Ecuador: maternal mortality 87 deaths per 100,000

How much are Ecuadorians Willing to Pay to Reduce Maternal Mortality? Results from a Pilot Study on Contingent Valuation

ncbi.nlm.nih.gov/María Isabel Roldós, MPA, MA, DrPH,1 Phaedra Corso, PhD,2 and Justin Ingels, PhD2

Abstract
Context:

There is an established association between the provision of health care services and maternal mortality. In Ecuador, little is known if the societal value is greater than the resources expended in preventive medicine.
Aims:

The purpose of this research is to investigate Ecuadorians’ willingness to pay to prevent maternal death and disabilities due to complications of care during childbirth in the context of universal coverage.

Results:

The average amount participants are willing to pay (WTP) to prevent maternal mortality in the context of universal coverage, was $176 a year (95% CI=$172, $179). The unadjusted mean WTP for a reduction in the maternal morbidity risk was $135 (95% CI=$132, $139). Translated into Value of statistical Life, participant´s from this study valued the prevention of one statistical maternal death at USD $352,000.
Conclusion:

Results suggest that the costs of maternal care do not outweigh the benefit of prevention, and that Ecuadorians are willing to pay a significant amount to reduce the risk of maternal mortality.

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1. Introduction

Reducing population-level rates of maternal morbidity and mortality is an important developmental goal for many countries of the world. Ecuador´s maternal mortality is 87 deaths per 100,000 of live births.[1] The United Nations and governments around the world targeted a 75% reduction in maternal mortality by 2015, through two main strategies: (i) increasing antenatal care and[2] training of skilled birth attendants.[3] Ecuador’s specific strategy to meet this goal is the CONE program (Spanish acronym for Essential Obstetric and Neonatal Care). CONE is implemented through the public network of health services and private partnerships for patient referrals.[4] Thus, the implementation is segmented in a network of services. Maternal health specifically is delivered at the first level of care. According to the World Health Organization’s (WHO) “3 delays” model, maternal mortality can be attributable to inadequate health care provision.[5,6] In brief, the 3 delays framework provides an understanding of the factors that result in obstetric emergencies into the following delays: i) the women’s and family’s decision to seek health care; ii) issues related to accessing medical facilities such as transportation barriers, roads or others; and iii) the receipt of inadequate and appropriate care.[7]

Universal coverage is undoubtedly a critical component to reducing maternal mortality and improving the general health of a nation.[5] In Ecuador, universal coverage was first applied to maternal health care through the Free Maternity and Child Care Law (LMGAI). LMGAI was launched in 1994 and implemented through 2006. It was set to improve maternal and child health care outcomes of Ecuador’s most vulnerable populations.[8] However, even with the implementation of LFMC maternal mortality did not decrease, and maternal services remained partial. For example, around 28% of deliveries nationwide took place without the presence of a skilled birth attendant, of which, 75% occurred in rural areas.[9]

In Ecuador, little is known about how society values maternal health, particularly whether that societal value is greater than the resources expended for free access to services through the universal health care system. One way to assess the societal value given to the prevention of maternal deaths in particular, is to ask society about their willingness to pay (WTP) to prevent these deaths. This approach, called contingent valuation, is a survey-based method whereby respondents are asked to trade off mortality risk for wealth or income.[10] The resulting estimate, averaged across a population and multiplied times the risk reduction, represents the value that society places on preventing a statistical death. This estimate can then be used as the measure in a cost-benefit analysis where the costs of the free access to maternal health services through the universal healthcare system can be compared to the benefits of preventing maternal deaths.

The purpose of this research was to investigate Ecuadorians’ WTP to prevent maternal death and disabilities due to complications of care during childbirth in the context of universal coverage. To our knowledge, this is the first study to bring the question to individual citizens of how much they value universal coverage in relation to one of the most critical health problems in Ecuador. This question has rarely been studied recently and elsewhere. Evidence on WTP studies on alternatives to prenatal care was studied with a comparison between a general practitioner/midwife led care versus obstetrician led care with no significant differences between them and a WTP of 2500 Euros,[11] while in Tanzania a group of researchers investigated the willingness of patients and households to pay for rural district hospital services in the north-western region with significant differences between outpatient services and in-patient services ranging from 358 Tsd per a one day admission day to 2218 Tsd for an hernia operation.[12] In the United States a WTP study was used to inform The United States Preventive Services Task Force on the frequency and WTP of pregnant women to receive a sonogram during their pregnancy. Their results indicates that most women want a sonogram during pregnancy, and many are willing to pay for the examination.[13]

Ecuador is a country of 16,144,000 people with close to equal distribution between men and women, with a live expectancy of 74 years for men and 79 years for women and a total expenditure on health per capita of 1,040 USD.[1] Under-five infant mortality is 57 live births per 1,000 with other and congenital causes as main causes, and main causes of adults deaths as Ischaemic heart disease, stroke and lower respiratory diseases.[1]

The results of this study have the potential to influence future assessments of the returns on investment in the Ecuadorian healthcare infrastructure to prevent maternal mortality. Read Full Paper