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Journal ArticleDOI

Maternity or catastrophe: A study of household expenditure on maternal health care in India

11 Jan 2013-Health (Scientific Research Publishing)-Vol. 5, Iss: 1, pp 109-118
TL;DR: It was found that maternal health care expenditure in urban households was almost twice that of rural households, and increasing education level, higher consumption expenditure quintile and higher caste of women was associated with increasing odds of impoverishment due to maternalhealth care expenditure.
Abstract: Using data from 60th round of the National Sample Survey, this study attempts to measure the incidence and intensity of ‘catastrophic’ maternal health care expenditure and examines its socio-economic correlates in urban and rural areas separately. Additionally, it measures the effect of maternal health care expenditure on poverty incidence and examines the factors associated with such impoverishment due to maternal health care payments. We found that maternal health care expenditure in urban households was almost twice that of rural households. A little more than one third households suffered catastrophic payments in both urban and rural areas. Rural women from scheduled tribes (ST) had more catastrophic head counts than ST women from urban areas. On the other hand, the catastrophic head count was greater among illiterate women living in urban areas compared to those living in rural areas. After adjusting for out-of-pocket maternal health care expenditure, the poverty in urban and rural areas increased by almost equal percentage points (20% in urban areas versus 19% in rural areas). Increasing education level, higher consumption expenditure quintile and higher caste of women was associated with increasing odds of impoverishment due to maternal health care expenditure. To reduce maternal health care expenditure induced poverty, the demand-side maternal health care financing programs and policies in future should take into consideration all the costs incurred during prenatal, delivery and postnatal periods and focus not only on those women who suffered catastrophic expenditure and plunged into poverty but also those who forgo maternal health care due to their inability to pay.

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Citations
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Journal ArticleDOI
04 Nov 2014-PeerJ
TL;DR: Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence.
Abstract: Background. Low use of maternal healthcare services is one of the reasons why maternal mortality is still considerably high among adolescents mothers in India. To increase the utilization of these services, it is necessary to identify factors that affect service utilization. To our knowledge, no national level study in India has yet examined the issue in the context urban adolescent mothers. The present study is an attempt to fill this gap. Data and Methods. Using information from the third wave of District Level Household Survey (2007-08), we have examined factors associated with the utilization of maternal healthcare services among urban Indian married adolescent women (aged 13-19 years) who have given live/still births during last three years preceding the survey. The three outcome variables included in the analyses are 'full antenatal care (ANC)', 'safe delivery' and 'postnatal care within 42 days of delivery'. We have used Chi-square test to determine the difference in proportion and the binary logistic regression to understand the net effect of predictor variables on the utilization of maternity care. Results. About 22.9% of mothers have received full ANC, 65.1% of mothers have had at least one postnatal check-up within 42 days of pregnancy. The proportion of mother having a safe delivery, i.e., assisted by skilled personnel, is about 70.5%. Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence. Receiving full antenatal care is significantly associated with mother's education, religion, caste, household wealth, parity, exposure to healthcare messages and region of residence. Mother's education, full antenatal care, parity, household wealth, religion and region of residence are also statistically significant in case of safe delivery. The use of postnatal care is associated with household wealth, woman's education, full antenatal care, safe delivery care and region of residence. Conclusion. Several socioeconomic and demographic factors affect the utilization of maternal healthcare services among urban adolescent women in India. Promoting the use of family planning, female education and higher age at marriage, targeting vulnerable groups such as poor, illiterate, high parity women, involving media and grass root level workers and collaboration between community leaders and health care system could be some important policy level interventions to address the unmet need of maternity services among urban adolescents.

58 citations

Journal ArticleDOI
TL;DR: NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers and Regulating private health centres and continuing cash incentive under NHM is recommended.
Abstract: The National Health Mission (NHM), one of the largest publicly funded maternal health programs worldwide was initiated in 2005 to reduce maternal, neo-natal and infant mortality and out-of-pocket expenditure (OOPE) on maternal care in India. Though evidence suggests improvement in maternal and child health, little is known on the change in OOPE and catastrophic health spending (CHS) since the launch of NHM. The aim of this paper is to provide a comprehensive estimate of OOPE and CHS on maternal care by public and private health providers in pre and post NHM periods. The unit data from the 60th and 71st rounds of National Sample Survey (NSS) is used in the analyses. Descriptive statistics is used to understand the differentials in OOPE and CHS. The CHS is estimated based on capacity to pay, derived from household consumption expenditure, the subsistence expenditure (based on state specific poverty line) and household OOPE on maternal care. Data of both rounds are pooled to understand the impact of NHM on OOPE and CHS. The log-linear regression model and the logit regression models adjusted for state fixed effect, clustering and socio-economic and demographic correlates are used in the analyses. Women availing themselves of ante natal, natal and post natal care (all three maternal care services) from public health centres have increased from 11% in 2004 to 31% by 2014 while that from private health centres had increased from 12% to 20% during the same period. The mean OOPE on all three maternal care services from public health centres was US$60 in pre-NHM and US$86 in post-NHM periods while that from private health center was US$170 and US$300 during the same period. Controlling for socioeconomic and demographic correlates, the OOPE on delivery care from public health center had not shown any significant increase in post NHM period. The OOPE on delivery care in private health center had increased by 5.6 times compared to that from public health centers in pre NHM period. Economic well-being of the households and educational attainment of women is positively and significantly associated with OOPE, linking OOPE and ability to pay. The extent of CHS on all three maternal care from public health centers had declined from 56% in pre NHM period to 29% in post NHM period while that from private health centres had declined from 56% to 47% during the same period. The odds of incurring CHS on institutional delivery in public health centers (OR .03, 95% CI 0.02, 06) and maternal care (OR 0.06, 95% CI 0.04, 0.07) suggest decline in CHS in the post NHM period. Women delivering in private health centres, residing in rural areas and poor households are more likely to face CHS on maternal care. NHM has been successful in increasing maternal care and reducing the catastrophic health spending in public health centers. Regulating private health centres and continuing cash incentive under NHM is recommended.

56 citations

Journal ArticleDOI
20 Jul 2020
TL;DR: Evidence, moving from descriptive towards explanatory studies which provide insights into the “hows” and “whys” of processes and pathways are essential for guiding policy and programme actions.
Abstract: If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-a-vis universal cove...

33 citations

Journal ArticleDOI
TL;DR: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.
Abstract: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care.

28 citations

Journal ArticleDOI
TL;DR: Results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery and Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.
Abstract: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period. Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE. The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE. Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.

26 citations

References
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Journal ArticleDOI
TL;DR: There is an urgent need to assess the actual quality of postnatal care provided in Nepal and there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal Care where this is of sufficient quality.
Abstract: Postnatal care is uncommon in Nepal, and where it is available the quality is often poor. Adequate utilisation of postnatal care can help reduce mortality and morbidity among mothers and their babies. Therefore, our study assessed the utilisation of postnatal care at a rural community level. A descriptive, cross-sectional study was carried out in two neighbouring villages in early 2006. A total of 150 women who had delivered in the previous 24 months were asked to participate in the study using a semi-structured questionnaire. The proportion of women who had received postnatal care after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Women in one village had less access to postnatal care than women in the neighbouring one. Lack of awareness was the main barrier to the utilisation of postnatal care. The woman's own occupation and ethnicity, the number of pregnancies and children and the husband's socio-economic status, occupation and education were significantly associated with the utilisation of postnatal care. Multivariate analysis showed that wealth as reflected in occupation and having attended antenatal are important factors associated with the uptake of postnatal care. In addition, women experiencing health problems appear strongly motivated to seek postnatal care. The postnatal care has a low uptake and is often regarded as inadequate in Nepal. This is an important message to both service providers and health-policy makers. Therefore, there is an urgent need to assess the actual quality of postnatal care provided. Also there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal care where this is of sufficient quality.

203 citations


Additional excerpts

  • ...Health Care; Poverty; NSSO; Catastrophic Expenditure...

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Journal ArticleDOI
TL;DR: Multivariate regression results indicate that antenatal care and delivery care in private facilities increased the chances of ME-1 and ME-2, and measuring maternal expenditure against 'capacity to pay' (ME-2) may be better than measuring it as a proportion of overall household expenditure when assessing financial constraints in the use of maternal services.
Abstract: Using data from the 60(th) round of the National Sample Survey of India (2004), the study investigates the incidence and correlates of 'catastrophic' maternal expenditure (ME) in India. Data on ME come from 6879 births that took place during 365 days prior to the survey. The study adapts earlier definitions and methods for catastrophic total health care expenditure to measure 'catastrophic' ME as: (i) maternal health care expenditure more than 10% of the annual normative household consumption expenditure (ME-1), and (ii) maternal health care expenditure more than 40% of the annual 'capacity to pay' (ME-2). The 'capacity to pay' was derived by subtracting state-wise poverty-line household expenditure from household consumption expenditure. The average maternal expenditure varied by place of delivery: US dollar 9.5, US dollar 24.7 and US dollar 104.3 for birth at home, in a public facility and in a private facility, respectively. Sixteen per cent of households incurred ME of more than 10% of total household consumption expenditure (ME-1), while 51% households incurred ME of more than 40% of household 'capacity to pay' (ME-2). While incidence of ME-1 increased with income decile, the reverse was observed for ME-2, reflecting higher non-utilization of institutional maternal care and its non-affordability among poorer households. All the households from the poorest decile and 99% from the second poorest decile paid more than 40% of their capacity to pay. Multivariate regression results indicate that antenatal care and delivery care in private facilities increased the chances of ME-1 and ME-2 (P < 0.001). Measuring maternal expenditure against 'capacity to pay' (ME-2) may be better than measuring it as a proportion of overall household expenditure when assessing financial constraints in the use of maternal services. Improving the performance of the public sector, appropriate regulation of and partnership with the private sector, and effective direct cash transfers to pregnant women in the poorest households may increase utilization of maternal services and reduce the financial distress associated with ME.

147 citations


"Maternity or catastrophe: A study o..." refers methods in this paper

  • ...Health Care; Poverty; NSSO; Catastrophic Expenditure...

    [...]

  • ...The survey adopts a stratified twostage design with sampling of census villages in the rural areas (Panchayat wards in case of Kerala) and the NSS urban frame survey (UFS) blocks in the urban areas in the first stage, followed by sampling of households in the second stage [24]....

    [...]

01 Jan 2011
TL;DR: Significant changes in the 1990s and early 2000s that appear to have occurred as a result of out-of-pocket spending on health care in 16 Indian states indicate that new policies have significantly increased both catastrophic expenditure and impoverishment.
Abstract: Out-of-pocket payments are the principal source of health care finance in most Asian countries, and India is no exception. This fact has important consequences for household living standards. In this paper the author explores significant changes in the 1990s and early 2000s that appear to have occurred as a result of out-of-pocket spending on health care in 16 Indian states. Using data from the National Sample Survey on consumption expenditure undertaken in 1993-94 and 2004-05, the author measures catastrophic payments and impoverishment due to out-of-pocket payments for health care. Considerable data on the magnitude, distribution and economic consequences of out-of-pocket payments in India are provided; when compared over the study period, these indicate that new policies have significantly increased both catastrophic expenditure and impoverishment.

141 citations


Additional excerpts

  • ...Health Care; Poverty; NSSO; Catastrophic Expenditure...

    [...]

Journal ArticleDOI
TL;DR: The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India and recommend that facilities in public health centres of poorly performing states are improved and public-private partnership models are developed to reduce the economic burden for households of maternal care.
Abstract: Context Though promotion of institutional delivery is used as a strategy to reduce maternal and neonatal mortality, about half of the deliveries in India are conducted at home without any medical care. Among women who deliver at home, one in four cites cost as barrier to facility-based care. The relative share of deliveries in private health centres has increased over time and the associated costs are often catastrophic for poor households. Though research has identified socio-economic, demographic and geographic barriers to the utilization of maternal care, little is known on the cost differentials in delivery care in India. Objective The objective of this paper is to understand the regional pattern and socio-economic differentials in out-of-pocket (OOP) expenditure on institutional delivery by source of provider in India. Methods The study utilizes unit data from the District Level Household and Facility Survey (DLHS-3), conducted in India during 2007-08. Descriptive statistics, principal component analyses and a two-part model are used in the analyses. Findings During 2004-08, the mean OOP expenditure for a delivery in a public health centre in India was US$39 compared with US$139 in a private health centre. The predicted expenditure for a caesarean delivery was six times higher than for a normal delivery. With an increase in the economic status and educational attainment of mothers, the propensity and rate of OOP expenditure increases, linking higher OOP expenditure to quality of care. The OOP expenditure in public health centres, adjusting for inflation, has declined over time, possibly due to increased spending under the National Rural Health Mission. Based on these findings, we recommend that facilities in public health centres of poorly performing states are improved and that public-private partnership models are developed to reduce the economic burden for households of maternal care in India.

120 citations


Additional excerpts

  • ...Health Care; Poverty; NSSO; Catastrophic Expenditure...

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Journal ArticleDOI
TL;DR: The WHS was found to report lower total household expenditure but higher out-of-pocket expenditure comparing with other types of surveys, and further efforts to standardize the questions in collecting expenditure data in household surveys are suggested for the purpose of cross-country and over time comparison.

79 citations


Additional excerpts

  • ...Health Care; Poverty; NSSO; Catastrophic Expenditure...

    [...]