Original Research••

Assessment of economic burden due to COVID-19 pandemic during institutional childbirth in Nepal: before-and-after design

Abstract

Introduction The COVID-19 pandemic caused disruptions in global health and economic stability. In Nepal, before the pandemic, more than 50% of healthcare costs were out-of-pocket expenditure (OOPE). This study aimed to assess the OOPE for maternity care during before and during the COVID-19 pandemic in nine hospitals in Nepal.

Method We conducted a before-and-after study between March 2019 and December 2020 with 13 months of prepandemic period and 9 months of pandemic period. OOPE was assessed using a semistructured interview with 53 864 women. Bivariate (unadjusted) and multivariate (adjusted) linear regression modelling was conducted to assess the change in OOPE in US dollar between the periods. Adjustment in linear regression model was done for population characteristics different between the periods.

Result The OOPE for childbirth increased by 28.1% during pandemic, with an increase of OOPE from US$19.2 to S$23.9 (adjusted-β coefficient 5.4; 95% CI 4.5 to 5.7; p<0.0001). The OOPE of laboratory diagnosis increased by 15.3% for spontaneous birth during the pandemic (adjusted-β coefficient, 1.6; 95% CI 1.4 to 1.8; p<0.0001). OOPE increased by 29.8%, 40.0% and 10.3% for spontaneous vaginal birth, instrumental birth and caesarean section, respectively. The OOPE among the poorest family increased by 12.9%, and OOPE for richer family increased by 57.6% during the pandemic period.

Conclusion OOPE for maternity care increased by more than 28% during the COVID-19 pandemic in Nepal. OOPE increased in all wealth quintile with marked rise in richer wealth quintile group. Mitigation efforts to secure affordable maternal healthcare services are required during pandemic.

What is already known on this topic

  • To our knowledge, this is one of few studies that has been conducted on out-of-pocket expenditure (OOPE) before and during the COVID-19 pandemic related to childbirth in Nepal.

  • During the COVID-19 pandemic, the inequity in childbirth has increased.

What this study adds

  • The overall OOPE significantly increased by 28.1% during the pandemic with a rise from US$19.2 prepandemic to US$23.9 during the pandemic (p<0.0001).

  • Among those who delivered by C-section, the expense increased by 10.3% and those who had instrumental birth increased by 40.0%.

  • OOPE among the poorest wealth group increased by 12.9%, whereas the costs for the richer wealth quintiles increased by up to 57.6% during the pandemic period.

How this study might affect research, practice or policy

  • During the pandemic, there is an increase in economic burden for childbirth services in public health facilities.

  • There is a need for essential health services, such as childbirth cost covered by health facilities, to prevent delay in access due to financial barriers.

Introduction

The COVID-19 pandemic caused disruptions in the health and economic steadiness globally.1 2 Any emergency and disease outbreak increases existing health disparities and economic inequality.3 4 The COVID-19 pandemic critically impacted the global health systems and economies resulting in a major global recession, severely affecting public health and livelihood.5 6 A World Bank survey reported that pandemic-related economic deceleration had a crucial impact on jobs and incomes in Nepal. More than two in five economically active workers reported job dismissal or absenteeism and there was a decline in the country’s Gross Domestic Product from 6.7% in 2019 to 2.1% in 2020.7 The pandemic, which accelerated unemployment, caused the economic indicators for Nepal to drop by 14.5%, with a disproportionate impact on vulnerable and socially disadvantaged groups, resulting in an increase in poverty, lack of food and nutrition as well as poor health outcomes.8 9

Universal health coverage (UHC) is one of the targets set in the health-related Sustainable Development Goal (SDG), to reduce the expenditure for essential health services.10 11 Furthermore, UHC also focuses on providing a foundation for resilient health systems that can abruptly respond to any crisis and recover from it in the most constructive way.12 13 In the global health agenda, out-of-pocket expenditure (OOPE), defined as direct payment of money for healthcare, is one of the main barriers to achieving SDG Goal 3.14 15 Almost three-quarters or more of total expenditure on health is accounted by OOPE in many developing countries.16 17 Nepal, a lower-middle-income country (LMIC) has a high incidence of OOPE for health.18 Despite the Government of Nepal’s (GoN) commitment to achieve UHC by 2030, almost 48% of the total expenditure on health is still financed by OOPE.19

Catastrophic health expenditures can lead people to poverty, debt burden and intolerable household expenditure.20–22 In Nepal, more than two-thirds of the population OOPE in health is related to communicable diseases.23 During the COVID-19 pandemic, families experienced financial challenges due to the closure of businesses.24 Vulnerable populations such as pregnant women and children were also adversely affected during the pandemic. Childbirth in healthcare facilities during the pandemic was also a challenging issue due to fear of infections as well as financial barriers.25 Despite the policy on no OOPE ‘Free’ institutional birth, a recent study showed that even during the prepandemic period, women and families had to pay for maternity care services which were free of cost.26 In such cases, expenditure from the pocket of women and families is used.27 This is a huge financial burden for those who cannot afford healthcare services, especially during the crisis of the pandemic resulting in direct or indirect impacts on childbirth. It is critical to design effective policy through pragmatic financing strategies to overcome these financial barriers.28 In addition, the COVID-19 outbreak has put additional stress on both social and economic well-being, affecting households directly or indirectly.29

The pandemic hit Nepal’s economy hard and disrupted health service delivery, including maternal and neonatal health services.30 31 Two nationwide lockdowns restricted all international and domestic travel and there was a shut-down of non-essential services for 190 days. Income-generating activities were prohibited, and few essential services were allowed during the lockdowns. Mobility declined more than 20% in 9 out of 10 districts, which negatively impacted the livelihood and health of the general population throughout the country.7

Studies report that the unavailability of accessible and affordable health services during the pandemic has created low accessibility for pregnant women to healthcare facilities, which in turn has resulted in increased maternal and child mortalities and morbidities.32 33 However, there is limited evidence of the level of OOPE (medical or non-medical expenses) for childbirth during the COVID-19 pandemic. This study was conducted with the aim of assessing the household economic burden for maternity care during the COVID-19 pandemic in Nepal.

Method

Study design

This is a before-and-after design, nested within the scaled up quality improvement projects in nine hospitals in Nepal between 1 March 2019 and December 2020.27 34 35 The quality improvement projects collected data on the OOPE during childbirth using semistructured questionnaires to mothers at the time of discharge from the hospital. During the study period, the pandemic took place, so we compared the prepandemic period OOPE with the pandemic period. Data were over 22 months, comparing a prepandemic period of 13 months from 1 March 2019 to 31 March 2020 with a pandemic period of 9 months from 1 April 2020 to 31 December 2020.

Study setting

This study was implemented in nine public hospitals that provided Comprehensive Emergency Obstetric and Neonatal Care services and referral care for mothers and newborns in Nepal. The hospitals were distributed across all seven provinces of the country, each with more than 1000 deliveries per year, representing 11.2% of national annual births for 2019.34 These hospitals followed components from the Safe Motherhood programme launched by the GoN regarding delivery and transportation incentives during discharge from the hospital.36 Mothers received benefits including transport incentive for institutional delivery such as cash payment immediately following institutional delivery: US$13.6 in the mountain, US$9.1 in the Hill and US$4.5 in the Terai district. Similarly, a cash payment of US$3.6 was provided to women on completion of four antenatal care visits at 4, 6, 8 and 9 months of pregnancy. The benefits were not only limited to pregnant women and newborns but also health facilities, and health workers for deliveries, and newborn care.36 The hospitals charge a minimum fee as per government policy for the care and services provided to the patients in terms of admission, bed, laboratory diagnosis and medicines, which may vary for different periods of delivery and special services. The provision of free antenatal, delivery and postnatal care services at public health facilities helped in a significant decrease of OOPE for the families while financial incentives offered support for indirect costs such as travel expenses.37

Study population

Participants in this study included mothers who delivered in the hospitals and gave consent for interviews. Those mothers who did not consent or avail themselves of interviews were excluded from the study.

Data collection and management

An independent data collection team was established in all hospitals, and data were collected through a tablet-based application. Obstetric and neonatal information of those delivered was collected from patient charts and case notes. Sociodemographic variables were extracted from medical records, and economic burden information was collected through a semistructured interview with mothers before discharge. The economic burden information included charges during the time of admission, bed charges for normal and special services such as regular bed, cabin or private room, laboratory charges for different types of diagnosis, medicine charges and other expenses during the hospital stay, including daily expenditure such as travel, food and accommodation.

Data entered in the tablet-based application were reviewed by an independent database manager and discussions and clarifications were discussed with data collectors after review. Data cleaning and data consistency checks were done, and mismatched cases were retrieved and corrected accordingly before analysis.

Patient and public involvement

During the design of the primary study before the pandemic, we consulted women and families about the cost of care at the health facility. They provided evidence of out-of-pocket payment for childbirth care. During the early phase of the pandemic restriction lockdown in Nepal, families identified the cost of care as one of the economic burdens to access care. This study is aimed to provide evidence of the rising cost of care during the pandemic to policy-makers.

Outcome measures and variables

OOPE: OOPE was defined as expenses for various services by women in their delivery process. It includes women’s expenditure from hospital admission until discharge, such as admission charges, bed charges, drugs and laboratory charges. We also included additional/other expenditure which covered the expenditure made for transportation, accommodation, food and expenditure of the family during childbirth. In LMICs such as Nepal, OOPE constitutes a significant portion of spending on childbirth.27 This may be due to limited insurance coverage in childbirth and a lack of public healthcare funding.

Wealth index: The wealth index assesses one’s socioeconomic situation. It is a combined indicator of the overall standard of living in a household. It serves as a gauge of wealth that is in line with household spending and income measurements. During the interviews with mothers, data were collected on ownership of Ddrable assets (eg, car, refrigerator, bicycle, radio, television); housing characteristics (eg, number of rooms, dwelling floor and roof materials, toilet facilities) and access to services (eg, electricity supply, drinking water source). Using the scores from the first principal component analysis, a wealth index (asset index) was constructed. Based on the value of this index, individuals were sorted, and population quintiles were established using cut-off values. These quintiles were then ranked from bottom to top as poorest, poorer, middle, richer and richest.38

Sociodemographic, obstetric and neonatal characteristics: Ethnicity was mainly categorised into two groups: relatively advantageous (Brahmin and Chhetri) and relatively disadvantageous (Janajati, Madhesi, Muslim and Dalit).27 Parity was defined as women who had no previous birth (nulliparous), one previous birth (primiparous) and two or more previous birth (multiparous). Mode of delivery included vaginal delivery, instrumental delivery and C-section.

Data analysis: The data were analysed by using SPSS Software (IBM SPSS Statistics for Windows, V.23.0). Descriptive statistics were presented by mean, SD, frequency and percentage before and during the pandemic. The Pearson’s χ2 test was used for comparing the proportion of background characteristics. Bivariate and multivariate linear regression analysis was used to compare the adjusted OOPE difference between the two periods. Geometric mean was used to calculate the OOPE difference between the prepandemic and pandemic periods among the different wealth quintile groups.

Results

There were a total of 106 530 women delivering at the hospitals during the study period, of which 73 219 mothers participated in the study. Among the women who participated in the study, 53 864 (74%) had information regarding the expenses they paid for the services during their childbirth process, and the remaining 19 355 (26%) did not have any information regarding the cost during the childbirth process. Of the 53 864 women, a total of 37 517 (74%) provided information regarding OOPE during the ‘prepandemic period’ (1 March 2019–31 March 2020), whereas 16 347 (72%) women provided OOPE information ‘during the pandemic period’ (1 April 2020–31 December 2020) (online supplemental figure 1).

The overall proportion of women undergoing C-sections increased during the pandemic compared with the prepandemic period, from 23.2% to 26.3% (p<0001). The proportion of C-sections increased among the poorest, poorer, middle and richer group of wealth from 17.9% to 24.1%, 19.8% to 26.0%, 23.7% to 29.2%, 26.1% to 27.8% (p<0.0001), respectively, and no statistically significant change was seen in the richest group (p=0.085) from prepandemic to pandemic period (figure 1).

Figure 1
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Figure 1

Proportion of C-section before and during pandemic among wealth group.

The proportion of women from the relatively advantageous ethnic group decreased from prepandemic 34.0% to 29.1% during the pandemic, and the proportion of the relatively disadvantageous group ‘Madhesi’ increased from prepandemic period 19.5% to 25.2% during the pandemic period (p<0001). The proportion of women with complications at admission increased from 8.1% to 14.1% during the pandemic (p<0.001) (table 1).

Table 1
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Background characteristics of study participants

After adjusting the demographic and obstetric characteristics, the overall expenses increased by 28.1% during the pandemic with an adjusted β coefficient increase of US$5.4 from that of the prepandemic period (adjusted β coefficient, 5.0; 95% CI 4.5 to 5.7; p<0.0001). Expenses for laboratory diagnosis increased by 15.7% with adjusted β coefficient increase of US$1.6 during the pandemic (adjusted β coefficient, 1.6; 95% CI 1.4 to 1.8; p<0.0001), and expenses for purchasing medicine increased by 49.2% with an adjusted β coefficient increase of US$3.2 during the pandemic (adjusted β coefficient, 3.2; 95% CI 3.0 to 3.4; p<0.0001) (table 2).

Table 2
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Mean expenditure (US dollar) of services before and during pandemic and change using bivariate and multivariate linear regression

After adjusting the demographic and obstetric characteristics, the total costs for C-section increased by 10.3%, (adjusted β coefficient, 2.7; 95% CI 1.6 to 3.9; p<0.0001). For those who delivered by C-section, laboratory charges increased by 13.3% (adjusted β coefficient, 1.6; 95% CI 1.2 to 2.0; p<0.0001) while medicine charges were increased by 32.4% (adjusted β coefficient, 3.4; 95% CI 3.0 to 3.9; p<0.0001). The overall costs of instrumental delivery increased by 40.0% (adjusted β coefficient, 8.2; 95% CI 6.7 to 9.6; p<0.0001), during pandemic. The laboratory diagnosis costs increased for instrumental delivery by 43.8%, (adjusted β coefficient, 3.9; 95% CI 3.2 to 4.5; p<0.0001), β=3.9 (95% CI 3.2 to 4.5), during pandemic. The medicine charges were increased for instrumental delivery by 46.5%, (adjusted β coefficient, 4.7; 95% CI 3.6 to 5.8; p<0.0001), during pandemic. For vaginal delivery, costs increased by 29.8% (adjusted β coefficient, 5.1; 95% CI 4.8 to 5.5; p<0.0001), during pandemic (table 3). The economic burden of OOPE increased during the pandemic for all wealth groups, ranging from 12.9% in the poorest quintile to 57.6% in the fourth quintile group (figure 2 and online supplemental table 1).

Figure 2
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Figure 2

Distribution of OOPE by wealth group before and during pandemic. OOPE, out-of-pocket expenditure.

Table 3
|
Mean expenditure (US dollar) of services by mode of delivery before and during pandemic and change using bivariate and multivariate linear regression

Discussion

OOPE for facility-based delivery increased by 28.1% during the COVID-19 pandemic in Nepal. Costs increased for all modes of delivery (vaginal, C-section or instrumental), with the highest increase among deliveries conducted by C-sections. Increase in obstetric complications at admission led to an overall increase in C-sections, with a consequent rise in the economic burden.

Prepandemic studies in Nepal and India showed that OOPE for C-sections to be higher than for vaginal delivery.27 39–41 Cost is a major barrier for families with low socioeconomic status to access facility-based maternal care.41 This study reports that women from a relatively disadvantaged ethnic group (Madhesi) contributed a higher proportion of women seeking maternity care in public hospitals during the pandemic as compared with the advantaged ethnic group (Brahmin/Chettri). Advantaged ethnic groups and richer wealth groups who are better resourced might have sought healthcare elsewhere, such as the private sector for childbirth, due to heightened fear of contracting the virus.

We earlier identified that despite the government’s free delivery care policy, families had additional OOPE for care.26 While COVID-19 aggravates poverty and deteriorates access to essential services, such an increase in financial burden for maternity care can be detrimental for poor and disadvantaged family.7

The fragile health system of Nepal is facing challenges in providing quality health services during the COVID-19 pandemic, especially to the most vulnerable groups.30 While also facing challenges in managing the quarantine, human resources, laboratory testing and medical supplies including personal protective barriers, the government failed to address the increased burden for pregnant women and their newborns.31 That women of relatively disadvantaged ethnic groups made up a larger proportion of women seeking care in public hospitals compared with advantageous groups indicates a widening equity gap due to the COVID-19 pandemic.32 The government’s policies and regulations for COVID-19 testing did not cover costs for mothers and their newborns, leading to increased household economic burden. Mothers who failed to present COVID-19 test results were not allowed to receive inpatient care and some mothers lost their lives during interfacility referral and delay in care.

In our study, the economic burden during the pandemic period increased regardless of the mode of delivery (normal vaginal, instrumental, C-section), and an increase in OOPE was seen in all wealth groups. During the pandemic, the increased proportion of delivery expenses was also aggravated by an overall economic recession. Reducing the economic burden for delivery is critical to minimise the risk of poverty. The COVID-19 outbreak has hindered the growth momentum and worsened structural vulnerabilities.

It can be considered that increased OOPE on childbirth has always been an ongoing issue for Nepalese families. No change in OOPE for sick newborns was identified even after the free neonatal care programme implementation.26 Despite the availability of incentives, institutional birth care has been more expensive than incentives provided. Further, it might not cover the whole range of costs incurred due to delivery, such as transportation charges, opportunity costs, and housing and food for low-income women.27 It can be inferred that OOPE existed during the prepandemic period as well as the postpandemic period in terms of childbirth.

This study includes a large sample size from an established data surveillance system in multiple hospitals in Nepal. It identifies the impact of the COVID-19 pandemic in terms of OOPE. This study has not incorporated the data on morbidities of mothers which could have further increased the additional expenses for the treatment. This study may also not represent more rural communities of the country as the study was conducted in referral-level hospitals. The generalisability of this study is, therefore, partially restricted to public referral hospitals (selection bias). Also, there may be bias relating to the mothers’ recall of expenditure paid for the services they received (information bias). We were unable to cover the total expenses of the families who were referred to other health facilities. We assumed participants may have sometimes reported information based on mother’s interpretation. In addition, 26% of the missing data on the outcome of interest also represents non-response bias. Comparison of characteristics of women with and without missing data could have provided insights and implications for interpreting our results. Future research can address and minimise the bias to ensure robust findings.

Despite the provision of incentives, the hidden costs associated with childbirth remain a concern. Thus, financial incentive schemes provided by the government should be revised to reflect the actual cost incurred by families ensuring it covers all necessary expenses.

Conclusion

This study identified an increased economic burden for women giving birth during the COVID-19 pandemic in hospitals in Nepal. There is an urgent need for the government to tackle these inequalities, which pose an existential threat to mothers and their newborns. This may jeopardise the progress in institutional birth that Nepal has made in the past few decades, derailing the on-track efforts to achieve UHC and SDG by 2030, especially for maternal and newborn survival.

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