Maternal Health Care Expenditure among Women in Rural Areas of Pakistan

Background: With Pakistan failing to achieve Millennium Development Goals we have now entered into a new era of Sustainable Development Goals. Decreasing child mortality, improving maternal health and increasing the proportion of births by trained birth attendants, are the areas with unmet goals. As 29.5% of population of Pakistan is below the poverty line, expenditure on maternal health care services is of great importance as it determines the utilization of health care services to a large extent. Objective: To assess maternal health care expenditure and its sociodemographic predictors in rural Khanewal, Punjab, Pakistan. Methodology: In this cross sectional study average cost on delivery (both SVD and Cesarean section) was assessed in both public and private sector of rural 1 Medical Officer BHU 55/10R, Tehsil Jahanian, District Khanewal, Pakistan 2 Medical Officer Neurosurgery ward, DHQ teaching hospital, D G Khan, Pakistan 3 Department of Public Health and Community Medicine, SKZMDC, Lahore, Pakistan 4 PG Trainee Medicine, Nishtar Hospital, Multan 5 Department of Public Health and Community Medicine, SKZMDC, Lahore, Pakistan Date of Submission: 20-03-2017 Date of 1 st Revision Received: 22-05-2017 Date of Acceptance for Publication: 26-05-2017 Conflict of Interest: None Funding Source: None Contribution All Authors have contributed in Study Design, Data Collection, Data Analysis, Data Interpretation, Manuscript Writing and Approval. Khanewal. Total 257 women who had delivered in the last one year were included. Results: Results revealed that 69.3% of mothers were illiterate.56.8% sought antenatal care in public health unit and 43.2% in a private health care facility. 49.8% delivered in a public health unit and 50.2% in private health care facility. Total expense on antenatal care and delivery was found to be <4,000PKR (<$38.16) in 55.6% (reportedly in a public health care unit) and was >16,000PKR (>$152.65) in 23.3% (reportedly in a private health care facility). A significant difference was found between expense, in public vs private sector and SVD vs. C-section. Conclusion: This study revealed that there is high financial cost on maternal health services in both public and private sector of rural Khanewal. Although in private sector the cost is more as compared to public sector but still it is high keeping the notion of free health care services in Pakistan by the government. Therefore it is suggested to improve the quality of health care in public sector and if possible to provide free of cost services to mothers during delivery.


Introduction
During maternity, mothers need continuum of care to ensure that their pregnancy, birth and postnatal period remains free of any complication for best possible health outcomes for themselves and also for their newborns. 1There are approx.500,000maternal deaths each year worldwide,most of which are in rural areas of developing countries including Pakistan. 2 Risk of a woman dying during pregnancy and child birth is about 1 in 6 in poorest parts of the world. 3Maternal ANNALS VOL 23, ISSUE 2, APR.-JUN.2017 mortality rate is highest for Asia including Pakistan. 2 Most maternal deaths are clustered around the period of labour, delivery and in immediate postpartum period. 3In Pakistan utilization of health care services i.e., public or private is usually dependent on the socio-demographic factors, level of education, economic factors, cultural beliefs, status of women in the society, gender discrimination, political environment etc. 4 Health care system itself is also a major determinant. 4With WHO recommending every country to spend at least 5% of GDP on health, Pakistan has managed to raise it to 3.5% with government contributing only 0.5% and rest by the private sector i.e., approximately 2.5%. 5 Cost of maternity care can be a barrier in accessing a health care unit which may result in increased maternal or neonatal deaths. 6Poverty gap and severity of poverty has increased in rural as well urban areas thus concluding that poverty in Pakistan is a major issue. 7The current study high-lights the impact of financial burden in maternal health care services in rural areas of Pakistan and emphasizes the need of effective health reforms to ensure timely, safe and free obstetric facilities for the poor.
The objective of this studyis to assess maternal health care expenditure in rural Khanewal, Pun-jab, Pakistan.

Methods
This is across sectional study conducted in Chak 56/10 R having population of about 2,400 and Chak 57/10 R having population of about 2,500 in Khanewal district, Punjab, Pakistan.With population of approx.5,000 in both these areas, estimated proportion of 50% and confidence level of 90% sample size was calculated using epi info version 7 which came out to be 257.10% was added for the possibility of non-response so the sample size came out to be 283.Mothers who had delivered either by SVD or Cesarean section in the last 1 year were our study population and these eligible females were identified and included in the study through consecutive sampling until the sample size was complete.A structured, self-constructed questionnaire was administered after taking verbal informed consent.Questionnaire was pre-tested on subjects not part of the study.Cronbach alpha came out to be 0.8 showing that questionnaire was valid.257complete questionnaires were entered and data was analysed on SPSS version 21.Client data recorded was kept anonymous and all other ethical concerns were addressed keeping in view the ethical guidelines of Helsinki's declaration.

Results
Monthly income was categorized showing that majority i.e., 32.3% of the families had income ranging between 5,000PKR ($47.7)-10,000PKR($95.41).Occupation of head of family was asked which revealed that 46.3% of the people were labourers, 22.6% were doing private jobs, 20.6% were government servants, 5.4% were farmers, 2.7% were businessmen and 2.3% were land owners.The results also showed that 69.3%of the mothers were illiterate and only 30.7% were literate (Table 1).Antenatal care was sought in a public unit by 56.8%of mothers and by 43.2% in a private health care facility.69.6% of mothers delivered had SVD and 30.4% had C-section.49.8% of mothers delivered in a public unit and 50.2% in private sector.Total expense of delivery was reported to be less <4,000PKR (<$38.16) in 55.6% of mothers and was >16,000PKR (>$152.65) in 23.3% with the rest lying in between (Table 2).Expense in relation to antenatal and natal care variables was calculated which showed that public sector provided cheaper antenatal care as compared to private sector.In majority of mothers who had SVD the expense was less than 8000 PKR ($76.32)ascompared to mothers who had Csection, in whom it was >16000 PKR ($152.65).Delivery as observed was cheaper in public health care unit as compared to private health care facility.A significant difference was found between expense, in public vs. private sector and SVD vs. C-section (Table 3).

Discussion
Poverty as in other developing countries is a core issue in Pakistan. 8A study done on low-middle income countries of Asia showed that health care payments exacerbate poverty.As reported > 60% of health care costs are paid out of pocket by households.Number of Asians living below $1/day can be reduced by reducing such out of pocket health payments. 9Education is one of the predictor in utilization of health care facility at individual level whereas socioeconomic status is a significant predictor at house hold level. 10Cost can be a major issue in seeking alternate maternity health care. 11Another study done in Pakistan showed that low literacy rate of mothers and low socioeconomic status may contribute to poor utilization of primary health care services. 12This study showed that literacy rate was 30.7% among mothers which is in line with literacy rate of women in rural areas of Pakistan i.e., 25%. 13Our study revealed that total expense was on extremes in public as compared to private health care facility i.e., cost was <4,000PKR ($38.16) in a public heath care unit and was >16,000PKR ($152.65) in a private health care facility as reported by mothers.Private health care facility was considered more reliable but was more expensive as reported.It is seen that health care expenditures can exacerbate poverty of a household. 14In our study significant difference was seenbetween expense in public vs private sector, SVD vs C-section, which shows health care is expensive in private sector as compared to private sector.In contrast to other countries where public sector is considered more reliable, 15 in Pakistan the use of private health facility increases with increasing maternal education and socio-economic status of the family. 16With minimum suggested rate of < 5% for C-section by WHO, 17 the rates are rising alarmingly worldwide with its determinants being controversial in lower-middle income countries. 18Our study also showed that rate of C-section in private sector is moreas compared to mothers in public sector, though WHO recommends 5 to 15% C.Sec rate for a comprehensive Emergency Obstetric Care facility.This raises questions about the efficacy of private sector hospitals and its client-centeredness.
Our study also have some limitations for e.g. it is relied totally upon respondent's recall and only one district of Punjab was selected, so caution is needed in generalizing the results.

Conclusion
The present study revealed high financial cost on maternal health both in public and private health care facilities in rural Khanewal.Although private sector cost is more but public sector cost is also high keeping in view, the notion of free health care services raised by Governments in Pakistan.Place of antenatal care, place of delivery and mode of delivery is significantly associated with income level .It is suggested that alternative financing mechanisms may be used in public sector health system to improve its utilization by community.

Table 1 :
Distribution of Socio-demographic Factors.