The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

Abstract

Introduction While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. Methods We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. Results Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). Conclusion Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Determinants of cesarean mode of childbirth among Rwandan women of childbearing age: Evidence from the 2019–2020 Rwanda Demographic and Health Survey (RDHS)

“…Various studies have suggested that financial constraints in the developing world contribute to the unavailability of many healthcare interventions, including CD [38]. Given that CD is one of the most expensive healthcare interventions in Rwanda, it is possible that women from wealthier families have better financial access than their counterparts from resource‐limited families in this study context [39]. In the same way, this study found a link between emergency cesarean delivery and women saying they had trouble paying for medical care.…”

Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

“…Developing strategies to improve the functional recovery for women after c-section could thus have substantial impact on improving physical and emotional wellbeing for families in the postpartum period, as well as potentially mitigate the financial impact of childbirth by c-section on families. Indeed in this same cohort we have previously reported that 6.4% and 27% of women experienced impoverishing and catastrophic expenditures, respectively due to hospital expenses alone, without consideration of the impact of lost economic productivity [ 59 ]. Both upstream and downstream strategies should be considered to help aid in the return to normal functional during the postpartum period.…”

Patients’ experiences undergoing breast evaluation in Rwanda’s Women’s Cancer Early Detection Program

“…All interviewed patients had Rwanda's community-based health insurance, and described travel costs that were consistently higher than medical expenditures; this nding is consistent with other studies showing that non-medical costs pose barriers to care in LMICs even when medical costs are minimized. [32][33][34] Average monthly income in rural areas of Rwanda is about $27 USD; for farmers it is about $19 USD. [35] Repeated hospital visits consumed a signi cant portion of that income.…”