Academic journal article Bulletin of the World Health Organization

Emergency Obstetric Care in Mali: Catastrophic Spending and Its Impoverishing Effects on households/Soins Obstetricaux D'urgence Au Mali Les Depenses Catastrophiques et Leurs Effets Appauvrissants Sur Les Menages/ Atencion Obstetrica De Urgencia En Mali: Gastos Catastroficos Y Sus Efectos Empobrecedores En Los Hogares

Academic journal article Bulletin of the World Health Organization

Emergency Obstetric Care in Mali: Catastrophic Spending and Its Impoverishing Effects on households/Soins Obstetricaux D'urgence Au Mali Les Depenses Catastrophiques et Leurs Effets Appauvrissants Sur Les Menages/ Atencion Obstetrica De Urgencia En Mali: Gastos Catastroficos Y Sus Efectos Empobrecedores En Los Hogares

Article excerpt

Introduction

Most efforts designed to reduce inequities in maternal health in low-income countries have been focused primarily on averting maternal deaths. However, in countries with poorly functioning health systems, severe obstetric complications can lead to other adverse outcomes. The following outcomes can be associated with poor access to obstetric services: maternal death, neonatal death, mental or physical sequelae among surviving women, and financial hardship. This last outcome, which results from the catastrophic expenditures sometimes associated with emergency obstetric care, has not been as frequently explored as the others.

Any health expenditure that threatens a household's ability to meet its subsistence needs is termed "catastrophic". (1) Emergency obstetric care, far more costly than normal delivery, can generate catastrophic expenses capable of pushing certain households below the poverty line or of plunging them deeper into poverty. (2-6) Several studies have explored the frequency of catastrophic health payments in sub-Saharan Africa, (1,7-10) but few of them have focused on catastrophic expenditure resulting from emergency obstetric care (5,6) and none has examined the factors that contribute to such expenditure. In addition, the ways in which households cope with these costs and their effects on their welfare have seldom been explored. Little public health research has been devoted to examining the social and economic consequences of obstetric complications, (5,11,12) despite evidence from one study that the high cost of emergency obstetric care can strain a household's survival capacity from day to day and shape its physical, social and economic well-being for as long as one year. (5) The coping strategies used by households--e.g. using savings, selling assets or borrowing money--can provide important insights into how catastrophic expenditure can affect a household's future welfare. (13,14)

Mali is a low-income country with an annual income of 600 United States dollars (US$) per capita in 2010 and a population of 15.3 million, 51% of which lives below the international poverty line of US$1.25 per day per capita. (15) The study took place in Mali's western region of Kayes, which has 120 760 [km.sup.2] and seven districts with a combined population of 1.9 million. Because Mali has one of the highest maternal mortality ratios in the world, (15) two policies have been put into place to improve access to emergency obstetric care. The first policy, a national maternity referral system launched in 2002, consists of community cost-sharing schemes to help women pay for transportation to obstetric health centres. (16) The second policy, in effect since 2005, is the elimination of user fees for Caesarean sections. The fee exemption policy is applied to the direct costs of the Caesarean procedure, including preoperative examinations, provision of a Caesarean kit (drugs and surgical supplies), surgery, post-operative treatment, hospitalization and laboratory tests. (17)

This study has two objectives. The first is to investigate the frequency of catastrophic expenditure generated by emergency obstetric care and the risk factors associated with such expenditure. The second is to identify the coping strategies that households use to obtain the money needed to pay for the emergency obstetric care and how these strategies affect their well-being.

Methods

Data

Our study was conducted on a main sample of 484 women--242 maternal deaths and 242 near-misses--and on a nested subsample of 56 women who had had a near miss. The first data collection took place in the context of an ongoing case-control study on the impact of three types of delay on institutional maternal mortality in the Kayes region from February 2008 to June 2011. The delays in question were: (i) delay in deciding to seek care; (ii) delay in reaching a health facility and (iii) delay in being provided with appropriate care. …

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