A cost analysis of deliveries conducted in various health care settings in a city of India.

Background: Health is associated with various socio-economical issues which affects accessibility of a common man to the health care delivery systems. Cost analysis can be an important element in setting levels of user fees and can help sort out important economical issues. The present study was carried out to study the total cost borne in case of normal delivery and caesarean section in various health care settings and to compare them. Material & Methods: Personal interviews of 101 women delivered either by normal (ND) or by caesarean section (CS) in Government, Corporation or Private Hospital or in Home were taken. Information was collected regarding the direct medical cost, direct non medical cost and the indirect cost was analyzed by using appropriate statistical software. Results: Mean of Total cost in case of normal delivery was Rs. 575.13 (+ 172.04), Rs. 1839.73 (+ 887.07), Rs. 3035.56 (+ 1538.32), and Rs. 812.27 (+ 658.21) in Government, Corporation and Private Hospitals and in Home respectively. Mean of total cost in case of CS delivery was Rs 1823.67 (+ 801.13), Rs. 4232.87 (+ 1135.94), & Rs. 9754.67 (+ 2450.28) in respective institutions. Significant difference (p < 0.001) was found in total cost among above mentioned settings both for ND & CS. However after Post hoc analysis, no significant difference was found between total cost of normal delivery at home and at government hospital. Conclusions: The above analysis helped us to explore the cost of delivery care in above settings. As there was no significant difference found between total costs of normal delivery at home and at government hospital, people should be motivated for the Government hospital deliveries instead of home deliveries. Further research on long term outcome needs to be done. Key-words: cost analysis, direct cost, indirect cost, delivery, hospital delivery, home delivery, India Introduction: Maternal mortality and infant mortality are two important indicators for adequacy and utilization of health care delivery system and for over all development of the country. In India MMR is 254 per 100000 live births (1) and IMR is 53 per 1000 live births (2) . The institutional delivery or delivery by skilled personal plays major role in reducing MMR and IMR. In India rate of institutional deliveries is 41% and deliveries assisted by health professional are 49% (3) . The major deterrent for institutional delivery is economic condition of the family. Current health expenditure in India is 3.6%. Of which 75% is private expenditure and out of that 91.4% is out of pocket expenditure (1) . Economic issues have had a growing importance in the health care field as the sector’s share of the gross national product has risen (4) . Cost is a measurement, in monetary terms, of the amount of resources used for some purpose (5) . Cost, in simple words, means the total of all expenses. Cost analysis includes examining the costs of alternatives (6) . In India looking at the present scenario of health insurance cost of care is major factor which needs to be attended. Cost analysis can be an important element in setting levels of user fees (7) which is affordable to a common man. Measuring unit cost can be of definite help sort out important economical issues (8) . The present study was conducted in Ahmedabad, a premier city of Gujarat state in western part of India. There are three municipal corporation hospitals, one civil hospital, one municipal urban health centre per each ward of city and many private nursing homes available for providing pregnancy and delivery care. However in many of urban slums deliveries are still conducted in home by h e a l t h l i n e ISSN 2229-337X Volume 2 Issue 1 January-June 2011 62 untrained elderly females of the locality. The present study was carried out to analyse out of pocket expenditure incurred for child birth in various settings and to assess whether cost of health care services is a significant factor in choice of the setting for delivery care. Methods: It was a Cross sectional study carried out in various health care settings of Ahmedabad city during SeptemberOctober 2008. For data collection following settings were chosen: Civil hospital, one of the municipal corporation hospitals, purposively selected three private hospitals and two of urban slum areas (Gulbai Tekra and Kagdivad area). The private hospitals were chosen based on the results of survey conducted in the mentioned slum areas regarding the favourable private hospitals for the local population. 30 cases from each of the health care settings (15 of normal delivery and 15 of Caesarean section delivery) based on experience of getting similar replies after such a number of interviews. And 11 cases of home delivery could be taken out of around 13 cases occurred at home in last 2 months preceding the interview with live issue in study area to limit recall bias. The women having any complication during or after pregnancy or delivery were excluded. The women registered under Janani Suraksha Yojana (9) or Chiranjeevi Yojana (10) (schemes by Government to increase institutional deliveries) were also excluded. Total 56 cases of normal delivery with or without episiotomy and 45 cases of cesarean section were taken. After obtaining oral consent total 101 women and/or care taker in these settings were personally interviewed by the investigators. For the hospital setting the interviews were taken every day till the women got discharge. Information was collected regarding Direct Medical Cost, Direct Non Medical Cost and Indirect cost. Terms: Direct Medical Cost includes: cost of medicines and consumables, hospital bill i.e. Cot charges, charges of Investigations, Operation Theatre charge if any, Charge of Anesthesia if any and charge of Caesarian section if any, Dai charges in case of home delivery Direct Non Medical Cost includes: cost of food, cost of accommodation for attendants, cost of transport Indirect cost includes: wage loss of self and/or care taker Statistical Analysis was done by calculating averages, proportions and applying test of significance using appropriate statistical software. Results: Mean age of the women in the study was 23.3+3.22 years. Socio economic status of women showed 90 % of women fell below class 3 of Modified Prasad. Mean duration of Hospital stay was 2.2 +1.99 days and 7.9+ 4.41 days in ND and in CS respectively. Average of total cost is in case of Normal Delivery is highest for private hospital while lowest for government hospital (Table 1). The difference was found to be significant (KW= 41.37, ptotal cost among above mentioned settings for ND. However on Posthoc analysis no difference was found between mean cost of ND at Government hospital Vs Home delivery. Average of total cost is in case of Caesarean Section Delivery is highest for private hospital while lowest for government hospital (Table 2) and the difference in total cost was found to be significant (KW= 37.65, ptotal cost in case of normal delivery in each setting except in government hospital where direct non medical cost contributes highest (figure 1). However in case of CS direct medical cost contributes the most to the total cost in all the institutions (figure 2). In both the cases it is lowest at the government hospital. When expenditure for child birth is calculated as a percentage of total monthly income, average expenditure for ND was found to be 38.61% and that for CS it was 116.56%. Maximum percentage of income was spent in case of private hospital delivery and lowest for government hospital for both ND and CS (figure 3). Even 21% of family had to take debt to meet the expenses of delivery. Of which 64% had CS delivery, 18% had home delivery and rest 18% had normal delivery. h e a l t h l i n e ISSN 2229-337X Volume 2 Issue 1 January-June 2011 63 Table 1 Each type of cost in case of Normal Delivery in each setting Go ver nm ent Corpor ation Priv ate Home