Unmet health care needs are a simple tool for monitoring access and the extent of inequalities in access to health services. Unmet health needs are the gap between the services needed and the services actually received . The aim of this study was to assess the unmet health needs and its causes during COVID-19 pandemic among pregnant women in Iran (Kurdistan province).
According to the findings of this study, the most unmet health needs were related to dental services with 66%, rehabilitation services with 58.6% and psychological services with 43.2% and the lowest were related to hospital services with 12%, midwifery services with 15.6% and physician visit services with 39.1%. The most important reasons for not receiving the required services were "fear of getting COVID-19" and "service cost". Findings showed that a significant percentage of the need for health services, especially the need for dental and rehabilitation services, was not met and there was a deep gap between the perceived need and use of health services in the population of pregnant women. Although according to studies conducted in Iran, unmet health needs are significant, the findings of this study reported more unmet health needs than other studies in Iran [6, 23, 24]. The reasons for this discrepancy can be found in differences in the study population (pregnant mothers) and the crisis and conditions caused by COVID-19. According to previous studies, economic factors have been one of the serious barriers on the way of access to health services. As indicated by the findings of this study, the fear of getting COVID-19 made people not to look for receiving health services [23–26].
In Iran, according to statistics, more than 90% of people have basic health insurance; nevertheless, "services covered by insurance" and "depth of coverage of services cost" are one of the problems of the insurance system in the country and insurance organizations lack the necessary efficiency to prevent households from facing catastrophic health expenditures . Also, the significant difference between the tariff rate of the private and public sector is another problem of the country's health system. Basic insurance, if the patient refers to the private sector, does not cover this difference in the tariff rate and all costs must be paid by the patients. In Iran, dental, midwifery, rehabilitation and psychological services are not covered by basic health insurance and the cost of these services must be paid by the patients out of pocket [25, 27, 28].
In Iran, most hospital services are provided by public sector and most outpatient services (such as physician, and dentist visits as well as rehabilitation, psychology and laboratory services) are provided by private sector . In addition, the queue for receiving specialist doctor services is usually long. The reasons for this can be the low proportion of physician to population per capita and inefficiency of the referral system. Although in the first level of care in Iran, which is provided by public sector, routine pregnancy care is given to mothers in 8 visits (2 visits in the first half and 6 visits in the second half of pregnancy), a few number of people may receive such services due to regular absence of physicians, inadequate information about the existence of these services especially in urban areas, and lack of proper trust in quality of services. According to a study conducted by Rezapour et al. in the general population of Iran, the highest unmet needs were reported for dental services (39.8%) and physician visits (32.4%). Lack of financial means and economic inefficiency were the two main reasons for unmet health needs . Based on the study of Motlagh et al. in Iran, one of the most important reasons for not using health services was lack of financial resources . The results of a systematic review by Moynihan et al. on the impact of COVID-19 pandemic on benefiting from health services in 20 countries showed a median reduction of 37% in the use of health services. This decrease was 42% for visit services, 28% for hospitalization services, 31% for diagnostic services and 30% for medical services . According to a study in France and Romania, unmet health care needs during pregnancy were caused mainly due to financial issues . As reported by "European Union statistics on income and living conditions" survey in 2014, an average of 26.5% of adults in European countries needed health care in the last 12 months. The index ranged from less than 10% in Cyprus and Norway to more than 40% in Ireland, Lithuania, Estonia and Portugal. The main reasons for unmet health care needs were services cost and waiting time, respectively. On average, unmet needs were 12.3% for dental care, 5.9% for physician visits and 2.7% for mental health. The index ranged from less than 5% for dental services in the Czech Republic, Cyprus, Malta, the Netherlands and Norway to more than 30% in Portugal, Ireland and Estonia. Also, it ranged from 0.7% in the UK to 33.1% in Iceland for mental health services . In another study based on "European Union statistics on income and living conditions" survey in 2018, the average unmet needs for medical care index was 3.2% in the last 12 months among adults in EU countries. There was a big difference between countries in terms of this index. The highest rate was in Estonia (19%), followed by Lithuania and Greece, and the lowest was in Austria, Spain, Malta, Germany, the Netherlands and Luxembourg (less than 1%). The main reasons for these unmet needs were service cost, waiting list and distance, respectively. People in low-income quintiles had more unmet health care needs. According to this study, unmet needs for dental care was 4% in the last 12 months and the main reason was the service cost in all countries . According to the commonwealth fund international health policy survey, unmet needs for medical care among adults ranged from 7% in the United Kingdom to 33% in the United States, and the value of this index was significantly higher in lower income groups. In almost all countries, the main reason for unmet needs was reported to be the service cost. In the preceding study, unmet needs for dental care were reported by a larger segment of the population because dental services for adults are not covered by public insurance in most countries. The value of this index varied from 11% in Netherlands and the United Kingdom to 28% in Canada and 32% in the United States . In another study by Pappa et al. in Greece, 10% of health needs were not met and the main reason was the high cost of services . In the study of Barman et al. in India, financial status was one of the main determinants of unmet health needs. According to a 2014 New Zealand Health Survey, 29% of adults reported unmet health care needs .
Based on the adjusted model in this study, the level of unmet needs for medical services was associated with variables of higher age group and lower level of education of the spouse; the level of unmet needs for midwifery services was associated with a lower age group; and the level of unmet needs for dental services was linked with variables of lower age group, lower education and non-employment of pregnant women. Also, unmet needs for rehabilitation services was connected to lower age group, lack of supplementary insurance and lower economic status and the level of unmet needs for psychological services was directly and significantly related to variables of lower age group and lower economic status. According to a study by Rezapour et al. in Iran, poor households were less likely to receive the services they needed .
As indicated by the study of Motlagh et al. in Iran, the most important factors affecting the use of health services were economic status, age, employment status, insurance coverage, level of education and household size . According to the study of Rezaei et al. in Iran, the economic status of the household, age and level of education of the head of the household were among the factors affecting the use of dental services . A study in Canada also found that households with better economic status had fewer unmet health needs . According to a study by Haddad et al. which was carried out using data from the Demographic Health Survey of seven countries of Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda, a significant relationship was found between antenatal care use and household wealth, female education and place of residence . The results of a study in France and Romania showed that household income status affected the likelihood of pregnant women ignoring the services they needed; this probability decreased with increasing income levels. Having basic health insurance in Romania and supplementary insurance in France reduced the unmet health care needs odds significantly. People without supplementary insurance were two times more likely to have unmet health care needs. In Romania, the odds of having unmet health care needs were higher for low-educated women, and women under 25 and over 40 were also more likely to have unmet health care needs. According to a study in India, women's level of education and household economic status were influential factors in use of prenatal health care .
Strengths of the Study
This is the first study in Iran to calculate the unmet health care needs among pregnant women in the COVID-19 crisis.
Limitations of the study
In this study, information about perceived need and using health services was collected based on self-report of pregnant women and may be accompanied by a reminder error, although the research team tried to reduce this error by shortening the reminder period for outpatient services to one month and for inpatient services to 6 months.