Health insurance coverage and access to maternal healthcare services by women of reproductive age in Nigeria: a cross-sectional study

Background

Access to affordable, high-quality maternal healthcare services (MHS) is a fundamental human right of all women irrespective of their age, residence and socioeconomic status.1 Inequitable access to MHS has been reported globally, especially among the rural poor in low-income and in lower and middle-income countries (LMICs).2 3 The United Nations reported in 2019 that an estimated 1.9 million families in Africa spend more than 40% of their non-food, out-of-pocket expenses on MHS each year, which makes the cost of childbirth services catastrophic.4 A systematic review on MHS costs in LMICs showed that the median cost for antenatal care (ANC) visits could be as high as $30 and $78 in public and private health facilities, respectively, in India. The median cost for normal delivery in public health facilities ranged from $50 to $350 in Nepal and as high as $580 in private hospitals in India. These costs would be catastrophic for women and their households considering that 46.0% and 49.0% of the extremely poor people in the world reside in LMICs.5 For example, in Myanmar, the poverty ratio among women increased to 4.3%, 1.3% and 6.1% after the women made out-of-pocket payments to access ANC services, delivery services and both antenatal and delivery services, respectively.6

In 2021, a systematic review on the cost of MHS in LMICs reported ₦39 000~$246.3 as the mean expenditure estimate for delivery in Nigeria from a 2013 study, which was greater than the monthly income for 94.6% of the respondents assessed.5 7 There are also indirect costs incurred by women accessing MHS such as non-medical transportation costs, guardian costs and provider-induced fines that all worsen the impact of these costs on women and their households.8 The high cost of MHS deters women from accessing quality MHS, and drives them towards unsafe birth practices and home deliveries. According to the former Executive Director of the United Nations Children’s Fund, ‘When families cut corners to reduce maternal health care costs, both mothers and their babies suffer.’4

The inability to afford safe childbirth delivery services has contributed to numerous maternal and neonatal deaths globally, in Africa and in Nigeria. In 2019, the WHO reported that 94% of all maternal deaths occur in LMICs.9 Africa was reported to have a maternal mortality ratio (MMR) of 545/100 000 live births in 2020, which accounted for 70% of all global maternal deaths.10 Similarly, with Nigeria’s MMR reported as 512/100 000 in its 2018 Nigeria Demographic and Health Survey (NDHS),11 Nigeria was ranked fourth among countries with the highest MMR according to modelled global estimates.1 The WHO attributed the high prevalence of maternal deaths in Nigeria to inequalities in access to health services.12 The highest proportion of maternal deaths of the poorest of women was 68% in 1990, which then increased to 80% in 2015.1 13 This disproportionately high prevalence of maternal deaths among the poorest of women can be reduced by increasing their uptake of health insurance programmes. The mean direct cost of accessing ANC services at a tertiary health facility in Southwest Nigeria by women with health insurance coverage was statistically and significantly lower when compared with the cost incurred by women who paid out of pocket.14

Countries with poor financing mechanisms for health service utilisation rely heavily on out-of-pocket payments and then suffer from catastrophic health expenditures, which leads to a vicious cycle that makes the poor poorer and in need of more critical health services. According to the 2018 NDHS, only ~3% of women had a health insurance coverage.11 The National Health Insurance Scheme (NHIS) was launched in 2005 but with a perennially low coverage rate. To strengthen the Nigerian healthcare financing system, the NHIS was replaced with the National Health Insurance Authority (NHIA) Act which was enacted in 2022.15 The NHIA now mandates every Nigerian to register for a health insurance package.15 By the Act, the NHIA provides health insurance packages for employees in formal settings and individuals in informal settings. It also coordinates all the public and private health insurance programmes in the country. The NHIA also implements the Vulnerable Group Fund and 50% of the Basic Health Care Provision Fund to ensure the free provision of the basic minimum healthcare packages to the populace, especially indigents.16 These basic minimum health services include, but are not limited to, ANC, delivery and postnatal services. As the NHIA implements its strategic plan for assuring that all Nigerians are insured within the shortest possible time, it is critical to provide evidence that would guide the prioritisation of the populations to be insured during the implementation of the NHIA Act.17 New global targets for ending preventable maternal deaths have been established, and Nigeria must meet these targets.18 The Nigerian government had also established an 80% target for pregnant women who would attend at least eight ANC visits and 54% who would deliver in a health facility by 2021.19

Previous studies had reported the inequitable access to MHS using the 2008 and 2013 NDHS datasets,13 20 although only a few compared women’s access to MHS with their health insurance status.21 22 Nigeria was included in one publication that reported the effect of health insurance on women’s access to MHS in 28 African countries,23 although none provided country-specific narratives on the effect of health insurance coverage on access to MHS. Therefore, this study aims to determine the association between health insurance coverage and access to MHS among women of reproductive age in Nigeria, after controlling for other individual, household and community-level factors related to MHS utilisation.

Conceptual framework

The study was guided by the conceptual framework as shown below which was conceptualised by the authors. The framework identifies individual, household and community-level factors that could influence women’s uptake of health insurance coverage and also influence their access to MHS. Their access to MHS was measured as ‘the number of ANC visits attended by the women, and their decision to deliver at the health facility’. However, central to the women’s access to MHS is their financial accessibility which can be provided for with their health insurance coverage. The women’s physical accessibility and social accessibility to MHS are also very important but they were not explored in this study and thus presented with broken lines (see figure 1).

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Figure 1

Conceptual framework.

Methods

Study population and size

These were a total of 41 821 women of reproductive age (15–49) who participated in the 2018 NDHS. This study was limited to the 12 935 women who had their last birth within the 2 years before the 2018 NDHS (see figure 2).

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Figure 2

A schematic representation of the sample determination. NDHS, Nigeria Demographic and Health Survey.

Results

Table 2 shows the individual and community-level factors of Nigerian women aged 15–49 with a birth in the previous 2 years before the survey. The mean age of respondents when giving birth was 27.4±6.7. The majority of the respondents were within the age group of 20–34 (71.2%), were in union or living with a man at the time of the study (95.5%) and were employed in the last year before the survey (8971; 69.4%). Fewer than half of the respondents (40.8%) had completed a secondary-level education or more. Only 264 (2.0%) of the women aged 15–49 who had a delivery within 2 years of the survey had any form of health insurance coverage. With the community-level factors, the highest proportion of respondents in our analytical sample (35.9%) were residents in the North West Region of Nigeria and were predominantly rural (61.5%).

Figure 3A,B show the distribution of the outcome variables, which were women who had eight or more ANC visits and those who delivered their most recent birth in the last 2 years in a health facility. Only 18.5% had ≥8 ANC visits, while 40.6% delivered in a health facility.

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Table 3 presents the sociodemographic characteristics and community-level factors of women with health insurance coverage. A higher proportion of women with higher level of education (12.8%) and from the richest quintile (7.7%) had a health insurance coverage, compared with less than 2% among women with less education and from the lower wealth quintiles, respectfully. Women with health insurance coverage who were residents in urban areas had more than three times the health insurance coverage compared with women who lived in rural areas (3.6% vs 1.1%).

The distribution of the women’s individual and community-level factors across the two outcome variables is shown in table 4. Having ≥8 ANC visits had statistically significant associations with all independent variables (age, educational status, household wealth index, work status, birth order, geopolitical zone and residence), except for marital status. Health facility delivery had statistically significant associations with all independent variables. The distribution showed that those with health insurance coverage, with increasing wealth quintile, current employment, higher education, urban residence and residence in the southern part of the country had higher percentages of having at least eight ANC visits and a delivery in a health facility.

Table 5 shows the role of having a health insurance coverage on women who had ≥8 ANC visits and facility delivery. In the unadjusted model, health insurance coverage had a statistically significant association with attending ≥8 ANC visits, so that women with health insurance had three times greater odds of ≥8 ANC visits compared with those with no health insurance coverage (OR 3.0; 95% CI 2.15–4.12). The statistically significant association persisted after controlling for the possible confounding factors in the full model (adjusted OR (AOR) 1.9; 95% CI 1.26–2.95).

As with the number of ANC visits, the unadjusted model showed a statistically significant association with facility delivery, which also persisted after controlling for confounding factors. In the full model, those with health insurance coverage had 2.0 times greater odds of delivering in health facilities compared with those without health insurance coverage (AOR 2.0; 95% CI 1.39–2.82).

The southern regions had greater odds, while the northern regions had lower odds for accessing 8+ ANC visits compared with the North Central Region. However, for facility delivery, only the South East Region had greater odds compared with the North Central Region. In addition, ANC visits and facility delivery were significantly higher among urban dwellers, the employed, the more highly educated and those with increasing wealth.

Discussion

In this study, we explored the influence of having health insurance coverage on access to MHS (defined as attending ≥8 ANC visits and health facility delivery) among women of reproductive age who delivered within 2 years of the survey using the latest 2018 NDHS dataset. Having a health insurance coverage was significantly associated with attending ≥8 ANC visits and delivering at a health facility after controlling for individual and community-level factors.

These findings reveal the critical role that health insurance coverage plays in increasing the uptake of ANC and health facility delivery, and in improving women’s access to the skilled birth attendants who work in health facilities. This is expected to reduce the incidence of maternal morbidities and mortalities. This also shows the pivotal role that a substantial health insurance coverage has on Nigeria’s prospects of meeting the maternal health targets of the Sustainable Development Goal (SDG) 3, which includes Targets 3.1 (reduced maternal mortality), 3.2 (neonatal and child mortality) and 3.7 (improved access to sexual and reproductive health services).29 The findings also strongly contribute to Nigeria’s meeting the Target 3.8 of SDG 3, which addresses financial risk protection and access to quality essential healthcare services, including MHS. In addition, women who choose to deliver at a health facility because they have a health insurance coverage will be encouraged to attend ANC visits during their subsequent pregnancies.

The current abysmally low uptake of health insurance coverage (2.0%) among Nigerian women of reproductive age who delivered in the last 2 years before the survey is worrisome. This is similar to the findings across Africa, with only four African countries having ≥20% of their population with health insurance coverage: (Rwanda (79%), Ghana (58%), Gabon (41%) and Burundi (22%)) of the 36 sub-Saharan African countries assessed in 2021.30 With a mean average of <10% health insurance coverage, Nigeria ranked 26th of the 36 countries assessed. In Nigeria, with a 44.5% poverty rate and 5.5% employment rate in 2021, a low health insurance uptake may lead to catastrophic health spending, preventable deaths and worsening maternal health indices.30

There were significant disparities in the uptake of health insurance coverage across the different categories in the individual characteristics of the women and the community-level factors explored in our study. The prevalence of health insurance coverage was least among the adolescent mothers and peaked in the 30–34 age group, although it declined afterwards. There is the need to investigate the reasons for this low uptake of health insurance among adolescents, with many of them within the age limit (<18 years) that is usually covered under their parents’ insurance.16 Having health insurance coverage was highest among the most educated women and the women in the highest wealth quintile. This is similar to the findings from a meta-analysis of 48 studies across 17 countries, which showed greater odds of health insurance enrolment in the most educated and wealthiest households.31 Older age, better educational levels and wealth status also consistently significantly predicted health insurance ownership among women of reproductive age across five sub-Saharan African countries.32 Our findings also showed significant inequalities in health insurance coverage with the worst among the rural dwellers and women residents in the northern regions in Nigeria. This suggests that the more vulnerable populations such as the poor, rural dwellers and least educated are not being reached with government interventions such as having health insurance coverage.

Having health insurance coverage is expected to provide financial risk protection and reduce disparities in financial access to MHS.21 29 To ensure this, the Nigerian government established the National Health Insurance Scheme (NHIS) in 1999 which became fully operational in 2005. However, since the formal launch of the NHIS in 2005, the scheme had yet to enrol up to 10% of the population in 2022.33 Several packages had been introduced to improve the coverage of health insurance uptake. These targeted the general population irrespective of their gender, with some focus on the disabled, the vulnerable and students.34 However, many of these efforts were not women focused. Universal health coverage may thus not be universal in access to care, when the needs and demands of women’s health are yet to be met.35 In the past, some state governments had offered free MHS in an attempt to meet the needs of women, but many have been unsustainable because of changes in the government and a worsening economy. There is a need for affordable health insurance packages that would cover women’s reproductive years and address all their MHS needs. In 2022, the National Health Insurance Authority (NHIA) Act was promulgated, which now makes a health insurance coverage mandatory for all in Nigeria.15 In its recently published operational guidelines in October 2023,36 indigent pregnant women were included under its non-contributory health insurance scheme. This is a good step but a detailed implementation plan may be needed.37

Having health insurance coverage was significantly associated with women attending ≥8 ANC visits and delivering in a health facility after controlling for both the individual and community-level factors. Health insurance removes the financial barrier to accessing MHS caused by out-of-pocket payments and its catastrophic effects that makes the poor poorer. The resultant effect is a more equitable access to care with the potential for improved maternal health outcomes. Ownership of health insurance was a predictor of ≥4 ANC visits and skilled birth attendance during childbirth in Ethiopia and 28 countries in sub-Saharan Africa reported in 2021 and 2022 by reusing the countries’ most recent DHS data.22 23 The WHO has since raised the minimum standard for ANC visits during pregnancy from at least four to eight visits.25 This stresses the need for greater health insurance coverage among women of reproductive age to increase their likelihood of complying with the WHO minimum standards. Eighty per cent of 63 266 women of reproductive age who had given birth 5 years before the 2018 and 2020 DHS conducted in eight countries, Nigeria inclusive, were not compliant with the WHO-recommended ≥8 ANC visits.38 However, women enrolled in health insurance had lower odds of non-compliance.38 The findings measured women’s ANC practice in periods preceding the release of the new guideline in 2016. Our study is more representative since we included women who delivered only 2 years before the 2018 NDHS and presented our findings based on the new WHO recommendation.

Conclusion

Access to health insurance was a strong predictor of women attending at least eight ANC visits and delivering in a health facility after controlling for confounders. Irrespective of the other determinants of women’s access to MHS, there is a need to pay close attention to improving uptake of health insurance among women of reproductive age, especially targeting the rural dwellers and women who reside in the northern regions of Nigeria. Authorities may need to prioritise women of reproductive age in the design and implementation of health insurance programmes in order to increase their uptake. This would provide financial risk protection and facilitate access to MHS and possible attainment of Nigeria’s SDG 3 targets.