Socioeconomic equity in the utilization of antenatal and delivery care services women's and providers' perspectives, Yangon, Myanmar

Abstract

Background Approximately 303,000 women died from complications of pregnancy and childbirth worldwide in 2015. Timely and appropriate antenatal and delivery care by a skilled birth attendant can help to improve pregnancy outcomes as well as reduce maternal deaths. Equity of access to and utilization of healthcare across socioeconomic groups is important to achieve universal health coverage. Inability to pay is a major barrier of accessibility and utilization of appropriate maternal health care and delivery. Although the utilization of maternal health care and economic indicators have been increasing in low- and middle-income countries, inequities and financial barriers in the utilization of the antenatal and delivery care have been reported in many countries leading to worse health outcomes. Therefore, inequity issues, the actual financial burden in terms of impoverishment and catastrophic expenditure due to out-of-pocket payments and its determinants, and a clear understanding of maternal health care services with the inequity context of women's and providers' perceptions of financial burden in utilizing maternal health care services are useful for planning and decision- making in health policies for policy improvement. Objectives This study aimed to identify socioeconomic equity in the utilization of antenatal and delivery care and assess household expenditure on utilization of antenatal and delivery care and its effects on the economic burden and determine the perception of socioeconomic equity in the utilization of antenatal and delivery care by women's and providers' perspectives. Methodology To achieve three specific objectives, the methodology of this study was divided into two parts. Part I uses quantitative methods to focus on the socioeconomic equity, and household expenditure on utilization of antenatal and delivery care and its effect on the economic burden. Part II uses quantitative and qualitative methods to measure women's and providers' perspectives of socioeconomic equity in the utilization of antenatal and delivery care. In part I, a community-based cross-sectional survey was conducted in north and south districts of the Yangon Region from October to November 2016 using a multi-stage cluster sampling technique. Women aged 15-49 years with a history of delivery within the past 12 months and residing in the selected districts were included in the sample. Face-to-face interviews were conducted using a structured questionnaire. Information collected included demographic, housing and obstetric characteristics, access to the antenatal and delivery care, household expenses and women's perception of their own expenditure on utilization of antenatal and delivery care services. Household expenses were measured in terms of direct medical costs, indirect costs and costs of productivity loss. Inequities in the utilization of antenatal and delivery care were determined by evaluating concentration curves and concentration indexes. Impoverishment and catastrophic expenditure were used to measure the effects of expenditures due to out-of-pocket payment. The determinants of impoverishment and catastrophic expenditure were analyzed by multiple logistic regression with standard error adjusted for the complex survey design. In part II, a mixed quantitative and qualitative design was conducted in two selected townships in the Yangon Region. All women from part I and together with 164 health care providers were included in the quantitative component. Of these, a total of 48 women were selected according to their wealth index and previous experience of giving birth and 24 health care providers according to their service loads were included in the qualitative component. In-depth interviews were conducted to obtain information related to women's perceived needs and barriers for utilization of antenatal and delivery care. Perceived barriers was used to measure inequity. For the quantitative method, women's perceived needs and barriers for seeking antenatal and delivery care between women and health care providers was analyzed using prevalence-adjusted bias-adjusted kappa. Factors associated with women's perceptions were also analyzed using logistic regression. Thematic analysis was used in the qualitative component. Results Of 762 women who participated in part I, more than two-thirds of women were aged 20- 34 years and had a secondary school and above level of education. Almost all women had at least one antenatal care visit, 79% had at least four and one-third had early initiation of antenatal care. Of all women, 88.5% and 26.8% delivered with a skilled birth attendant present or by cesarean section, respectively. There was no evidence of inequity in utilization of antenatal care; however, inequity of at least one antenatal care visit among women aged less than 20 years was found with a concentration index of 0.04. The concentration indexes for delivery by a skilled birth attendant and cesarean section were 0.05 and 0.14, respectively. Delivery by cesarean section was disproportionately higher in adolescents and women with higher a middle- school level of education. Out-of-pocket payments had made by 75% of the women for the antenatal care and by 99.6% for delivery care. The impact of these payments was to increase the poverty headcount ratio by 4.3% among those utilizing antenatal care sample, by 1.3% among those utilizing delivery care, and by 6.1% overall. Similarly, these payments increased the incidences of catastrophic expenditure by 12%, 9.1% and 20.9% for the three aforementioned groups, respectively. The determinants of impoverishment and catastrophic expenditure due to accessing antenatal and delivery care varied significantly with women's occupation, number of household members, number of antenatal care visits, and utilization of health personnel and health facilities. Almost all women and health care providers agreed on the perceived needs for women seeking antenatal and delivery care; however, different perspectives were evident regarding their perceived barriers. Internal factors such as level of education, occupation status and income, and external factors such as perceived affordability of delivery care, informal payment, service availability and geographical accessibility were related to perceived barriers in terms of the women's utilization of antenatal and delivery care. Conclusion There were no overall inequities in the utilization of antenatal care, but inequities were found in women who had delivery by cesarean section and/or delivery by a skilled birth attendant. High OOP payments for utilizing antenatal and delivery care in Yangon Region of Myanmar resulted in one-tenth of the women becoming impoverished and one-fourth suffering catastrophic expenditure. Women with no income or those who accessed health facilities with high levels of services provided were more likely to be impoverished or face catastrophic expenses. Women's education and economic status, cost and affordability of maternal health care were important factors for perceived barriers to women seeking antenatal and delivery care. Adolescent pregnant women should be targeted for strategic plans to reduce inequities in utilization of delivery care. Policy integration is required to improve maternal health outcomes and to reduce the financial burden on the poor and vulnerable due to maternal health expenditures as a step towards implementation of universal health coverage in Myanmar.