Background
Methods
Study setting
Population
Study
Data collection
Structured interview and document review
Semi-structured interviews
Data management and analysis
Results
Profile of women
Variables | Total (n = 1627) | Percent |
---|---|---|
Health Zones | ||
Lubumbashi | 274 | 16.8 |
Katuba | 181 | 11.1 |
Mumbunda | 126 | 7.7 |
Vangu | 127 | 7.8 |
Kisanga | 133 | 8.2 |
Ruashi | 354 | 21.8 |
Kamalondo | 61 | 3.7 |
Tshiamilemba | 103 | 6.3 |
Kenya | 82 | 5.0 |
Kampemba | 186 | 11.4 |
Type of facility | ||
Health center | 684 | 42.0 |
Sendwe (provincial referral hospital) | 74 | 4.6 |
General referral hospital | 574 | 35.3 |
University Clinics of Lubumbashi (UCL) | 75 | 4.6 |
Polyclinics | 220 | 13.5 |
Sector of ownership | ||
Private, religious | 214 | 13.1 |
Public | 655 | 40.3 |
Para-statal commercial | 108 | 6.6 |
Private, non-religious | 650 | 40.0 |
Age (years) | ||
< 20 | 172 | 10.6 |
20–34 | 1215 | 74.6 |
≥ 35 | 240 | 14.8 |
Marital status | ||
Married | 1589 | 97.7 |
Not married | 38 | 2.3 |
Partner’s age (years) | ||
< 25 | 114 | 7.0 |
25–34 | 784 | 48.2 |
35–44 | 589 | 36.2 |
≥ 45 | 115 | 7.1 |
Unknown | 25 | 1.5 |
Wealth quintile | ||
Q1 (very poor) | 302 | 18.6 |
Q2 | 317 | 19.5 |
Q3 | 311 | 19.1 |
Q4 | 344 | 21.1 |
Q5 (very rich) | 353 | 21.7 |
Type of delivery | Non-catastrophic expenses | Catastrophic expenses |
p
| ||
---|---|---|---|---|---|
Total (n) | Median in US$ (minimum-maximum) | Total (n) | Median in US$ (minimum-maximum) | ||
Total expenditures for obstetric and neonatal care | |||||
Uncomplicated vaginal | 906 | 34 (10–220) | 95 | 38 (10–163) | 0.043 |
Complicated vaginal | 356 | 43 (12–396) | 73 | 42 (12–272) | 0.69 |
Caesarean | 104 | 323 (82–966) | 93 | 388 (108–924) | 0.005 |
Total | 1366 | 38 (10–966) | 261 | 54 (10–924) | < 0.001* |
Total household capacity to pay | |||||
Uncomplicated vaginal | 906 | 104 (20–2462) | 95 | 65 (20–222) | 0.03 |
Complicated vaginal | 356 | 122 (19–3009) | 73 | 54 (20–199) | 0.04 |
Caesarean | 104 | 569 (112–3201) | 93 | 392 (55–1297) | 0.031 |
Total | 1366 | 114 (19–3201) | 261 | 123 (20–1297) | 0.015* |
Variables | Total | Incidence of CE (%) | RR | 95% CI |
p
|
---|---|---|---|---|---|
Health Zones | < 0.001 | ||||
Lubumbashi | 274 | 25.9 | 1 | ||
Katuba | 181 | 32.6 | 1.3 | 0.9–1.7 | |
Mumbunda | 126 | 18.3 | 0.7 | 0.5–1.1 | |
Vangu | 127 | 17.3 | 0.7 | 0.4–1.0 | |
Kisanga | 133 | 15.0 | 0.6 | 0.4–0.9 | |
Ruashi | 354 | 11.6 | 0.5 | 0.3–0.6 | |
Kamalondo | 61 | 8.2 | 0.3 | 0.1–0.7 | |
Tshiamilemba | 103 | 7.8 | 0.3 | 0.2–0.6 | |
Kenya | 82 | 4.9 | 0.2 | 0.1–0.5 | |
Kampemba | 186 | 4.3 | 0.2 | 0.1–0.3 | |
Type of facility | < 0.001 | ||||
Health center | 684 | 11.6 | 1 | ||
Sendwe (provincial referral hospital) | 74 | 23.0 | 2.0 | 1.2–3.1 | |
General referral hospital | 574 | 20.0 | 1.7 | 1.3–2.3 | |
University Clinics of Lubumbashi (UCL) | 75 | 18.7 | 1.6 | 0.9–2.6 | |
Polyclinics | 220 | 16.4 | 1.4 | 0.9–2.0 | |
Sector of ownership | < 0.001 | ||||
Private, religiousa | 214 | 6.1 | 1 | ||
Public | 655 | 20.5 | 3.4 | 2.0–5.8 | |
Para-statal commercial | 108 | 12.0 | 2.0 | 1.1–4.1 | |
Private, non-religious | 650 | 15.5 | 2.6 | 1.5–4.5 |
Variables | Total | Incidence of CE (%) | RR | 95% CI |
p
|
---|---|---|---|---|---|
Age (years) | 0.10 | ||||
< 20 | 172 | 20.4 | 1.6 | 0.9–2.5 | |
20–34 | 1215 | 16.1 | 1.3 | 0.9–1.9 | |
≥ 35 | 240 | 12.5 | 1 | ||
Marital status | < 0.001 | ||||
Married | 1589 | 15.5 | 1 | ||
Not married | 38 | 36.8 | 2.4 | 1.5–3.5 | |
Partner’s age (years) | 0.39 | ||||
< 25 | 114 | 14.9 | 0.8 | 0.4–1.4 | |
25–34 | 784 | 16.7 | 0.9 | 0.6–1.3 | |
35–44 | 589 | 15.3 | 0.8 | 0.5–1.2 | |
≥ 45 | 115 | 19.1 | 1 | ||
Unknown | 25 | 4.0 | 0.2 | 0.1–1.1 | |
Wealth quintile | < 0.001* | ||||
Q1 (very poor) | 302 | 44.7 | 22.5 | 11.0–46.8 | |
Q2 | 317 | 31.6 | 15.9 | 7.7–33.3 | |
Q3 | 311 | 3.2 | 1.6 | 0.7–4.1 | |
Q4 | 344 | 2.6 | 1.3 | 0.5–3.4 | |
Q5 (very rich) | 353 | 2.0 | 1 | ||
Referral status | < 0.001 | ||||
Referred | 114 | 40.4 | 2.8 | 2.2–3.6 | |
Not referred | 1513 | 14.2 | 1 | ||
Complications | < 0.001 | ||||
Post-partum infection | 50 | 58.0 | 9.1 | 6.4–12.5 | |
Pre & post-partum hemorrhage | 86 | 41.9 | 6.5 | 4.6–9.1 | |
Eclampsia | 27 | 40.7 | 6.4 | 3.6–10.1 | |
Placenta Prævia | 22 | 31.8 | 5.0 | 2.5–8.8 | |
Soft-tissue tears | 214 | 25.7 | 4.0 | 2.9–5.6 | |
Placental abruption | 20 | 25.0 | 3.9 | 1.7–7.7 | |
Obstructed labor | 240 | 23.3 | 3.6 | 2.6–5.1 | |
None | 968 | 6.4 | 1 | ||
Type of delivery | < 0.001 | ||||
Uncomplicated vaginal | 1001 | 9.5 | 1 | ||
Complicated vaginal | 429 | 17.0 | 1.8 | 1.4–2.4 | |
Caesarean | 197 | 47.2 | 5.0 | 3.9–6.3 | |
Neonatal care | < 0.001 | ||||
Basic | 971 | 9.1 | 1 | ||
Emergency | 163 | 39.9 | 4.4 | 3.3–5.8 | |
Intensive | 493 | 21.9 | 2.4 | 1.9–3.1 | |
Type of skilled birth attendant | < 0.001 | ||||
Nurses and midwives | 1446 | 14.0 | 1 | ||
General physician | 97 | 29.9 | 2.1 | 1.5–2.9 | |
Specialist physician | 84 | 35.7 | 2.6 | 1.8–3.4 | |
Delivery facility | 0.03 | ||||
Planned | 1287 | 15.0 | 1 | ||
Not planned | 340 | 20.0 | 1.3 | 1.1–1.7 | |
Length of stay (days) | < 0.001 | ||||
≤ 3 | 1143 | 12.4 | 1 | ||
4–14 | 419 | 19.8 | 1.6 | 1.2–2.0 | |
≥ 15 | 65 | 55.4 | 4.5 | 3.4–5.7 |
Variables | [n = 1627; CE = 261] | ||
---|---|---|---|
aOR | 95% CI |
p
| |
Sectora&b | 0.65 | ||
Public vs private religious | 1.3 | 0.6–2.6 | |
Parastatal entity vs private religious | 1.3 | 0.5–3.8 | |
Private non-religious vs private religious | 1.5 | 0.7–3.2 | |
Not married vs marrieda&b | 1.6 | 0.7–3.4 | 0.24 |
Socioeconomic levela&b | < 0.001 | ||
Q1 vs Q5 | 38.7 | 17.6–85.2 | |
Q2 vs Q5 | 23.5 | 10.7–51.8 | |
Q3 vs Q5 | 1.6 | 0.6–4.2 | |
Q4 vs Q5 | 1.3 | 0.5–3.6 | |
Referred vs not referreda | 1.9 | 1.1–3.6 | < 0.001 |
Type of deliverya | < 0.001 | ||
Complicated vaginal vs uncomplicated | 1.9 | 1.2–2.9 | |
Caesarean vs uncomplicated | 7.5 | 3.6–15.4 | |
Obstetric complicationsb | < 0.001 | ||
Infections vs none | 20.8 | 7.4–58.0 | |
Pre & post-partum hemorrhage vs none | 9.4 | 5.0–17.7 | |
Eclampsia vs none | 4.7 | 1.5–15.0 | |
Placenta Prævia vs none | 5.6 | 1.5–21.0 | |
Soft-tissue tears vs none | 4.2 | 2.5–7.1 | |
Placental abruption vs none | 2.4 | 1.2–9.5 | |
Obstructed labor vs none | 4.8 | 2.8–8.2 | |
Newborn carea | < 0.001 | ||
Emergency vs basic | 2.8 | 1.4–5.4 | |
Intensive vs basic | 2.9 | 1.9–4.3 | |
Skilled birth attendant at deliverya | < 0.001 | ||
Generalist physician vs midwives | 2.2 | 0.9–5.1 | |
Specialist physician vs midwives | 3.9 | 1.8–8.5 | |
Length of stay (days)b | < 0.001 | ||
3–14 | 1.3 | 0.9–1.9 | |
≥ 15 | 3.6 | 1.5–8.1 |
Alternatives for the payment of obstetric and neonatal care
Quantitative aspects
Qualitative aspects
“I didn’t know it was a caesarean, I didn’t even know how much I had to pay; I was referred urgently from a health center.” [Participant 1]
“I didn’t know how much it should cost, the nurses were discussing with my sister.” [Participant 2]
“I planned to save in the last month of my pregnancy, but the birth was premature, it took us by surprise.” [Participant 3]
“Not a single medication was given to us by the maternity [unit]; we always paid for them out of our own pocket [woman or family] … if we’d had the money for the hospital stay and the surgical intervention, I would have left immediately, because I was not ill.” [Participant 4]
“At the time of the last caesarean, my family paid for everything even though they shouldn’t have; this time, he (husband) had to get by with his family.” [Participant 5]
“My husband gave me everything, I don’t know how he did it, I don’t know how much he earns approximately per month; I think at least he did what was necessary to save during the pregnancy.” [Participant 6]
“My husband hasn’t worked for several months, and I didn’t work either in the last months of my pregnancy: I had no money when I delivered, I didn’t know who would pay these fees; but my family and my in-laws did.” [Participant 7]
“In any case, my husband is a man: he had to manage, this time my family should not have to take on so much expense.” [Participant 8]
Consequences to households of catastrophic expenses associated with obstetric and neonatal care
Economic Consequences
“Since I was in the hospital, I couldn’t trade and I couldn’t help my husband: everything was screwed [messed up]. On his own, he had to pay for everything: food, school fees, transportation, clothes, etc. In these conditions, that’s how we didn’t have money to pay for health care.” [Participant 9]
“I had to stop my petty trading, to stay in the hospital until someone pays all the bills.” [Participant 10]
“As for the children, I have seven, and they stay by themselves at home because their dad is a motorcyclist [motorcycle taxi driver] and he stays downtown late to earn what’s needed; my oldest daughter even got pregnant.” [Participant 11]
“I had asked the nurses to keep my baby if they wanted, and to let me go look for money until I could pull together the necessary sum.” [Participant 12]
“We pawned some of our clothes, the chairs, our flatscreen and my capital (trading money), with a view to getting the first installment of the fees … when the hospital asked us to pay the rest, we took on debt from one of our neighbors.” [Participant 13]
Quality of care during the stay in the maternity
“There were days when I didn’t receive paracetamol and my dressing wasn’t changed because I hadn’t yet paid even a part of the fees for treatment … my baby’s cord was also not cleaned because I hadn’t paid for their medications.” [Participant 14]
“Because I was slow to pay for care, the person who took care of me wouldn’t greet me in the morning; she didn’t ask me how I’d slept, either.” [Participant 15]
“Before I’d paid for the care, when the midwife changed my dressing, she didn’t speak to me. When she spoke to me, it was to remind me that I should pay the bill. I couldn’t even complain about the pain when she rubbed my wound … I was afraid she would stop the dressing since I hadn’t yet paid.” [Participant 16]
Household subsistence
“Since I got out of the maternity, we haven’t paid our rent. The landlord threw us out. And since we weren’t able to find food with the children, I came here to my parents’ house until I can resume my activities, if I find money … the friends we borrowed from for the maternity come every day demanding payment and threatening to take us to court.” [Participant 17]
“My two children don’t go to school because we haven’t paid the fees for 3 months … they are with my parents, because here sometimes we go to sleep hungry.” [Participant 18]
Relationships with partner and family
“Since the delivery, my husband has left the house on the pretext that he was going to look for money … his friends and family have told me that I made him carry the responsibility for the pregnancy.” [Participant 19]
“We hadn’t quarreled, but he didn’t come see me at the hospital, not a single member of his family came to see me; they didn’t even think that I also needed to eat, it was my aunt who always brought me food.” [Participant 20]
“My mother-in-law said I wasn’t fit because I delivered by caesarean.” [Participant 21]
“They (my in-laws) told me that I was the cause of the unhappiness or curse of their child [my husband] … because of me, everything he does doesn’t work … and that my pregnancy made him poor.” [Participant 22]
Access to care for other members of the household
“Since I had no money to go to the health center, when my daughter fell ill, I went to get, on credit, malaria medications from the pharmacy of my friend’s little brother.” [Participant 23]
In Fig. 2, we show a schematic of the consequences tied to CE from obstetric and neonatal care in Lubumbashi.“After discharge from the maternity, I didn’t go back to the hospital for the weighing and vaccination of the child: I didn’t have the fees for transport and to pay to the hospital … I’m using traditional medicine for hemorrhoids which bother me since the delivery.” [Participant 24]