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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.
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