key: cord-0989220-mm0j3gkn authors: Banke‐Thomas, Aduragbemi; Makwe, Christian Chigozie; Balogun, Mobolanle; Afolabi, Bosede Bukola; Alex‐Nwangwu, Theresa Amaogechukwu; Ameh, Charles Anawo title: Utilization cost of maternity services for childbirth among pregnant women with coronavirus disease 2019 in Nigeria’s epicenter date: 2020-11-26 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.13436 sha: f373ca41aad24d590470658c4b2ca290dbd5e608 doc_id: 989220 cord_uid: mm0j3gkn OBJECTIVE: To estimate utilization costs of spontaneous vaginal delivery (SVD) and cesarean delivery (CD) for pregnant women with coronavirus disease 2019 (COVID‐19) at the largest teaching hospital in Lagos, the pandemic's epicenter in Nigeria. METHODS: We collected facility‐based and household costs of all nine pregnant women with COVID‐19 managed at the hospital. We compared their mean facility‐based costs with those paid by pregnant women pre‐COVID‐19, identifying cost‐drivers. We also estimated what would have been paid without subsidies, testing assumptions with a sensitivity analysis. RESULTS: Total utilization costs ranged from US $494 for SVD with mild COVID‐19 to US $4553 for emergency CD with severe COVID‐19. Though 32%–66% of facility‐based cost were subsidized, costs of SVD and CD during the pandemic have doubled and tripled, respectively, compared with those paid pre‐COVID‐19. Of the facility‐based costs, cost of personal protective equipment was the major cost‐driver (50%). Oxygen was the major driver for women with severe COVID‐19 (48%). Excluding treatment costs for COVID‐19, mean facility‐based costs were US $228 (SVD) and US $948 (CD). CONCLUSION: Despite cost exemptions and donations, utilization costs remain prohibitive. Regulation of personal protective equipment and medical oxygen supply chains and expansion of advocacy for health insurance enrollments are needed in order to minimize catastrophic health expenditure. This was a hospital-based cost analysis from the user's (women's) perspective. Women were only approached after their discharge from the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. The inclusion and exclusion criteria used for recruitment are described in Table 1 . From the included women, we collected data on direct cost components spent within the facility, outside the facility (household), opportunity (loss of productivity) costs, and any other relevant costs that women claimed to have expended for their care. All of these made up total utilization cost. We noted any exemptions and donations that reduced the cost paid by women. A detailed review of patient financial account records in the hospital was used to capture all facility-based costs. In capturing facility-based costs, we separated those related to obstetric care from those for COVID -19 care. For comparison, we collected data on the standard SVD and CD facility-based cost for booked and unbooked pregnant women pre-COVID- 19 . A pre-tested online tool was administered to women to collect household and opportunity costs. We collected data on the monthly income of self-employed women and their caregivers. We only included a pro-rata cost of the typical monthly cost related to the number of days that the women spent in hospital. All cost data were collected in local currency (Naira [N] ). Analysis was conducted in Microsoft ExcEl (Microsoft Corporation, Redmond, WA, USA) following conversion of cost data to US $ as per the mean exchange rate for the year. 9 All costs were presented in US $. To synthesize findings, we identified the obstetric (pregnancy complications) 10 and COVID-19 (mild or severe) 11 features that may influence utilization costs for each woman. Individual utilization costs were summed, and key cost drivers were identified for each case. We estimated the mean and median cost of the component and total costs per service (SVD, elective CD, and emergency CD). We also estimated how much more women would have paid if there were no exemptions or donations. We then conducted a sensitivity analysis to test their influence on subsidy valuation. In addition, we compared mean facility-based costs for pregnant women with COVID-19 with standard facility-based costs pre-COVID-19. Ethical approval was obtained from the Health Research and Ethics Committee at LUTH (no. LUTHHREC/EREV/0520/24). Written informed consent was obtained from all participants. All nine pregnant women who had laboratory-confirmed COVID-19 and were managed in LUTH between April 1, 2020 and August 31, 2020 were recruited for this study. Their ages ranged from 22 to 40 years (median 33 years). All nine women were married and had attained tertiary education. Six of the women were employed, one was self-employed, and two were unemployed. The spouses of all nine women were employed. Of the nine women, two remained symptomatic during admission, presenting with acute respiratory distress syndrome, the other seven were asymptomatic until discharge. Seven presented with no obstetric complications during the index pregnancy. For mode of delivery, there were eight CDs (Cases 1-8); five were elective (Cases 1-5) and the other three were emergency CDs (Cases 6-8). All CDs were performed under spinal anesthesia. Case 9 was the only patient who gave birth by SVD. The women spent between 4 and 22 days in the hospital (median 15 days) ( to manage severe COVID-19 symptoms was the major cost driver (48%), followed by medicines (20%) and supplies (14%) ( Table 2 ). The cost of SVD for pregnant women with COVID-19 is more Those with severe COVID-19 symptoms requiring CD would have paid US $2181-US $5088, but their costs were subsidized by 42%-65% (Table 4 ). Using the most conservative estimates for the potential cost subsidies being received by the women, facility-based costs were subsidized by between 21% and 51% (Table S1 ). Regarding facility-based costs, we found that pregnant women with For the other cost components, the median transport cost (US $10) reported in our study is higher than in Tanzania (US $0.09) but lower than the US $51 reported in Bangladesh. 17, 18 In our study, opportunity costs ranged from US $243 to US $572, while in the literature, adjusted estimates ranging from US $3 in Lao PDR for SVD, to US $89 for CD in Nepal have been reported. 12 . This may be because pregnant women with COVID-19 were hospitalized for longer, so their partners had to stay away from work for longer. Our study findings have clear policy implications. Pre-COVID-19, providers used some PPE, albeit not as much as is now being required. Indeed, demand currently far outstrips supply, with 60% of providers reporting insufficient PPE to keep them safe while providing care. 19 With such gaps in the PPE supply chain, costs are being passed on to women. This increases the risk of catastrophic health expenditure. Providers, more so those in low-to middle-income countries, need to explore innovative ways to source PPE without passing the burden on to pregnant women. 20 There is a case for governments to mobilize local PPE production and negotiate with sellers, while offering incentives for reduced costs and regulating sell-on costs. New thinking is also needed for oxygen supply. Pre-COVID-19, there was already concern about oxygen sufficiency in Africa. 16 enabling private construction of oxygen plants, and use of solar-powered oxygen delivery are being implemented to boost oxygen supply during the pandemic, 16 but these costs should not be passed on to pregnant women. It should be noted that the women in our study were all educated and they and/or their partners were employed, yet, as our results showed, they benefited from 32%-62% of subsidies in facility-based costs. With 40% of the population living below the poverty line, 21 many will not be able to afford the increased service There are limitations to bear in mind when interpreting the findings of this study. First, we did not collect data on household costs in the pre-COVID-19 era. Second, we only reported costs from one public tertiary hospital, and this cost may not be representative of the costs being incurred by women around the country, especially within the private sector, where costs for using services are typically higher than in the public sector. 12 Follow-up studies should be conducted to capture utilization costs for using other public and private facilities. In conclusion, the cost of using maternity services for childbirth has increased and is likely to remain significantly high for women if the exemptions being offered by governments become unaffordable, donations reduce, or new requirements for universal testing have a chargeable fee. If COVID-19 becomes the new normal, then there will be many more pregnant women with COVID-19, including many who cannot afford the huge costs of care. Urgent measures are needed to ensure that women and their families are not being locked out of the health system. We are indebted to all the staff of the Lagos University Teaching Hospital who made data collection for this study possible; we would like to particularly acknowledge the support of pharmacist Olabisi Opanuga. We are especially grateful to the pregnant women with COVID-19 who took time post-discharge to take part in this study. The authors have no conflicts of interest. AB-T conceived the study. AB-T and CAA led the study design. 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