternal mortality ratio for the period 1995–1996 was estimated at 637/100,000 live births but it declined to 373 maternal deaths per 100,000 live births based on an estimate for the period 2002–2004, representing a 40% reduction in the ratio [24]. With regards to health care, the KND has a district hospital located in the capital town (Navrongo) that serves as a referral point for all health facilities in the district. The hospital is the only health facility equipped to offer comprehensive emergency obstetric care in the district [11]. There are six health centres, one private clinic and twenty seven Community-based Health Planning and Services (CHPS) compounds. The CHPS initiative started in 1999 by the government of Ghana with the aim of increasing access to primary health care in the entire country. In this initiative, midwives and community health nurses are trained and sent to rural communities to provide basic preventive and curative services as well as doorstep services. These include antenatal care, delivery and postnatal services [25]. A cross sectional quantitative survey design was employed in data collection. Data was collected between February and April 2014 from the patient’s perspective. Two graduate research officers conducted all the interviews after two weeks of training on the study tools. Women with pregnancy-related complications were defined as women who were diagnosed by health staff during pregnancy or delivery to have a maternal complication and were referred from the health centre to the hospital for treatment. Data on all women who had pregnancy-related complications at the six main health centres in the district between April 2012 and March 2013 (12 month period) were obtained from the six health centres. A total of 296 women with maternal complications were referred from the health centres to the hospital within the period. However, contact information for 145 cases were never recorded by the health centre and therefore could not be traced in the community. In addition, 91 women had migrated from the district when their homes were visited. Thus only 60 women who were met during our visits were interviewed. Information on socio-demographic characteristics, direct and indirect costs of treating the complications were obtained. The reasons for referral reported by the women were also obtained. Since the aim was to capture official and unofficial payments made by women, all expenditures incurred within the hospital and outside the hospital were included. This study was part of a larger project (QUALMAT project) which aimed to improve quality of maternal and prenatal care in Ghana, Tanzania and Burkina Faso by testing two interventions: a computer-assisted clinical decision support system and performance-based incentives for improvement of the quality of maternal health services provided [26,27]. Ethical approval was obtained from the ethics committee of the University of Heidelberg (S-173/2008) and the Institutional Review Board of the Navrongo Health Research Centre in Ghana (NHRCIRB 085) before the study was conducted. In addition, individual oral informed consent was obtained from respondents before being interviewed. Data were entered into Epidata 3.1 and exported into STATA 11.0© for analysis. Descriptive analysis on background characteristics of respondents was done. The direct out-of-pocket costs for each pregnancy-related complication were estimated. Direct and non-direct medical costs were estimated by summing the costs and means calculated. The direct medical costs covered out-of-pocket payments for drugs, laboratory tests and medical supplies. Direct non-medical costs included all expenditure made on food during the health seeking process and transportation to the hospital and back home. The transportation cost included both the woman and the person who accompanied her to the hospital. Indirect costs associated with productivity lost were estimated by multiplying the number of days spent at the hospital by the daily minimum wage for the year 2013 (GH¢5.24/US$2.8). This was calculated for both the patient and the caretaker. Pre-referral costs were not collected and for that matter are not part of the analysis. Given that health centres are generally closer to the people, indirect cost such as transportation will be negligible. Also health centres do not have in-patient services hence costs related to in-patient care will be marginal. To determine the financial impact of maternal complications for households, actual cost incurred by the household was measured in relation to average annual household expenditure obtained from the Ghana Living Standards Survey Report of the fifth round (GLSS 5)_ Gh¢1,918 (US$1009) [28]. Catastrophic Health Expenditure (CHE) was also assessed. CHE is when a household’s out-of-pocket (OOP) payments are so high relative to its available resources which would require the household to forego the consumption of other essential goods and services [29]. Thus total OOP health care payments in excess of a certain threshold of household resources (household income, expenditure or consumption) are catastrophic. There is no consensus regarding the threshold for defining catastrophic health expenditures. Most authors have used threshold levels of 2.5%, 5%, 10% 15% and 20% of total household income. All costs were collected in Ghana Cedis (GH¢) and results presented in US$. The US$ conversion was based on the average exchange rate for 2013 (1US$ = 1.9GH¢). Given that the numbers interviewed were small, results on expenditures are presented in median.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health (mHealth) applications: Develop and implement mobile applications that provide pregnant women with information on prenatal care, nutrition, and warning signs of complications. These apps can also facilitate communication between pregnant women and healthcare providers, allowing for remote consultations and appointment scheduling.

2. Telemedicine services: Establish telemedicine services that connect pregnant women in remote areas with healthcare professionals. This would enable them to receive prenatal care and consultations without the need for long-distance travel.

3. Community-based health workers: Train and deploy community-based health workers, such as midwives and community health nurses, to provide basic maternal health services in rural areas. These workers can conduct antenatal visits, provide education on maternal health, and identify and refer high-risk cases to higher-level facilities.

4. Financial support programs: Implement programs that provide financial support to pregnant women and their families to cover the costs associated with maternal health services. This could include subsidies for transportation, medication, and hospital fees.

5. Health insurance schemes: Expand and improve health insurance schemes to include comprehensive coverage for maternal health services. This would help alleviate the financial burden on households and ensure that pregnant women have access to the care they need.

6. Infrastructure development: Invest in improving the infrastructure of healthcare facilities in rural areas, including the availability of equipment and supplies necessary for safe deliveries and emergency obstetric care.

7. Health education campaigns: Launch targeted health education campaigns to raise awareness about the importance of prenatal care and the signs of complications. This would help empower pregnant women to seek timely and appropriate care.

It is important to note that these recommendations are based on the information provided and may need to be adapted to the specific context and needs of the Kassena-Nankana District in northern Ghana.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health in the Kassena-Nankana district of northern Ghana is to address the financial burden faced by households when treating maternal complications. The study found that even though maternal health services are free in Ghana, women still incur substantial costs when complications occur, leading to potential catastrophic health expenditure for households.

To address this issue, the following innovation can be developed:

1. Financial Support Program: Implement a financial support program specifically targeted at households facing maternal complications. This program could provide financial assistance to cover the direct and indirect costs associated with treating maternal complications, such as transportation, medical supplies, and lost productivity. The program could be funded through government or donor resources and administered through the existing health facilities in the district.

2. Health Insurance Coverage: Expand health insurance coverage to include comprehensive coverage for maternal health services, including the treatment of complications. This would help alleviate the financial burden on households by providing them with insurance coverage for the costs associated with maternal complications. Efforts should be made to ensure that the insurance coverage is affordable and accessible to all households in the district.

3. Strengthening Community-based Health Planning and Services (CHPS) compounds: CHPS compounds play a crucial role in providing basic preventive and curative services, including antenatal care, delivery, and postnatal services. Strengthening and expanding the capacity of CHPS compounds in the district can help improve access to maternal health services and reduce the need for referrals to the hospital for complications. This can help reduce transportation costs and other indirect costs associated with seeking care at the hospital.

4. Public Awareness and Education: Increase public awareness and education about the importance of seeking timely and appropriate maternal health care. This can help reduce the occurrence of complications and the associated costs. Efforts should be made to educate women and their families about the signs and symptoms of complications, the importance of regular antenatal care visits, and the availability of free or subsidized maternal health services.

By implementing these recommendations, it is expected that access to maternal health services will be improved, and the financial burden on households when treating maternal complications will be reduced. This will ultimately contribute to better maternal health outcomes in the Kassena-Nankana district of northern Ghana.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening transportation services: Since transportation costs accounted for the largest cost in treating maternal complications, improving transportation services can help reduce the financial burden on households. This can be done by increasing the availability and accessibility of ambulances or providing subsidies for transportation to healthcare facilities.

2. Enhancing community-based health services: The Community-based Health Planning and Services (CHPS) initiative has shown promise in increasing access to primary healthcare. Expanding and strengthening this initiative can improve access to maternal health services, especially in rural areas.

3. Increasing awareness and education: Many women in the study faced complications due to lack of knowledge or delayed seeking of healthcare. Implementing awareness campaigns and educational programs can empower women with information about the importance of timely maternal healthcare and the available services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the number of women accessing maternal health services, reduction in transportation costs, improvement in timely healthcare seeking behavior, etc.

2. Collect baseline data: Gather data on the current state of maternal health access, including the number of women seeking care, transportation costs, awareness levels, etc. This can be done through surveys, interviews, or analysis of existing data.

3. Simulate scenarios: Develop different scenarios based on the recommendations, considering factors like increased transportation services, expanded CHPS initiatives, and awareness campaigns. Estimate the potential impact of each scenario on the identified indicators.

4. Analyze the impact: Compare the baseline data with the simulated scenarios to determine the potential improvements in access to maternal health. This can be done by calculating the percentage change in the indicators or using statistical methods to assess the significance of the changes.

5. Validate the results: Validate the simulated impact by conducting field studies or pilot projects to assess the actual changes in access to maternal health resulting from the implemented recommendations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions on implementing the most effective strategies.

Author

Dima Health

Statistics:

Citations: 25

Identifiers:

DOI: 10.1186/s12913-014-0659-1

Research Areas:

Community Interventions, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Burkina Faso, Ghana, Multi-Countries, Tanzania

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female