Maternity Waiting Home in Ethiopia : Cost Analysis and Utilization of Delivery Care

Abstract

Background High maternal mortality is one of the targets in the Sustainable Development Goals, especially among low-income countries. The main contributing factors of high maternal mortality are delays in the decision to seek care, delays in reaching care and delays in receiving good care. Geographic barriers are the most common contributor to delays in reaching care. The establishment of the maternity waiting home (MWH) is a strategy to bridge the geographic gap for women living in remote areas. Two important issues of the MWH are financial sustainability and essential services provided. In addition, the systems and services provided by a MWH in different facilities within and across countries vary and thus leads to different additional costs incurred. The MWH was first introduced in Ethiopia 45 years ago. Nowadays, more than 100 MWHs are operational throughout the country; however, there is no data on healthcare costs for establishment and maintenance of MWHs and information on essential services provided are largely unknown. Moreover, a woman and her family members are responsible for costs of travelling from home to the MWH and together with productivity loss during the waiting period before delivery the healthcare costs incurred by using a MWH can be substantial. Objectives This study aimed to describe essential services provided and establishment and operating costs of MWHs, to identify the influence of perceived geographic barriers to the utilization of maternity waiting homes (MWHs), to explore factors associated with current delivery complications among MWH users and non- users and to compare healthcare expenditures between maternity waiting home (MWH) users and non-users and in Ethiopia. Methods A cross-sectional study was conducted between December 2017 and June 2018. The study was conducted in eight health facilities with MWHs in the Gurage zone of Ethiopia. The methodology of this study comprises two parts. Part 1, MWH users exit interview and observational checklist were used to collect data on essential services provided. Cost related data were retrieved from health facilities' documentations. MWH building costs, overhead costs and running costs of MWH were estimated for the year 2018. Part 2, all postpartum women who were admitted to the maternity ward of the study hospitals or health centers were included and those who were critically ill, and/or had mental problems which hindered communication were excluded. The eligible women were then classified into MWH users or MWH non-users. The data were collected face to face by trained research assistants in a private area using a structured questionnaire. Bivariate analysis of socio-demographic and obstetrics characteristics was compared between MWH users and non-users. For the outcome variables of MWH utilization and delivery complications, each independent variable, covariates were selected for inclusion in the models based on a Directed Acyclic Graph (DAG) to minimize bias in the estimated results using multiple logistic regression. Healthcare expenditure for delivery care among MWH users and non-users was also another outcome variable which was then classified into out-of-pocket payments, women's costs, total costs and overall costs. Those health expenditures were then compared among MWH users and non-users. Association of out-of-pocket (OOP) payments and MWH utilization were further analyzed using quantile regression. Results Most clinical services and basic amenities were available and provided for MWH users. Estimated total annual cost was $17,197 ±9,660 US of which capital costs predominant followed by variable costs and fixed/overhead costs, respectively. Average estimated MWH utilization and delivery cost was $46 US per women. The unit cost of MWH utilization and delivery service varies among health facilities from $27 US to $112 US. This varying unit cost could be accredited to the number of MWH users, the higher the number of MWH users, the lower per head cost, and vice versa. The women who used a maternity waiting home were more likely to be >35 years old, had a perceived financial barrier, had traveled a longer time (31-60 min with adj. OR 1.80, 95% CI 1.23-2.63; >60 min with adj. OR 2.92, 95% CI 1.38-6.17), to have had the decision to visit a health facility made by a health extension worker or healthcare provider. Maternity waiting home users (adj. OR 0.56, 95%CI 0.35-0.91) had lower odds of developing delivery complications. Lower odds of developing delivery complications were found among women who gave birth in non-C/S facilities. Women with pregnancy complications and did not use MWH (adj. OR 5.86, 95% CI 2.91-11.81) were more likely to develop delivery complications. Women with delivery complications had higher odds of undergoing cesarean delivery and neonatal death. Significantly higher OOP payment, women's costs, total costs and overall cost were found among MWH users compared to non-users regardless of duration of MWH stay. MWH users were more likely to have higher OOP payment compared with MWH non-users in linear and quantile regression for both unadjusted and adjusted analyses. Higher OOP payments were observed for Most MWHs provided essential clinical services and basic amenities. The majority of the cost of MWHs was attributed to building construction costs. Once the construction of MWH was in ground, the cost of operating MWHs reduced substantially. The increasing unit cost of MWHs was due to under-utilization. This study strengthens the evidence of maternity waiting home utilization as a useful strategy to overcome geographic barriers and lower delivery complications, though utilization of MWHs incurred higher OOP payments, total costs, women's costs and overall costs compared with MWH non-users. Higher OOP payments for delivery care among MWH users were observed in all quantiles of expenditure. Encouraging and promoting the utilization of MWHs is required to achieve efficiency of MWH investment and improve the health of pregnant women. Keywords: maternity waiting homes, geographic barriers, delivery complications, health expenditure, out-of-pocket payment, costs, essential services