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Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review

Health Economics Review volume 10, Article number: 26 (2020) Cite this article

Abstract

Background

Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa.

Methods

A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices.

Results

Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6–52 and USD 8–73, but cesarean section costs between USD 56–377 and USD 80–562, respectively. Patient and health system costs of abortion range between USD 11–66 and USD 40–298, while post-abortion care costs between USD 21–158 and USD 46–151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52–231 and USD 123–186, while for maternal hemorrhage they range between USD 65–196 and USD 30–127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38–489 while the health system cost was estimated to be USD 514.

Conclusion

This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.

Introduction

An estimated 303,000 preventable deaths occurred during pregnancy and childbirth globally in 2015, mostly as a result of pregnancy and birth-related complications. Most of these maternal deaths occurred in low-income countries, particularly in sub-Saharan Africa. About three-quarters of these complications include unsafe abortions, hypertensive disorders in pregnancy i.e. pre-eclampsia and eclampsia, sepsis, severe bleeding, and complications arising at the time of delivery [1, 2]. Globally, about 17 million girls aged less than 19 years give births every year, and about 4 million undergo unsafe abortions to terminate unwanted pregnancies, and these adolescent pregnancies are associated with elevated risks of complications [1,2,3]. Pregnancy and childbearing complications are ranked fourth globally and second in low- and middle-income countries among the leading causes of death in adolescent girls [4].

The United Nations Development Fund reports that the prevalence of adolescent pregnancy has decreased globally, but remained relatively unchanged in sub-Saharan Africa [5]. By 2030, it is expected that the population of adolescent girls in sub-Saharan Africa will grow by 50%; hence, escalating the problem of teen pregnancy and childbearing [5]. Since adolescent pregnancy is associated with elevated risk of complications [1,2,3], it is likely that the total costs of treating pregnancy and childbearing complications in sub-Saharan Africa will also increase. The cost of pregnancy and birth-related complications have been synthesized and documented in systematic reviews conducted elsewhere [6,7,8] but not in sub-Saharan Africa despite being the region that carries the largest burden of maternal death globally [5].

This study aims to assess patient and health system costs associated with the management of pregnancy and birth-related complications in sub-Saharan Africa. The results will feed into a cost-benefit analysis study comparing two adolescent pregnancy prevention strategies in Zambia to help policymakers to choose the strategy with the greatest potential for return on investment [9]. The study findings may also be useful to researchers and policymakers elsewhere as it aims to provide cost evidence that can facilitate economic evaluation and budget impact analyses of maternal and child health interventions to demonstrate whether they represent value for money or not in addition to positive public health impact.

Methods

We used the PRISMA checklist that is recommended for reporting a systematic review and meta-analysis of clinical trials [10], with slight modifications to suit the review of costing studies. The study protocol was registered with PROSPERO-the International Prospective Register of Systematic Reviews with registration No. CRD42019119316.

Search strategy and inclusion criteria

The search of the literature was conducted by ATM in Pubmed, EMBASE, Cinahl, and Web of Science databases using combinations of the following search terms: cost, costs, cost of illness, economic burden, cost analysis, healthcare costs, health care costs, preterm birth, low birth weight, preeclampsia, eclampsia, abortion, post-abortion complication, cesarean section, and individual names of sub-Saharan African countries. An example of a search code used to search in Pubmed is shown in Table 1. The last search of these databases was conducted on 26th November 2018. However, we allowed Pubmed and Web of Science to send us weekly updates on the saved search terms until 13th May 2019, during which two more qualifying articles were found. Other articles were identified by scanning reference lists of review papers and relevant costing studies and searching with the Google search engine using the above-mentioned search terms. We also contacted some authors to ask for unpublished articles.

Table 1 Search in PubMed
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We included costing studies that i) were conducted in sub-Saharan Africa ii) published from January 2000 to 13th May 2019 iii) targeted normal delivery as well as pregnancy and birth-related complications including pre-eclampsia, eclampsia, pre-term birth, low birth weight babies, small for gestational age babies, unsafe abortion and post-abortion complications. The search was limited to humans and the English language. Review papers and reports were excluded because we were only interested in primary cost data, but they were instead used to identify other relevant studies. Two reviewers (ATM and PB) independently screened the titles and abstracts of all the articles to assess eligibility and the qualifying ones were subjected to further screening for eligibility by the two reviewers by reading the full text.

Quality assessment

Quality assessment was conducted independently by ATM and PH. To the best of our knowledge, there is no quality assessment guideline for cost studies: hence, we developed an 8-item checklist from Drummond et al. [11], Liers et al. [12], and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) [13]. The 8 items were: i) description of the characteristics of the study population and the reasons why it was chosen; ii) the costing methodology used must be clearly reported, whether micro-costing or gross costing approach or a combination; iii) the sources used to collect resource utilization data should be reported clearly (e.g. clinical trials, administrative databases, clinical databases, medical records and published literature); iv) resource quantities should be reported or described independently from the costs, so that assessment of the measurement method is facilitated; v) the viewpoint/ perspective of the analysis such as the provider, patient and family or societal perspectives should be clearly described;vi) all costs should be adjusted to a specific price year so that the effects of inflation are removed from the cost estimation; vii) If the time horizon for estimating costs was longer than 1 year, discounting should have been performed to reflect time preferences viii) if prices were used instead of costs, they should reflect the true opportunity costs. Quality was assessed by scoring each of the items with a value of 1 if fully completed, 0.5 if not fully completed, 0 if not completed, and NA if not applicable. The quality scores were categorized as ‘low’ if ≤33%, ‘moderate’ if the score was between 33 and 66%, and ‘high’ if > 66%. Disagreements on eligibility or the quality assessments were resolved through consensus.

Data analysis

We extracted information about the name of the primary author, year of publication, year in which the data was collected, study design, the country in which data was collected, costing perspective used, the currency used, cost information, disease condition, target population from which data was collected and the level of the healthcare facility.

Costs were categorized as health system costs if they were borne by the healthcare facility and patient costs if they were borne by the patient or caregiver. Health system costs could further be categorized as recurrent if spent on items that are used up in the course of the year such as salaries, supplies, and utilities or capital costs if spent on items that last more than a year such as buildings, furniture, and equipment. Patient costs included both direct costs and indirect costs. Direct costs were those paid in the process of seeking/accessing care and included out-of-pocket payment for treatment (registration, diagnosis, radiology, drugs, bed days, etc), transport to and from the healthcare facility, food, and other related expenses. Indirect costs were those that resulted from the loss of income as a result of not being able to engage in economically productive activities due to illness. When costs were reported separately for public, private, or non-governmental organizations, etc., we computed a simple average.

Base year costs in local currencies were first converted to US dollars (USD) using the existing exchange rate for the base years of the individual studies, before adjustment to 2018 USD using relevant US Consumer Price Indices (CPI) [14]. Annual Gross National Income (GNI) per capita was used as a proxy of household income and out of pocket patient payments that exceeded 10% of this income were assumed to constitute catastrophic health expenditure [15].

Results

In total 1652 studies were identified from the systematic literature search, of which 373 studies were duplicates. The remaining 1279 unique studies were subjected to first stage screening for eligibility by reading the titles and abstracts, and as a result, 1201 studies were excluded because they were not relevant, and 6 articles were not available as full texts. The full-text screening was done for the remaining 72 articles, of which 48 were included (Fig. 1).

Fig. 1
figure 1

Flow diagram showing articles included and excluded in the systematic review

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Table 2 shows the summary characteristics of the included studies. Most of the studies used cross-sectional design and data were collected at households and healthcare facilities depending on the chosen costing perspective. Out of the 48 studies, 36 were relatively recent and were published in the year 2010 or after. All studies were of moderate to high quality and provided a good description of the study population and the reason for its selection and the sources used to collect information about resource use. Only a few studies were explicit about the costing methodology used, but the majority provided descriptions of the perspective used.

Table 2 Study characteristics
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Figure 2 shows the distribution of the studies in the sub-Saharan African region. The majority were from West and East Africa, while a few were from Southern Africa.

Fig. 2
figure 2

Distribution of studies in sub-Saharan Africa

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Table 3 shows the unit costs for normal delivery and C-section services. There were 19 studies from 27 countries that reported the costs of normal delivery and 20 studies from 24 countries that reported the costs of C-section. Patient cost (n = 13) for normal delivery range from USD 5.6–52.4 and the health system cost (n = 6) range from USD 8.4–72.8. However, only five of the thirteen studies reported both direct and indirect patient costs and four of the six studies reported both recurrent and capital health system costs. The patient cost (n = 11) for C-section ranges from USD 55.8–377.3 but only three of the eleven studies reported both direct and indirect patient costs. The health system cost (n = 9) for C-section ranges from USD 79.7–561.8 but only seven of the nine studies reported both recurrent and capital health system costs.

Table 3 Costs for normal delivery and Caesarean sections
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Table 4 shows the unit costs for abortion and post-abortion care services (PAC). There were 9 studies from 8 countries that reported the costs of abortion and 4 that reported the costs of PAC. Cost of abortion care represented mostly the medical abortion, while costs of PAC represented unsafe abortions (complete or incomplete), often performed outside the hospital setting with the woman ending up in hospital as a result of complications. Patient cost (n = 8) and health system costs for abortion care services (n = 4) range from USD 11.2–65.7 and USD 40.3–298.3, respectively. Only two of the eight studies reported direct and indirect patient costs while three of the four studies reported both recurrent and capital health system costs. For PAC services the reported patient cost (n = 6) ranges from USD 20.8–158.4 and all studies reported direct costs only. The health system costs for PAC (n = 8) were in the range between USD 46.1–151.1, and three of the eight studies reported both recurrent and capital costs.

Table 4 Costs for abortion and PAC
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Table 5 shows the unit costs for the management of eclampsia, low birth weight, and hemorrhage. There were 17 unique studies conducted in 22 countries. For the management of eclampsia, patient costs (n = 5) range between USD 51.6–230.5, and two of the five studies reported both direct and indirect costs. The health system costs for eclampsia (n = 2) range from USD 122.7–186.4 and no capital cost was measured. For care of low-birth weight babies, the patient cost (n = 3) ranged between USD 38.2–486.7, and two studies contained both direct and indirect costs, while only one study by Sicuri et al. (2011) from Mozambique reported an average health system cost of about USD 514 for caring such babies. For the management of maternal hemorrhage, patient cost (n = 4) ranges between USD 65.1–196.2, and half of the studies reported both direct and indirect costs. The health system cost for maternal hemorrhage range between USD 30.3–127.4 and all the studies reported recurrent health system cost only.

Table 5 Costs of other complications
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Figures 3 and 4 compare whether out of pocket health expenditures for normal delivery, C-section, eclampsia, and maternal hemorrhage was higher than 10% of the average gross national income per capita for different countries in sub-Saharan Africa. Out of pocket cost for normal delivery services was catastrophic for only one study from DR Congo [47], however, costs were catastrophic in eight studies out of the twelve [18, 19, 27, 30, 35, 44, 47, 54] that reported delivery by the C-section. Out of pocket payments were also catastrophic in three out of six studies on the management of eclampsia [21, 47, 54], one out of four studies about abortion services [31], one out of three studies on the management of low birth weight babies [59] and four out of five studies on the management of hemorrhage [21, 44, 47, 54]. None of the studies on PAC costs indicated that catastrophic health expenditures were incurred.

Fig. 3
figure 3

Out of pocket cost versus 10% of per capita income for normal vaginal delivery and C-section

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Fig. 4
figure 4

Out of pocket cost versus 10% of per capita income for specific birth complications

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Discussion

This review shows that pregnancy and childbearing expose women and their families to a lot of out-of-pocket (OOP) payments, particularly in the presence of complications. For normal spontaneous vaginal deliveries, women pay between USD 5.6–52.4 and for C-section they pay between USD 55.8–377.3, meaning on average it costs seven times more to deliver by C-section. The OOP payments usually constitute costs of drugs and medical supplies like cotton wools, syringes, transportation to and from the health facilities, food, drinks and unofficial payments to health workers. Mean OOP payments were either very close to or exceeded 10 % of an average national per capita income for some countries, thus most likely exposing patients and their families to substantial financial burden.

Results from the included studies show that catastrophic health expenditures were common among the study participants [16,17,18, 27, 30, 31, 59]. In Bunia DR Congo, the user cost of C-section was estimated at 79.7 USD, which was slightly above the monthly family income of 75.5 USD [27]. In Birnin-Kebbi Nigeria, average monthly family income was 18.8 USD compared to the average cost of care for emergency obstetric care (EmOC) of about 246 USD [16]. In rural Ethiopia, more than two-thirds of the studied families experienced catastrophic health expenditure for maternal healthcare [17]. In Mali, between 20 and 54% of the studies households incurred catastrophic health expenditure on EmOC [18]. In Burkina Faso, 12% of women with abortion experienced catastrophic health expenditure [31]. In Madagascar, the proportion of OOP for C-section among the richest and the poor was 33% and 109%, respectively [30].

Our study indicates that pregnancy and childbearing complications are also relatively expensive to the healthcare systems in sub-Saharan Africa. Health systems use between USD 8–73 per patient for normal deliveries, but a staggering USD 80–562 for C-section, USD 40–300 for medical abortion, USD 40–150 for post-abortion care, USD 120–190 to care for eclampsia, USD 30–130 to treat hemorrhage and about USD 500 to care for low-birth weight babies. In 2009 it was estimated that the annual cost to treat unsafe abortion complications in sub-Saharan Africa ranged from USD 68–76 million [64] and in 2014, it was estimated that the cost required to provide post-abortion care in developing countries was USD 232 million [65]. A large chunk of these costs could be prevented by investing in modern contraceptive use to prevent unwanted pregnancies, legalizing abortion where it is illegal and implementing policies with the potential to reduce adolescent pregnancies. High costs that are associated with access to healthcare hinder the utilization of maternal health services in resource-poor settings [66, 67].

This study has several limitations, which requires care in its interpretation. Firstly, the included studies were methodologically very heterogeneous in terms of range patient and health system costs included making it hard to fully disaggregate the costs. Secondly, costs are very context-specific especially for non-traded goods and services such as wages and salaries, which are usually one of the main cost drivers. Thus, in countries where salaries and prices of commodities are high always tend to skew the average costs. Also, there could be a lot of variations in the structure and complexity of the healthcare system and services available for managing pregnancy and birth-related complications between countries, hence resource requirements and costs could infinitely vary from one place to another. For this reason, we could not aggregate the costs into meaningful means or medians.

Our findings regarding the costs of maternal health care have several policy implications despite the limitations. First, it is well documented that adolescent pregnancy and childbearing are associated with elevated risks of complications [68, 69], which are mainly concentrated in sub-Saharan Africa [70]. Our study enhances the understanding of the financial implications of these complications both for patients, families, and health systems. Policies that can delay teen pregnancies, therefore, have the potential not only to reduce maternal morbidity and mortality but also to save patients and health systems a significant amount of healthcare resources. Second, this review shows that maternal complications may result in OOP expenditures that are largely catastrophic especially among the poorest households. New innovative strategies are urgently needed to protect women and their families from impoverishing OOP, otherwise, the real impact of abolishing user fees for maternal services will be hard to be realized.

Conclusion

This is the first systematic literature review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high. It further shows that patient costs were largely catastrophic relative to a 10 % of average national per capita income, thus exposing families to immense financial burden and impoverishment, in particularly poor families that live under one USD per day. Hence health policies that advocate for free maternal health services and universal health coverage on maternal and newborn care should be encouraged and prioritized on both national, regional, and international agenda. Otherwise, the high costs will continue to hinder access to maternal health services in sub-Saharan Africa, thus negating the efforts to reduce infant and maternal mortality rates which are relatively high in this region. Although the study found a relatively large number of studies, the evidence base on the costs of maternal care is nevertheless still scarce; hence, more studies are needed to fill the gaps.

Availability of data and materials

Not applicable.

Abbreviations

C-section:

Caesarean Section

EmOC:

Emergency obstetric care

GNI:

Gross National Income

OOP:

Out of pocket

PAC:

Post abortion care

USD:

United States Dollar

References

  1. Mombo-Ngoma G, Mackanga JR, Gonzalez R, Ouedraogo S, Kakolwa MA, Manego RZ, Basra A, Ruperez M, Cot M, Kabanywany AM, et al. Young adolescent girls are at high risk for adverse pregnancy outcomes in sub-Saharan Africa: an observational multicountry study. BMJ Open. 2016;6(6):e011783.

    PubMed  PubMed Central  Google Scholar 

  2. Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, Yamdamsuren B, Temmerman M, Say L, Tuncalp O, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014;121(Suppl 1):40–8.

    PubMed  Google Scholar 

  3. Gronvik T, Fossgard Sandoy I. Complications associated with adolescent childbearing in sub-Saharan Africa: a systematic literature review and meta-analysis. PLoS One. 2018;13(9):e0204327.

    PubMed  PubMed Central  Google Scholar 

  4. Mokdad AH, Forouzanfar MH, Daoud F, Mokdad AA, El Bcheraoui C, Moradi-Lakeh M, Kyu HH, Barber RM, Wagner J, Cercy K, et al. Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the global burden of disease study 2013. Lancet. 2016;387(10036):2383–401.

    PubMed  Google Scholar 

  5. Loaiza E, Liang M. Adolescence pregnancy: a review of evidence. New York: United Nations Population Fund; 2013.

    Google Scholar 

  6. Huynh L, McCoy M, Law A, Tran KN, Knuth S, Lefebvre P, Sullivan S, Duh MS. Systematic literature review of the costs of pregnancy in the US. Pharmacoeconomics. 2013;31(11):1005–30.

    PubMed  Google Scholar 

  7. Petrou S, Eddama O, Mangham L. A structured review of the recent literature on the economic consequences of preterm birth. Arch Dis Child Fetal Neonatal Ed. 2011;96(3):F 225–32.

    Google Scholar 

  8. Petrou S, Sach T, Davidson L. The long-term costs of preterm birth and low birth weight: results of a systematic review. Child Care Health Dev. 2001;27(2):97–115.

    PubMed  CAS  Google Scholar 

  9. Mori AT, Kampata L, Musonda P, Johansson KA, Robberstad B, Sandøy I. Cost-benefit and extended cost-effectiveness analysis of a comprehensive adolescent pregnancy prevention program in Zambia: study protocol for a cluster randomized controlled trial. Trials. 2017;18(1):604. https://doi.org/10.1186/s13063-017-2350-4.

  10. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    PubMed  PubMed Central  Google Scholar 

  11. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford University Press; 2005.

    Google Scholar 

  12. van Lier LI, Bosmans JE, van Hout HPJ, Mokkink LB, van den Hout WB, de Wit GA, Dirksen CD, Nies H, Hertogh C, van der Roest HG. Consensus-based cross-European recommendations for the identification, measurement and valuation of costs in health economic evaluations: a European Delphi study. Eur J Health Econ. 2018;19(7):993–1008.

    PubMed  Google Scholar 

  13. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E, et al. Consolidated health economic evaluation reporting standards (CHEERS) statement. Cost Effectiveness Resour Allocation: C/E. 2013;11(1):6.

    Google Scholar 

  14. IMF Data Access to Macroeconomic and Financial Data. International Monetary Fund: Washington D.C.; 2019.

  15. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998. Health Econ. 2003;12:921–33.

    PubMed  Google Scholar 

  16. Adamu AN, Adamu H, Yabagi AI, Sa'Ad Z. Expenditure on emergency obstetric care in a tertiary health centre in northern Nigeria. Int J Gynecol Obstet. 2012;3:S264–5.

    Google Scholar 

  17. Akalu T, Guda A, Tamiru M, Marian DH. Examining out of pocket payments for maternal health in rural Ethiopia: paradox of free health care un-affordability. Ethiop J Health Dev. 2012;26:251–7.

    Google Scholar 

  18. Arsenault C, Fournier P, Philibert A, Sissoko K, Coulibaly A, Tourigny C, Traore M, Dumont A. Emergency obstetric care in Mali: catastrophic spending and its impoverishing effects on households. Bull World Health Organ. 2013;91(3):207–16.

    PubMed  PubMed Central  Google Scholar 

  19. Asante F, Chikwama C, Daniels A, Armar-Klemesu M. Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana. Ghana Med J. 2007;41(3):110–7.

    PubMed  PubMed Central  Google Scholar 

  20. Benson J, Gebreselassie H, Manibo MA, Raisanen K, Johnston HB, Mhango C, Levandowski BA. Costs of postabortion care in public sector health facilities in Malawi: a cross-sectional survey. BMC Health Serv Res. 2015;15:562.

    PubMed  PubMed Central  Google Scholar 

  21. Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans C, Brugha R, Browne E, Alihonou E. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy Plan. 2003;18(4):383–90.

    PubMed  CAS  Google Scholar 

  22. von Both C, Jahn A, Fleba S. Costing maternal health services in South Tanzania: a case study from Mtwara Urban District. Eur J Health Econ. 2008;9(2):103–15.

    Google Scholar 

  23. Cornelissen D, Mwapasa G, Gajewski J, et al. The Cost of Providing District-Level Surgery in Malawi. World J Surg. 2018;42(1):46-53. https://doi.org/10.1007/s00268-017-4166-5.

  24. Dalaba MA, Akweongo P, Savadogo G, Saronga H, Williams J, Sauerborn R, Dong H, Loukanova S. Cost of maternal health services in selected primary care centres in Ghana: a step down allocation approach. BMC Health Serv Res. 2013;13:287.

    PubMed  PubMed Central  Google Scholar 

  25. Dalaba MA, Akweongo P, Aborigo RA, Saronga HP, Williams J, Aninanya GA, Sauerborn R, Loukanova S. Cost to households in treating maternal complications in northern Ghana: a cross sectional study. BMC Health Serv Res. 2015;15:34.

    PubMed  PubMed Central  Google Scholar 

  26. Deboutte D, O'Dempsey T, Mann G, Faragher B. Cost-effectiveness of caesarean sections in a post-conflict environment: a case study of Bunia, Democratic Republic of the Congo. Disasters. 2013;37(Suppl 1):S105–20.

    PubMed  Google Scholar 

  27. Deboutte D, O'Dempsey T, Mann G, Faragher B. User cost of caesarean section: case study of Bunia, Democratic Republic of Congo. Int J Health Plann Manag. 2015;30(2):88–97.

    Google Scholar 

  28. Enweronu-Laryea CC, Andoh HD, Frimpong-Barfi A, Asenso-Boadi FM. Parental costs for in-patient neonatal services for perinatal asphyxia and low birth weight in Ghana. PLoS One. 2018;13(10):e0204410.

    PubMed  PubMed Central  Google Scholar 

  29. Henshaw SK, Adewole I, Singh S, Bankole A, Oye-Adeniran B, Hussain R. Severity and cost of unsafe abortion complications treated in Nigerian hospitals. Int Fam Plan Perspect. 2008;34(1):40–50.

    PubMed  Google Scholar 

  30. Honda A, Randaoharison PG, Matsui M. Affordability of emergency obstetric and neonatal care at public hospitals in Madagascar. Reprod Health Matters. 2011;19(37):10–20.

    PubMed  Google Scholar 

  31. Ilboudo PG, Greco G, Sundby J, Torsvik G. Costs and consequences of abortions to women and their households: a cross-sectional study in Ouagadougou, Burkina Faso. Health Policy Plan. 2015;30(4):500–7.

    PubMed  Google Scholar 

  32. Ilboudo PG, Greco G, Sundby J, Torsvik G. Estimating the costs for the treatment of abortion complications in two public referral hospitals: a cross-sectional study in Ouagadougou, Burkina Faso. BMC Health Serv Res. 2016;16(1):559.

    PubMed  PubMed Central  Google Scholar 

  33. Johns B, Hangoma P, Atuyambe L, Faye S, Tumwine M, Zulu C, Levitt M, Tembo T, Healey J, Li R, et al. The costs and cost-effectiveness of a district-strengthening strategy to mitigate the 3 delays to quality maternal health care: results from Uganda and Zambia. Glob Health Sci Pract. 2019;7(Suppl 1):S104–s122.

    PubMed  PubMed Central  Google Scholar 

  34. Kalu-Umeh NN, Sambo MN, Idris SH, Kurfi AM. Costs and patterns of financing maternal health Care Services in Rural Communities in northern Nigeria: evidence for designing National fee Exemption Policy. Int J MCH AIDS. 2013;2(1):163–72.

    PubMed  PubMed Central  Google Scholar 

  35. Kowalewski M, Mujinja P, Jahn A. Can mothers afford maternal health care costs? User costs of maternity services in rural Tanzania. Afr J Reprod Health. 2002;6(1):65–73.

    PubMed  Google Scholar 

  36. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania. Trop Med Tnt Health. 2008;13(12):1442–51.

    Google Scholar 

  37. Le HH, Connolly MP, Yu JB, Pinchevsky Y, Steyn PS: The public health and economic consequences of unintended pregnancies in South Africa. Healthcare in Low-Resource Settings; 2015;3(1). https://doi.org/10.4081/hls.2015.5258.

  38. Levin A, McEuen M, Dmytraczenko T, Ssengooba F, Mangani R, Van Dyck G. Costs of maternal health Care Services in Three Anglophone African Countries. In: Special Initiatives report 22. Bethesda: Partnerships for Health Reform Project, Abt Associates Inc; 2000.

    Google Scholar 

  39. Lince-Deroche N, Constant D, Harries J, Blanchard K, Sinanovic E, Grossman D. The costs of accessing abortion in South Africa: Women's costs associated with second-trimester abortion services in Western Cape Province. Contraception. 2015;92(4):339–44.

    PubMed  Google Scholar 

  40. Lince-Deroche N, Constant D, Harries J, Kluge J, Blanchard K, Sinanovic E, Grossman D. The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa. PLoS One. 2018;13(6):e0197485.

    PubMed  PubMed Central  Google Scholar 

  41. Lince-Deroche N, Fetters T, Sinanovic E, Blanchard K. Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa. Contraception. 2017;96(2):72–80.

    PubMed  Google Scholar 

  42. Lince-Deroche N, Fetters T, Sinanovic E, Devjee J, Moodley J, Blanchard K. The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa. PLoS One. 2017;12(4):e0174615.

    PubMed  PubMed Central  Google Scholar 

  43. Lofgren J, Mulowooza J, Nordin P, Wladis A, Forsberg BC. Cost of surgery in a low-income setting in eastern Uganda. Surgery (United States). 2015;157(6):983–91.

    Google Scholar 

  44. Meda IB, Baguiya A, Ridde V, Ouedraogo HG, Dumont A, Kouanda S. Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey. Heal Econ Rev. 2019;9(1):11.

    Google Scholar 

  45. Ministry of Health, African Population and Health Research Center, Ipas. The Costs of Treating Unsafe Abortion Complications in Public Health Facilities in Kenya. Nairobi: APHRC; 2018.

    Google Scholar 

  46. Moore AM, Dennis M, Anderson R, Bankole A, Abelson A, Greco G, Vwalika B. Comparing women's financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia. Reprod Health Matters. 2018;26(52):1522195.

    PubMed  PubMed Central  Google Scholar 

  47. Ntambue AM, Malonga FK, Dramaix-Wilmet M, Ilunga TM, Musau AN, Matungulu CM, Cowgill KD, Donnen P. Commercialization of obstetric and neonatal care in the Democratic Republic of the Congo: a study of the variability in user fees in Lubumbashi, 2014. PLoS One. 2018;13(10):e0205082.

    PubMed  PubMed Central  Google Scholar 

  48. Odhiambo J, Ruhumuriza J, Nkurunziza T, Riviello R, Shrime M, Lin Y, Rusangwa C, Omondi JM, Toma G, Nyirimodoka A, et al. Health facility cost of Cesarean delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing. Matern Child Health J. 2019;23(5):613–22.

    PubMed  Google Scholar 

  49. Orach CG, Dubourg D, De Brouwere V. Costs and coverage of reproductive health interventions in three rural refugee-affected districts, Uganda. Tropical Med Int Health. 2007;12(3):459–69.

    Google Scholar 

  50. Parmar D, Leone T, Coast E, Murray SF, Hukin E, Vwalika B. Cost of abortions in Zambia: a comparison of safe abortion and post abortion care. Global Public Health. 2017;12(2):236–49.

    PubMed  Google Scholar 

  51. Paul M, Gebreselassie H, Samai M, Benson J, Kargbo SA, Lazzarino MM. Unsafe Abortion in Sierra Leone: An Examination of Costs and Burden of Treatment on Healthcare Resources. J Womens Health Care. 2015;4(1000228):2167–0420..

    Google Scholar 

  52. Pearson L, Gandhi M, Admasu K, Keyes EB. User fees and maternity services in Ethiopia. Int J Gynaecol Obstet. 2011;115(3):310–5.

    PubMed  Google Scholar 

  53. Perkins M, Brazier E, Themmen E, Bassane B, Diallo D, Mutunga A, Mwakajonga T, Ngobola O. Out-of-pocket costs for facility-based maternity care in three African countries. Health Policy Plan. 2009;24(4):289–300.

    PubMed  PubMed Central  Google Scholar 

  54. Ravit M, Philibert A, Tourigny C, Traore M, Coulibaly A, Dumont A, Fournier P. The hidden costs of a free caesarean section policy in West Africa (Kayes region, Mali). Matern Child Health J. 2015;19(8):1734–43.

    PubMed  PubMed Central  Google Scholar 

  55. Ridde V, Kouanda S, Bado A, Bado N, Haddad S. Reducing the medical cost of deliveries in Burkina Faso is good for everyone, including the poor. PLoS One. 2012;7(3):e33082.

    PubMed  PubMed Central  CAS  Google Scholar 

  56. Sambo MN, Abdulrazaq GA, Shamang AF, Ibrahim AA. Household cost of antenatal care and delivery services in a rural community of Kaduna state, northwestern Nigeria. Nig Med J. 2013;54(2):87–91.

    Google Scholar 

  57. Sicuri E, Bardaji A, Sigauque B, Maixenchs M, Nhacolo A, Nhalungo D, Macete E, Alonso PL, Menendez C. Costs Associated with Low Birth Weight in a Rural Area of Southern Mozambique. PLoS One. 2011;6(12):e28744.

    PubMed  PubMed Central  CAS  Google Scholar 

  58. Sundaram A, Vlassoff M, Mugisha F, Bankole A, Singh S, Amanya L, Onda T. Documenting the individual- and household-level cost of unsafe abortion in Uganda. Int Perspect Sex Reprod Health. 2013;39(4):174–84.

    PubMed  Google Scholar 

  59. Tongo OO, Orimadegun AE, Ajayi SO, Akinyinka OO. The economic burden of preterm/very low birth weight care in Nigeria. J Trop Pediatr. 2009;55(4):262–4.

    PubMed  CAS  Google Scholar 

  60. Vlassoff M, Fetters T, Kumbi S, Singh S. The health system cost of postabortion care in Ethiopia. Int J Gynecol Obstet. 2012;118(SUPPL. 2):S127–33.

    Google Scholar 

  61. Vlassoff M, Mugisha F, Sundaram A, Bankole A, Singh S, Amanya L, Kiggundu C, Mirembe F. The health system cost of post-abortion care in Uganda. Health Policy Plan. 2014;29(1):56–66.

    PubMed  Google Scholar 

  62. Vlassoff M, Musange SF, Kalisa IR, Ngabo F, Sayinzoga F, Singh S, Bankole A. The health system cost of post-abortion care in Rwanda. Health Policy Plan. 2015;30(2):223–33.

    PubMed  Google Scholar 

  63. Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy Plan. 2010;25(5):384–92.

    PubMed  Google Scholar 

  64. Vlassoff M, Walker D, Shearer J, Newlands D, Singh S. Estimates of health care system costs of unsafe abortion in Africa and Latin America. Int Perspect Sex Reprod Health. 2009;35(3):114–21.

    PubMed  Google Scholar 

  65. Singh S, Darroch JE, Ashford LS. Adding it up: The costs and benefits of investing in sexual and reproductive health 2014. New York: Guttmacher Institute.

  66. Dzakpasu S, Powell-Jackson T, Campbell OM. Impact of user fees on maternal health service utilization and related health outcomes: a systematic review. Health Policy Plan. 2014;29(2):137–50.

    PubMed  Google Scholar 

  67. Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review. Syst Rev. 2017;6(1):110.

    PubMed  PubMed Central  Google Scholar 

  68. Karatasli V, Kanmaz AG, Inan AH, Budak A, Beyan E. Maternal and neonatal outcomes of adolescent pregnancy. J Gynecol Obstet Human Reprod. 2019;48(5):347–50.

    Google Scholar 

  69. Althabe F, Moore JL, Gibbons L, Berrueta M, Goudar SS, Chomba E, Derman RJ, Patel A, Saleem S, Pasha O, et al. Adverse maternal and perinatal outcomes in adolescent pregnancies: The Global Network's Maternal Newborn Health Registry study. Reprod Health. 2015;12(Suppl 2):S8.

    PubMed  PubMed Central  Google Scholar 

  70. Neal S, Matthews Z, Frost M, Fogstad H, Camacho AV, Laski L. Childbearing in adolescents aged 12-15 years in low resource countries: a neglected issue. New estimates from demographic and household surveys in 42 countries. Acta Obstet Gynecol Scand. 2012;91(9):1114–8.

    PubMed  Google Scholar 

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Acknowledgements

This study is part of the project portfolio of the Center for Intervention Science in Maternal and Child Health (CISMAC), a Center for Excellence (CoE) funded by the Research Council of Norway (RCN) and the University of Bergen. We would like to thank RCN and CISMAC’s Scientific Committee for facilitating the conduction of this study.

Funding

The study was funded by the Research Council of Norway through its Centers of Excellence scheme to the Center for Intervention Science in Maternal and Child Health (CISMAC; project number 223269) and through the GLOBVAC program (project number 248121). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

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Authors and Affiliations

  1. Centre for International Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway

    Amani Thomas Mori, Bjarne Robberstad & Ingvild Sandoy

  2. Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway

    Amani Thomas Mori & Bjarne Robberstad

  3. Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway

    Amani Thomas Mori, Bjarne Robberstad & Ingvild Sandoy

  4. Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania

    Peter Binyaruka

  5. Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia

    Peter Hangoma

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  1. Amani Thomas Mori
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Contributions

ATM, BJ and IS contributed to the study conception and design. ATM, PB and PH conducted the search of articles. ATM and PB independently screened the articles. ATM and PH independently performed quality assessment. The first draft of the manuscript was written by ATM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Amani Thomas Mori.

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Mori, A.T., Binyaruka, P., Hangoma, P. et al. Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review. Health Econ Rev 10, 26 (2020). https://doi.org/10.1186/s13561-020-00283-y

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Keywords

Health Economics Review

ISSN: 2191-1991

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