This study found that C-section was significantly associated with higher chances of paying for health care, and had relatively higher direct and indirect costs to patients compared to normal delivery. Women from wealthier and urban households were more likely to access and receive C-section delivery and paid more direct costs on average than their counterpart women.
The prevalence of C-section deliveries was slightly higher (8.3%) than the national average of 6% reported in the 2015/16 Tanzania Demographic and Health Survey [40] and regional average of 7.3% for Africa [53]. The low coverage rate of C-section is typical in developing countries when compared to high-income countries [54, 55]. One of the reasons for low uptake of C-section in developing countries is the inadequate infrastructural and human resource capacity to offer emergency and surgical care [56–58]. For instance, only 19–50% of hospitals in sub-Saharan Africa can provide 24-hour emergency care. However, as countries reform their health systems and improve health care service utilisation [59–61], one would expect the C-section rates would increase over time.
The result of higher patient costs for C-section than normal delivery is consistent with the previous pattern reported elsewhere [7, 8, 17, 22, 25, 31, 33, 62, 63], although the incremental cost of 20 USD that we found was relatively lower. In comparison, the incremental cost for maternal complications/ C-section was 13.6 USD in Mali [7], 55.9 USD in Democratic Republic of Congo [33], and varied by time and measurement in Bangladesh including 86 USD per C-section birth [27], 34 USD per month [8] and around 269 USD from childbirth to six months postpartum [22]. A few studies in a recent review in sub-Saharan Africa reported the costs of C-section delivery ranging from 55.8–377.3 USD [31]. In Pakistan, postpartum mother after C-section incurred 204 USD (79 USD for normal delivery) as total direct and indirect cost including transport and food [29]. These costs incurred by patients and/or relatives suggest that accessing essential obstetric care including C-section can reduce household resources significantly [8, 22] and can reinforce catastrophic health spending [7, 64, 65].
Our study also revealed that C-section delivery was associated with much higher loss in productivity compared to normal delivery. A similar finding, though for maternal complications, was reported in Bangladesh [8, 22] and Ghana [34]. While women in Tanzania were hospitalised for an average of 2 days after C-section, women with maternal complications in Bangladesh lost 2 to 3 days after childbirth [8]. Another study in Bangladesh valued higher productivity loss between 30.1–33.1 USD for severe and less-severe complication than 14.1 USD for normal delivery [25]. Similarly, Ghanaian women with maternal complications spent 3 days on average (2 days median) for hospitalisation, while average productivity loss was estimated to be 8.92 USD [34].
The assessment of equity in health care benefits and payments is an important approach to monitor progress towards UHC [6, 66]. Equity is particularly needed to ensure that households receive health benefits according to their health care need and contributes to the health care according to their ability-to-pay [5, 66]. The available evidence is often in contrast to the above equity principle for UHC [6]. For instance, this study found that C-section delivery was more likely to be accessed by wealthier and urban women, yet inaccessible by their counterparts that may have the greatest health care need. The Tanzania Demographic and Health Survey also reports higher rates of C-section deliveries among the wealthier, educated and urban residing women [40]. This ‘socioeconomic gradient’ in utilising C-section have also been reported elsewhere [54, 55, 67–69]. In terms of equity in health care payment, however, the burden of direct payments was significantly higher among the richest as they are more likely to access C-section care than the poorest women. Consistently, the poorest typically spend less on treatment than other income groups due to lack of access, inability to pay, greater use of public services [23].
Fair and timely access to essential life-saving interventions is needed to reduce morbidity and mortality rates globally. For instance, to reduce maternal deaths may need fair and timely access to basic and comprehensive emergency obstetric care [70]. Consequently, many LMICs decided to offer ‘free maternity services’ or implement a user fee exemption policy to reduce the financial barriers [71–75]. Yet, a large body of evidence in these settings shows women are still paying for exempted services and facing financial barrier [16–18, 27, 65, 71, 76, 77]. One reason for such weak enforcement of free/ exemption policy is existing disruptions in health systems [71] including an inadequate budget allocation to the health sector [16–18] as well as difficulties to identify the eligible clients [19, 20]; which altogether undermines the effectiveness of the policy [78–82].
Our findings have important policy implications. Despite the efforts to reduce the direct medical costs by offering ‘free maternity services’ in many settings including Tanzania (or offering fee exemption for C-section specific in some settings), evidence shows that people are still paying OOP for exempted/ free services. This indicates weak enforcement of the policy and eventually affecting the effort to offer financial protection for UHC. Access to C-section care is also in favour of the better-off, which reflects the low affordability among the poorest population [7, 64]. It further implies that some women, especially the worse-off, are deterred to access life-saving interventions or losing their lives as they cannot afford C-section delivery care [7, 83]. It is even life-threatening concerning the unaffordability of life-saving interventions such as C-section since this care increases the chance of rehospitalisation [84]. Since C-section is an emergence and life-saving procedure for the mother and the baby, fair and timely access irrespective of women characteristics is necessary. Countries should therefore ensure timely access to effective and affordable basic and comprehensive emergency obstetric care to reduce maternal deaths [35, 85]. Efforts are also needed to improve access to surgical services especially in sub-Saharan Africa [86]. To reduce financial risks especially among the poor in the move to UHC, adequate funding to health facilities through prepayment mechanisms and strong enforcement of the exemption policy or user fee removal would help [2, 66]. Further research is needed to deeply understand the coping mechanisms and main drivers of paying for exempted services in Tanzania.
This study has the following limitations. First, we were unable to incorporate transport costs to access care due to data availability but its significant contribution to catastrophic health spending is well documented [4]. This data was lacking because the main evaluation study was not designed to accommodate this information. Second, while the assessment of the affordability of costs regarding C-section is important [7], we did not get data on household income/ expenditure to reflect a household’s ability to pay. Third, we did not identify the coping strategies to finance delivery care because of the limited data available. Fourth, the productivity loss was not quantified in monetary values, because of unreliable income or wage rate data for the rural and urban population. Fifth, the information about women’s medical conditions prior to C-section was not collected, while this information could be adjusted and used to explain the findings. Lastly, there is a possibility of a recall bias as we relied on recall data for costs incurred during childbirth in the last 12 months.