Abstract
After years of effort, sub-Saharan Africa has seen little improvement in maternal and neonatal health indicators. Providing all women with access to emergency obstetric care is an accepted effective strategy to reduce maternal and neonatal mortality. In many African countries such as Benin, the cost of health care is a major obstacle to access obstetric care. The aim of this study was to evaluate the caesarean section expenditures of households in Benin and to determine the strategies for obtaining the necessary resources to meet the caesarean section expenditures of the households. Three hospitals and 505 households in the Littoral region were sampled, and data were collected by applying a questionnaire to the people accompanying the woman to the hospital. The socioeconomic status of the households was evaluated using a wealth index created by principal component analysis. Factors significantly associated with expenditure were determined using multivariate linear regression analysis. Despite the free caesarean section policy in effect, households spend a median of US$180.60 (IQR: 148.13–222.35) for a caesarean section, of which 76.0% are direct costs, 17.0% are indirect costs, and 7.0% are opportunity costs. Expenditures vary considerably depending on the residence area of the household, the presence of complications, the presence of health insurance, the socioeconomic class of the households, the education level, and working status of the woman. Finally, households use 11 strategies to obtain funds to pay for the caesarean costs. While poor households resort to foreign aid, asset sales, and/or current spending cuts, the rich use their income and/or savings to cover their caesarean section expenses. The results favour the adoption of a mechanism for direct exemption of the costs of caesarean sections payable by the poorest households, in addition to the current free caesarean policy.
1. Introduction
Although maternal mortality has decreased by 44.0% globally in the last three decades, it is still an important public health problem, especially in developing countries. Worldwide, approximately 808 women die every day from complications related to pregnancy or childbirth [1]. It is estimated that in 2017, 295.000 women died during or after pregnancy and childbirth, and nearly all (99.0%) of maternal deaths occurred in developing countries, with more than half of these occurring in sub-Saharan Africa. While the maternal mortality rate in sub-Saharan African countries was 542 per 100.000 births in 2017, this rate was only 10 per 100.000 births in European countries [2].
Benin is one of the poorest countries in sub-Saharan Africa with a per capita income of US$1250.00 and a population of 11.94 million [3]. In Benin, 38.2% of the population fall below the global annual poverty line estimated at US$458.17 according to the Harmonized Survey on Household Living Conditions approach [4]. In addition, Benin is one of the countries most affected by maternal deaths. The maternal mortality rate was 391 per 100.000 births in 2019, with most of these deaths occurring in the country’s rural areas [5].
In order to reduce maternal mortality, it is necessary to ensure that birth is carried out by a qualified health personnel in a health center. In the event of complications, providing access to emergency obstetric care is essential to reduce maternal mortality [6]. At the United Nations meeting held in September 2000, access to obstetric care has an important place in the Millennium Development Goals planned to be fulfilled by 2015. The fourth of eight targets set was concerned with reducing child mortality worldwide by two-thirds, and the fifth was aimed at reducing maternal mortality by 75.0% [7]. To achieve these goals, most sub-Saharan African countries, including Benin, have adopted a variety of health care fee waiver strategies. Among these health policies is the free caesarean section, which was started in Benin in 2009 [8]. In practice, hospitals are paid a flat fee of CFA francs 100.000 (US$152.08) per caesarean section [9]. This measure helped bring the caesarean delivery rate to 5.1% and the participation rate by qualified health personnel to 78.0% in Benin in 2019 [3]. Despite this significant coverage, Benin is still far from the performance of developed countries which have caesarean section rates above 15.0% and assisted deliveries covering almost the entire population [2].
Despite this measure to exempt pregnant women from caesarean section fees, access to maternity care in Benin continues to face physical and financial challenges, according to the 2019 Demographic and Health Survey [3]. Physical disabilities are why households in sub-Saharan Africa are giving up or delaying demand for emergency obstetric care. These barriers are mainly related to the geographical distance between hospitals and the place of residence of the households, the availability of transport infrastructure and inadequate medical personnel, emergency obstetric care services, and medical supplies [10]. Likewise, the high cost of transportation and services in the city of Maroua in Cameroon has been identified as a major economic constraint in accessing emergency obstetric care [11]. In most studies, geographical distance between households and hospital centers is stated as an important barrier that hinders or delays women’s obstetric care demands [12, 13]. Almost none of the sub-Saharan African countries have health insurance coverage that covers the entire population, the majority of whom work in the informal sector and who have little capacity to finance health expenditures [14]. In sub-Saharan Africa, point-of-service direct payments remain the main method of financing health care and represent a major barrier to access obstetric care [15]. For example, in Ivory Coast, 59% of women in a precarious neighborhood discontinued obstetric care due to financial constraints [16]. In this context, considering the fact that the fertility level is 5.7 children per woman in 2019, almost the entire population does not have health insurance and households have difficulty in paying for their health expenses, and it would be interesting to conduct research on this subject [15].
Few studies have been done on caesarean section in Benin. The functionalization of the free caesarean section policy in the country has been evaluated [17, 18]. In a study, the sociodemographic characteristics of women who had a caesarean section and the cost of caesarean section were investigated [9]. In addition, a qualitative analysis of birth costs after the introduction of the free caesarean section policy was made [19]. Finally, the contribution of the free caesarean section policy in reducing inequalities in access to obstetric care in Benin and Mali has been addressed [20]. In addition to these studies, a detailed inventory of the caesarean section expenditures paid by the households was made in our study, the determinants of the caesarean section expenditures were shed light on, and the resource mobilization strategies used by the households were determined.
2. Methods
2.1. Research Questions
This cross-sectional study was conducted to evaluate the health expenditures of households during caesarean section in Benin. The main questions of this research are as follows. (i) What is the cost of caesarean section covered by the household? What are the factors that make up this cost? (ii) Does the use of resources differ according to the income of the households to cover the caesarean section expenses in Benin? (iii) What are the factors affecting the caesarean section expenditures of households in Benin?
2.2. Geographical Setting of the Study
The Republic of Benin is a country in West Africa that shares borders with Togo, Burkina Faso, Niger, and Nigeria [3]. In terms of health, Benin has established a two-dimensional (technical and administrative) pyramid type health system. The administrative dimension of the health pyramid is divided into three levels: the Ministry of Health at the national level, the Health Departments at the regional level, and the Community Health Offices at the peripheral level. The technical dimension of the health pyramid is also divided into three levels: university hospitals at the national level, departmental hospital centers at the regional level, and community hospitals at the peripheral level [21].
2.3. Population and Sample of the Research
The sample of the study consisted of women who had a caesarean section in Benin. A three-step sampling was chosen. In the first step, the sampling unit is the region. The study was carried out only in the Littoral region. The reason for choosing this region is the observation of the National Institute of Statistics and Economic Studies of Benin (INSAE), which revealed that Littoral is the region where emergency obstetric interventions are more frequent with a rate of 15.0% [3]. In the selection of hospitals, which are sampling units for the second step, those with accreditation for free caesarean section were preferred. In fact, a free caesarean section policy applies at 29 primary care hospitals, except for the national level hospitals (university hospitals) located in Littoral [22]. The research was limited to three hospitals that had authorized the study and in which free caesarean section is performed. Thus, Menontin, Saint-Jean, and Saint-Luc hospitals were the three hospitals selected for this study. In the third step, the sampling unit was determined. The sampling unit was the data collection period covering the period between 01 March 2021 and 31 May 2021. March was mostly dry, and April and May were the rainy season. The data collection period was limited to one quarter of 2021 due to financial and time constraints. As a result, the sample consisted of all women who underwent caesarean section between the data collection dates of the study, in three hospitals selected in the Littoral region. The information obtained from the service statistics of the three hospitals within the scope of the research shows that 470 to 552 caesarean sections are performed on average in a three-month period. Accordingly, the sample of the study consisted of 505 women who had a caesarean section during the research period. It represents all the women who had a caesarean section during the study period in the three hospitals.
2.4. Data Collection
After obtaining the women’s obstetrical and medical data from their medical records, a structured interview guide was used to interview one of the family members accompanying the woman. This interview made it possible to collect socioeconomic data as well as data on the costs (direct, indirect, and opportunity) incurred by the household during the last caesarean section. The interview was preferably held with the head of the household or with the patient’s companion, if any, on the date the woman was discharged from the hospital. The data collection form is included as an additional file (see supplementary file (available here)).
2.5. Data Analysis
The amount and nature of household expenses for a caesarean section in Benin were determined. Caesarean section expenses paid by households in Benin are divided into three main categories as direct costs, indirect costs, and opportunity costs. Direct costs represent all official medical expenses, the cost of medicines purchased inside and outside the hospital, and the cost of medical supplies. Indirect costs include transportation, meals, informal payments sometimes requested by medical personnel, and various other costs. Finally, the opportunity cost is an estimate of the monetary value of the time lost by the caregiver of the caesarean section woman. For this purpose, a two-stage analysis was carried out. First, the data obtained on household expenditures were grouped according to their characteristics. Eight expenditure categories were considered in the statistical analysis: treatment, drugs, medical supplies, transportation, food, informal payments, opportunity cost, and other costs.
Secondly, strategies for providing the necessary resources to meet the costs of caesarean delivery of households were determined. With reference to the study by Arsenault, 11 sourcing strategies have been identified for direct payment of emergency care expenditures [15]. These strategies are health insurance, income, sale of consumption or production assets, loans with or without interest, assistance from associations or families, savings, reduction of current consumption expenditures, and other strategies. The different strategies used by the households were analyzed according to the socioeconomic class of the households obtained from principal component analysis (PCA). In fact, it should be noted that it is difficult to know the exact household income in Benin, given that over 95.0% of active people work mainly in the informal sector and live on a daily and variable income [4]. In the case where income is not known, households can be classified according to their welfare level using an index based on their socioeconomic data. To determine the welfare index, socioeconomic studies in general [23, 24] and in similar studies about this research in particular [4, 25] use the PCA approach. This index is calculated based on indicators related to food, housing, and assets owned by households. The welfare index was organized in five dimensions (very poor, poor, moderate, rich, and very rich) and used as a categorical variable for analysis.
In the next step, Kruskal–Wallis analysis and Man–Whitney U analysis were performed to compare the total expenditures of the households with some variables. In addition, linear regression and quantile regression analyses were performed to determine the effects of variables on expenditures. These analyses made it possible to determine the effect of sociodemographic, obstetric, medical, and socioeconomic variables on the cost of caesarean section. The selection of independent variables included in the analysis model was based on the literature, especially the work of Ravit et al. [25]. Age of the woman, residence area of the household, monitoring of the pregnancy by the health personnel, the status of the woman’s referral, the length of stay in the hospital, indications for caesarean section, the presence of complications, the use of health insurance to cover the costs of the caesarean section, the socioeconomic level of the households, the education level of the women, the employment status of the women, and the type of hospital are the independent variables in the multiple linear regression model. As an alternative to multiple linear regression in studies on health expenditures, quantile regression, which is one of the powerful regression methods, is also used to analyze various quantiles [26]. Even if the regression equation obtained for the mean value of the dependent variable is not statistically significant, the regression equations obtained for different quantile values can be significant. Therefore, the quantile regression model was added to the analysis. For statistical tests, the limit of significance was determined as 0.05. SPSS version 25.0 was used for statistical analysis of research data.
3. Results
3.1. Sample Characteristics
The data from the three hospitals show that 35.6% of women surveyed had their last caesarean section at Saint-Jean Hospital, 31.9% at Saint-Luc Hospital, and 32.2% at Menontin Hospital. Only 43.2% of these households live in the Littoral region, where the three hospitals that are the subject of the research are located. The remainder of the households (i.e., 52.7%) live in other parts of the country and have moved to Littoral for their last birth. Women giving birth at an early age (before age 20) and older age (after age 40) represent 8.7% of the surveyed households. The average maternal age is 29. At least 17.6% of the women were not followed up by the health personnel, while 29.7% of caesarean section cases were referred from another health unit. It has been determined that the transportation vehicles used during the emergency transfer of women to the hospital were not suitable. Only 4.0% of the cases were transferred by ambulance, while 20.0% by non-medical means and 69.3% by motorcycle. After caesarean section, 9.1% of patients developed complications such as uterine injury, bleeding, and hysterectomy.
3.2. Caesarean Cost in Benin
The research shows that in Benin, households pay a median of US$180.60 (IQR: 148.13–222.35), excluding the cost of caesarean section paid by the government. Medical expenses account for the largest portion (42.0%) of caesarean section costs and median of US$80.22 (IQR: 50.58–97.01). Caesarean section expenditures made by households constitute 76.0%, 17.0%, and 7.0% of direct, indirect, and opportunity costs, respectively. Figure 1 summarizes the caesarean section expenditures incurred by Benin households by type and cost.
Figures 2–5 show the ratios of direct, indirect, and opportunity costs by hospital, indication, location, and complication, respectively. Research results show that the cost of caesarean section varied according to hospitals. Among the three hospitals considered in this study, the hospital with the lowest caesarean section cost was Saint-Luc Hospital with US$139.37 (IQR: 121.46–164.27). In contrast, the Saint-Jean hospital had the highest cost of caesarean section at US$230.64 (IQR: 201.38–258.02). The median cost of caesarean at Menontin Hospital was US$180.64 (IQR: 161.19–201.49) (Table 1).
One of the important factors highlighted earlier is the proportion of households (approximately 53.0%) traveling from other parts of the country to give birth in hospitals located in Littoral. Therefore, analysis of caesarean section costs by location shows that households residing outside Littoral spent more for caesarean section than those residing within. Median cost of caesarean section for Littoral residents was US$173.41 (136.47–214.69) versus US182.79 (153.92–226.35) for non-Littoral residents (Table 1).
The expenditures also varied depending on whether the intervention was planned or not, or whether an emergency medical intervention decision was made by the healthcare professional. It was found that scheduled caesarean sections were more expensive for households than emergency caesarean sections. In Benin, the median household spending for planned caesarean section was US$186.57 and that for urgent caesarean section was US$174.44. Caesarean section without any complication was less costly for the household than one with complications. Infections, bleeding, hysterectomy, and uterine damage were complications frequently encountered in patients after caesarean section. The costliest complication for the household after caesarean section was uterine damage. Due to this complication, households spent a median of US$274.56 (Table 1).
3.3. Financial Sources to Cover Costs
In Benin, where more than 95.0% of the population is not covered by insurance, different strategies were used to pay for the additional expenses not covered by the free caesarean section policy in effect. 68.3% of the households used the resources obtained from their activities to cover the cost of caesarean section. When these resources were insufficient, 42.0% used their savings and 28.5% had to reduce their consumption expenditures. In some cases, households resorted to external sources, especially support from family members (19.4% of households), aid from associations (8.5% of households), or interest-based (17.0% of households) or interest-free loans (14.1% of households). Finally, 8.9% of households had to sell consumer assets and 6.5% had to sell productive assets such as livestock or land.
Additionally, the wealth level of households played a great part in determining the financial sources to cover the different expenses. Figure 6 shows that 64.0% of the poorest households had to reduce their current expenses to pay for their caesarean section, 48.0% used family assistance, 43.0% used income from the activity, and more than 30.0% took interest or interest-free loans. Twenty-eight percent of these households are forced to seek help from community associations or sell consumer assets. In extreme cases, 18.0% sell their production assets and 13.0% use their savings. The top three strategies used by the middle class are earned income (57.0%), savings (49.0%), and reduction of current expenses (43.0%), while 20.0% of this class have applied for family assistance or loans with or without interest. Less than 10.0% sought help from community associations and sold assets. The wealthy classes often use their earned income or savings.
3.4. Determinants of Caesarean Section Expenses
The results of the multiple linear regression analysis and quantile regression analysis performed in order to evaluate the effect of the independent variables in Table 2 on the total expenditures of the households are presented in Table 3.
As a result of the multiple linear regression analysis, 33% of the total expenditures of the households are explained significantly by the independent variables included in the model. The estimates of the pseudo-R2 for the quantile regressions equation explained 9.5% of the variation at the 10th quantile and the explanatory power increased steadily across the conditional distribution to 25% at the 90th quantile.. According to the linear regression model, while increasing age, education, absence of complications, and living in the Littoral region decrease total expenditures, being employed and having health insurance and high socioeconomic class increase total expenditures. It was determined that other variables included in the model (pregnancy follow-up, hospital type, referral status, length of hospital stay, and indication for caesarean section) did not have a significant effect on total expenditures. In this context, the equation of the model can be written as follows, according to the results of the multiple linear regression analysis:
Considering the quantile regression results, the model established according to the 10% quantile was found to be significant in terms of constant, education level, employment status, region of residence, health insurance, and socioeconomic class. According to the model, the increase in the educational status of the women and the fact that they live in the Littoral region decrease expenditures, while the fact that women are working, have insurance, and have a high socioeconomic class increases total expenditures. The equation of the model for 10% quantile is as follows:
In the model established according to the 25% quantile, the increase in the educational status of women and their living in the Littoral region decrease their expenditures. The fact that women are working, have health insurance, and have a high socioeconomic class increases total expenditures. The equation of the model for the 25% quantile is as follows:
In the model established according to the 50% quantile, similar to the 10% and 25% quantiles, the increase in the education level of women and their living in the Littoral region decrease their expenditures, while the fact that they are working, have insurance, and have a high socioeconomic class increases total expenditures. Model equation for 50% quantile:
According to the 75% quantile model, living in the Littoral region and the absence of complications reduce expenses. The fact that women are working and their socioeconomic class is high increases total expenditures. In this quantile, unlike the other three quantiles, it was observed that education status and health insurance were not included in the model, and the presence of complications variable was included in the model. Model equation for 75% quantile:
Finally, when the model established according to the 90% quantile was examined, it was found that the independent variables of working status and socioeconomic class had a significant effect on the total expenditures. Therefore, by including only the constant and these two independent variables in the equation, the model equation for the 90% quantile can be written as follows:
In the 90% model, unlike the other quantiles, only working status and socioeconomic class were included in the model. Accordingly, the fact that women are working and their socioeconomic class is high increases the total expenditures.
4. Discussion
This study made it possible to estimate the cost of caesarean section to be paid by households in Benin. Despite the free caesarean policy in Benin, the household cost of caesarean section is still high, estimated to median of US$180.60 (IQR: 148.13–222.35). This result shows that the public policy regarding caesarean section that was put into practice in Benin in 2009 constitutes only a partial exemption from the cost of caesarean section and has not changed until today. Indeed, each approved hospital receives a lump sum of US$186.00 (FCFA100.000) per caesarean section, which corresponds to the cost of the caesarean section kit. Thus, it is accepted that the caesarean section policy in Benin covers only 50.0% of the total cost of the caesarean section, and the second half is paid by households. In a previous study from 2016, despite the implementation of the free caesarean section policy, the high costs for households after caesarean section were emphasized [9]. In their study, only the direct costs of caesarean delivery were evaluated, and it was determined that the expenditures ranged from US$0.00 to US$372.10 with an average of US$55.80 (FCFA30.000). In our study, the direct cost constituted 76.0% of the caesarean section cost covered by the household. In addition to the direct cost, it has been determined that there are 17.0% indirect and 7.0% opportunity costs. By way of comparison, in Mali, the average caesarean section expenditures undertaken by households, where similar caesarean section policies are implemented, are US$133.00 and consist of direct, indirect, and opportunity costs [15]. In 2017, the cost in Mali was revalued to US$142.70, including 70.0% direct cost [20]. Our results are also close to the recent caesarean cost assessment in Rwanda [27]. According to their results, the cost of caesarean section borne by the household in Rwanda is US$339.00, with 35.0% preoperative and 65.0% postoperative. It is important to recognize that even relatively low expenditures in poor households where all resources are used for basic needs can lead to disasters. In fact, catastrophic health expenditures are not always synonymous with higher health expenditures, and for some households, even small expenditures can lead to poverty [28]. Considering that the minimum wage in effect in Benin is FCFA 40,000 (US$73.20), a caesarean section expense of US$180.60 determined in this study would be catastrophic for Benin households, especially poor households [29].
The study showed that households often use several different procurement mechanisms at the same time. Middle-income and poor-class households, which make up 53.2% of the research population, tend to reduce current expenditures, seek help from family members or community associations, sell consumption or production assets, or take loans from moneylenders to pay for cesarean section costs. In contrast, wealthy households often use the earned income and savings to pay for caesarean section expenses. In another study, it was shown that the help that poor households receive from the social network can be important, and that they can sometimes cover the entire cost of the caesarean section with these aids. It has also been revealed that some households pay their caesarean section bills with money transferred from family members living abroad [30].
Selling consumption or production assets to finance caesarean section expenses is also a strategy commonly used by households in Mali and Burkina Faso [15, 30]. The assets sold in these countries are mostly livelihood animals, grain products or other agricultural products, and tangible assets. Households often use income from the sale of their livestock or crops to cushion the economic shocks they face. When households sell their livestock or productive assets such as land, economic fragility may enter a vicious circle, pushing them further into poverty [31, 32].
In this study, it has been determined that the main determinants of caesarean section expenditures in Benin are the residence area of the household, the presence of complications, the use of health insurance, the socioeconomic class of the households, the education level of the woman, and the working status. It has been determined that households residing outside Littoral have higher caesarean section expenditures than those residing in Littoral. This cost difference is mainly explained by the higher transportation and opportunity costs for non-residents of Littoral. In fact, since Benin is connected to a pyramid-shaped healthcare system, almost all referral hospitals are in Littoral (Cotonou). The supply of quality emergency obstetric care is concentrated in this part of the country [5]. In the absence of local emergency obstetric care services, most households are forced to go to Littoral and bear the higher cost of transportation. The same observation was made in Burkina Faso [33]. It is reported that despite the existence of a reference evacuation system aimed at reducing transport expenditures and inequalities in Mali, transport costs remain high and access to emergency obstetric and neonatal care is hindered [20]. Similarly, van Duinen et al. found that many women in Sierra Leone incur devastating expenses due to caesarean section, and these expenses are mostly related to food and transportation [34].
The cost of caesarean section varies depending on the complications observed after the surgery. Women with uterine damage after caesarean section specifically paid higher amounts for treatment than women with other complications. This result could be explained by the fact that uterine damage often results in prolonged hospital stays and expensive medications. It has also been determined that caesarean section expenditures vary according to the economic status of the households. Few studies comparing the cost of emergency obstetric care with household income have reported similar results. Emergency obstetric care expenditures were higher for poor households in Mali than for wealthy households [35]. The total cost of caesarean delivery in Madagascar was found to account for 32.9% of annual non-food expenditures of the rich and 109.1% of the poor [35]. Similar to our findings, these studies also show that the need for emergency obstetric care is not at an affordable level for a significant portion of the population in sub-Saharan Africa. Education level and working status of women are also factors that significantly affect caesarean section expenses in Zambia [36].
This study has some limitations. First, the principal component analysis method was used to divide the households into five groups, as household income data could not be obtained. The first five dimensions of PCA explained 61.0% of the total variation. This means that 39.0% of the information included in the variables included in the PCA model is lost to classify the surveyed sample into a socioeconomic group. This analysis would have been even more precise if the sum of the explained variance had been higher. The PCA approach in this study did not use predefined scores such as DHS. Assigning wealth quintile specific income to households would make it possible to identify impoverishing expenditures repeatedly, as in some extensive studies that identify catastrophic health expenditure [37, 38]. The other limitation that should be emphasized in our study is related to the representativeness of the questioned sample. The Littoral region was chosen as the geographic framework for this study as it is the region with the highest caesarean section rate, based on the findings of the most recent demographic and health survey [3]. However, it would be more interesting to plan a study that included the poorest areas of Benin to better understand the economic impact of household caesarean section expenditures.
One of the strengths of our study is that it was conducted with a relatively large sample of 505 households and in three different hospitals. Thus, certain biases associated with the studied sample were avoided and the validity of our results was strengthened. Also, to our knowledge, this is the only study in Benin that examines caesarean section costs beyond direct household costs. In addition to expenditures, the study highlights the sourcing strategies that households use to pay for caesarean section costs. This approach makes it possible to draw attention to the difficulties faced by households in general, and the poorest, in responding to the direct reimbursement of health expenditures imposed on them.
5. Conclusion
Although the introduction of a free caesarean policy in Benin plays a key role in accessing emergency obstetric care and reducing maternal and neonatal mortality, our study has shown that this policy does not cover all caesarean section-related expenses. The free caesarean policy is only a partial exemption from the cost of caesarean section, which consists of a lump sum of FCFA 100.000 per caesarean to accredited hospitals. The amount paid to the hospitals covers the cost of the caesarean section kit. Households paid a median of US$180.60 for a caesarean delivery, of which 76.0%, 17.0%, and 7.0% were direct, indirect, and opportunity costs, respectively. Furthermore, this research revealed that the household region of residence, the presence of complication, the use of health insurance, socioeconomic class of households, women’s education level, and working status of women were the main determinants of caesarean section cost in Benin. It has also been determined that households use several mechanisms to afford caesarean costs. Middle-income and poor households, about half of the study group, were cutting back on expenses, receiving aid from relatives or community groups, selling assets, or borrowing from moneylenders to pay for cesarean section costs.
In light of the above findings, governing bodies in Benin should take more measures to facilitate women’s access to emergency obstetric care and to protect households against high costs. The establishment of a stronger health infrastructure at the regional level and regular monitoring of women in the birth and postpartum period, starting with prenatal counselling with qualified health personnel, should be ensured.
Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.
Ethical Approval
Permissions were obtained from the ethics committee of Selcuk University and the hospitals chosen for the study.
Consent
The consent of the households was collected.
Disclosure
This article is grounded on Tchomi Oluwa Romuald Tchadrack Gnimassou’s master thesis titled “Evaluation of Caesarean Expenditures of Households in Benin,” Selcuk University/Konya/Turkey, 2021.
Conflicts of Interest
The authors declare that there are no conflicts of interest regarding the publication of this article.
Authors’ Contributions
TORT Gnimassou was responsible for study concept, collection and interpretation of data, and writing of the manuscript. E Filiz was responsible for study concept, interpretation of data, and revision of the manuscript.
Acknowledgments
We thank Dr. Handan ERTAŞ, Dr. Aydan YÜCELER, and Dr. Mehmet Akif ERİŞEN for their critical analysis which helped improve the quality of the study results.
Supplementary Materials
Supplementary file 1: research questionnaire. Survey questions to determine the socioeconomic status of the household and to obtain their sociodemographic and medical information. (Supplementary Materials)