Cuban Medical Research

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	Child And Adolescent Gynecological Services In Primary Care Sexual Function And Sex Hormones In Women With Premature Menopause Living Conditions And Maternal And Child Health Hormonal Contraception Cohort Study Cost Estimate For Pregnant Women Regarding Attendance At Prenatal Care Services In Three Havana Municipalities, Year 2000

COST ESTIMATE FOR PREGNANT WOMEN REGARDING ATTENDANCE AT PRENATAL CARE SERVICES IN THREE HAVANA MUNICIPALITIES, YEAR 2000

Giselda Sanabria Ramos MD, MPH [1] [1]
Ana María Gálvez González [2] [2]
Manuel Álvarez Muñiz [3] [3]

Introduction   

Background

A quick look at some health indicators for several countries1-4 shows a growing incidence of some disorders, the onset of new ones and the return of others that were considered practically under control. At the same time the world population grows, pioneering diagnostic and therapeutic techniques are created which are more and more precise but  more expensive. The analysis of these facts makes it possible to assert that health sector expenses increase by the day, and that these expenses oveburden the public sector budget as well as that of patients.

This fact, evident in whatever health sector, mostly affects developing countries; and even countries where governmental policies favor the tendency of meeting the health needs of the whole population. Therefore, decision-makers are confronted with the need to find the necessary tools to make a more rational use of the economic resources available; not to economize, but to increase and expand available services, and incorporate new services with no detriment to the existing ones. In this sense, economic assessment has become a valuable instrument for decision-making.

Cost assessments are part of economic evaluation. This is a procedure that has been long implemented in several productive branches, but in the health sector, the need for it began to increase in the second half of the present century, especially during the last decade. Available literature5-7 classifies economic studies into several types: cost-effectiveness, cost-benefit, and efficiency assessment, among others.

The wide range of economic evaluation tied to the health sector reinforces the scientific aspect of social policy decisions and planning for the future.

The utilization of cost assessments in the Cuban healthcare sector began to grow in the 1980s, and continued increasing during the 1990s.8-10  In the healthcare sector, this key economic phenomenon is based on the Cuban government’s  aspiration and will to make state management more effective and efficient11. In Cuba the Maternal and child Health Program is a top priority . However, although it is an important part of any health program involving mothers and children in any country, the form in which prenatal care is provided in Cuba has not been sufficiently evaluated, particularly from an economic point of view.

Rationale

The World Health Organization Health (WHO) is currently implementing a randomized clinical trial aimed at validating a new prenatal care protocol.12  This protocol includes a group of more rational actions than the ones currently in force, since it only includes healthcare interventions that have proven to be effective in improving maternal, perinatal and infant health, basically low-cost technological interventions. These interventions have been used in a four-doctor-visit program intended for women with low pregnancy-associated risks.

This research report reflects part of an economic study of the WHO’s protocol, specifically concerning the expenses which pregnant women incur when they attend prenatal care doctor’s visits. This type of study has also been termed “pocket expenses,” in contrast with “institutional expenses.”

For any program in general, and particularly for this one, it is important to study pocket expenses because when we speak of costs of prenatal care or of other health programs, we generally only think of the expenses which health institutions incur, not the ones which health service users can incur.

Users’ expenses, their potential or real effect on the patient’s decisions, and their relation with their family’s expense patterns, are rarely measured in healthcare service research. In contrast, health economists often refer to the costs of health service interventions for the society, but what they really refer to is the cost for healthcare providers. Data or information regarding the costs for patients are not often published; although more and more the need for this is acknowledged.

Our study determines the expenses which pregnant women incur, both in the group that participates in the new protocol of attention, with four doctor’s visits (intervention group), and for those in the regular program of fourteen prenatal visits (control group). The study of these expenses is beneficial.

Total social costs linked with the current prenatal care program can be considered independently, including the costs for both patients and the healthcare providers. In this study, only the costs for outpatient prenatal care services are considered. Although there are significant expenses regarding hospitalized pregnant women, these were not measured, since we assumed that such expenses do not vary from one group to the other in our study. The main differences between the two ambulatory prenatal care programs are identified.

Once the costs are known, policy makers will be in a better position to make recommendations about optimal prenatal care policies, as far as the society is concerned. Focus on the society was preferred over focus on health providers, since what can be more convenient for the health service may be more expensive and less convenient for the women.

The question this study has tried to answer is whether there is any difference between the expenses of pregnant women in the new prenatal care protocol and those in the general program in force.  

Objective

To estimate the costs or pocket expenses for pregnant women in the two groups studied, who are included in the prenatal care protocol in three municipalities of the City of Havana.

Methods

A partial cost analysis economic assessment13 was conducted in which two prenatal care programs were compared and the inflows (costs for pregnant women – pocket expenses) were examined in three municipalities (10 polyclinics) of the City of Havana.

Sample

We interviewed 340 women. This amount was selected to meet the statistical requirements for a reasonable amplitude of the confidence interval  for average values, and includes the adequate number of pregnant women—similar to the studies carried out in other countries. The sample was calculated based on the analysis of the number of pregnant women during 1997 in the polyclinics included in the study.

We gave survey forms to 30 women in each polyclinic and to 40 in the hospital. This amount made it possible to include in our study differences by type of consultation (first or subsequent). We decided to give survey forms to the total amount of pregnant women   in each polyclinic in this way: 10 who had just received their first consultation (incorporation into program) and 20 who came for their pregnancy follow-up consultation. This division was based on the fact that the research protocol for technology validation takes into consideration different procedures for each type of consultation, which can modify costs.

Of the 40 women interviewed in the hospital, 20 belonged to the control group, and 20 to the intervention group. Given that pregnant women from various health areas are seen at the hospital, only those belonging to one of the polyclinics selected for our study were interviewed. The following sample calculation formula was used:

           no                                                2
n =  ---------------,     where                Z        x P x q
        1 +  no -1                                      1 - a
              ---------                         no  = ------------------
                 N                                               2

                                                               E o
p      = 0,70 = 70 %                 q = 1- p = 30 %

E      = maximum allowed error = 7,0 %

Z 1 - a  =  1,96 ( 95 %  confidence)          Deef. = 2 % (design effect)

n0  =  164.64      n   =   157,5 x  2 (deef) = 314  

Required Information and Variables

It was necessary to include in our survey forms questions that supplied information on certain costs.

Calculation of time and opportunity loss Costs

For the monetary representation of this type of cost we carried out the following calculations: salary average for working women; calculation of the cost of one minute, in pesos; and application of the obtained results to calculate the travel and waiting and consultation time spent by these women and their companions.

Instrument

The questionnaire was first validated by experts and then by experience through use in a pilot group of 30 women that attended prenatal care consultations in the hospital and polyclinics of the municipalities studied.

Information Gathering

The questionnaire was applied, basically by the main researcher of the "women’s expenses study," who carried out interviews with pregnant women after their consultation or other relevant activities within the polyclinic, hospital or clinic.

Research ethics were observed in the program’s effectiveness assessment. All women who were eligible received detailed information on the study and were asked to sign an informed consent. In the case of the interview, they all were asked if they were willing to answer the questions, and were informed of the confidentiality of the information given, as well as of the purpose for which it was going to be used. Only if they agreed, the interview was conducted. If the husband accompanied the pregnant woman, his informed consent was also required.

Data Processing

The information gathered in the 340 survey forms was introduced into a database designed using the EPI-INFO software. Several visual revisions of the information were carried out and then were introduced in the data bank. Several revisions were made of all the questions to all the women, with the purpose of identifying "lost values."  Subsequently, we proceeded to make cross tables to verify data incongruence. When any discrepancy was found, the original survey form was reviewed and data introduction errors were corrected. Finally, all the information was "clean" and ready to be included in output tables.

Data Analysis and Interpretation

Descriptive Analysis: The data on expenses gathered in the survey forms, was tabulated and analyzed, per woman and per polyclinic. We also tabulated hospital expenses per group. In the analysis and interpretation of the data, we used absolute frequencies, percents, the mean, and the standard deviation. In our analysis it was necessary to roughly calculate the values of some variables, including the time cost for each pregnant woman.

Loss Assessment: The variables for which we considered that the patient’s expenses were significant, were identified, and validated using alternative values. Then we considered the implications of these estimates for the solidness and generalization of our conclusions for the groups studied.

Results

This study was conducted in three municipalities of the City of Havana. They were selected based on the fact that the women who belong to these healthcare centers are seen at the America Arias Hospital for childbirth care or other pregnancy-related proceedings unavailable at family doctor offices or in the polyclinics. This distribution of services results from Cuba’s healthcare system’s characteristics: uniqueness, comprehensiveness, and regionalization.

Half of the women in both groups did not have children. In the control group, 49.4% were in their first pregnancy; and 48.8% in the intervention group.

Two of the polyclinics had the women with the higher average of children, 0.80, and 0.83, respectively. In none of the polyclinics, the average was one child per woman. The lowest average was 0.35 children per woman. This information was useful to find out which women felt the highest economic burden regarding the advent of another  family member—a fact that was reported by 9.4% of the women interviewed. The data concerning the average amount of children per woman was not useful to formulate conclusions regarding fertility, nor was it among our aims.

The majority of women were in the age group 25 to 29 years. No statistically significant difference was found regarding the ages of the women in the groups studied.

As to pregnancy in women under 20 years of age, the figures found were below the expected standard for the year 2000 (15%).14  Although this indicator does not contribute conclusive data for the total of pregnant women in healthcare units studied, it is important for studying the institutional costs of the program, considering the additional care required in this type of pregnancy.

We also intended to verify the quantity of prenatal consultations received by each pregnant woman, according to the group to which they belonged (control or intervention). It is known that only four consultations were scheduled for women in the intervention group, following their incorporation to the program. We found that, except in one polyclinic, in which the average number of consultations was three, the average of consultations in the rest of the women in the intervention group was over five.  

This finding suggests that if an interview had been scheduled with these pregnant women after delivery, the number of doctor’s visits per woman, even in intervention polyclinics, would have been higher than the one established in the program.

The results of mean value comparisons for both groups, based on the data annotated on the women’s follow-up cards, were 6.28 for the control group, and 5.33 for the intervention group (t=2.3 and p=0.01). This represents a statistically significant difference—a result we expected. Furthermore, the mean value comparison for the number of doctor’s consultations referred to by the pregnant women, for both groups, showed statistically significant differences. An explanation could be that although these doctor’s visits are scheduled with an established frequency, pregnant women are free to visit their doctor at any time, in which case such consultations are not noted on the woman’s card, although they do keep mental track of it. This could explain the differences between the data on the pregnant women’s cards and what they reported.

As to the means of transportation used to get to the doctor’s office, 94.7% of those in the control group, and 93.55% of those in the intervention group, went by foot. Family doctor offices are widely distributed in each community. Regarding the time spent to get to the healthcare unit, it was higher in women whom we interviewed in the hospital than in those interviewed in the polyclinics. This is explained by the fact that polyclinics are closer to the patient’s house than hospitals are.

The difference in travel time between women of different polyclinics is explained by the fact that at times the specialist was sick or absent and the patient was obliged to go to another polyclinic.

Mean value and standard deviation concerning waiting time and consultation time, for both groups, as well as the results of comparisons among them, showed no statistically significant differences. Moreover, no significant difference was found regarding the total amount of time used by each pregnant women, including travel time and consultation time. These results show homogeneity between the time spent in medical procedures and in traveling, for all the units studied.

We expected to find differences between the time spent at the first consultation as compared to that at the subsequent ones. The data shows the difference existing between waiting time and consultation time on the first visit as compared with subsequent ones, in the control group.

However it was not the same for the intervention group. During the first visit the doctor spent time in completing forms and explaining details but in the following visits took up time in a detailed exam of the established parameters to evaluate the progress of the pregnant woman to detect if she was at risk and to give her health information knowing that the contacts with members of this group were limited in relation to the control group.

Another expense we measured with great interest was the opportunity cost. For this, we gathered information on whether the pregnant women liked to carry out other activities before going back home after consultation. We found that 25% of the women in the control group combined their consultations with other activities. In the intervention group only 18% did so. Opportunity cost will be dealt with again later in another analysis.

Although the values obtained may seem low, if we take other things into consideration, they may not. For instance, a woman who lives very near her doctor’s office does not need to make adjustments to take advantage of her trip. In our study we found that there were women who lived in the same apartment building where their family doctor’s office is located , or next door. Even, one of them only had to take the elevator to get to the ground floor, where her doctor’s office is.

Women who needed to travel longer distances to see their doctors, especially those who had to use a means of transportation, usually felt they could “take advantage of that opportunity” to do some errands in a place nearby the doctor’s office, especially considering public transport difficulties in Havana. The collateral activity more frequently reported was going shopping.

Time is a very useful indicator in cost calculations. An excessive waste of time has a negative impact on the possibility of carrying out collateral activities, as well as on loss of salary. For health providers, the time saved in a program can be used on another one. For our study, time was measured in two categories: “travel time” and “waiting and consultation time.”  Since interviews were carried out after doctor’s visits, it was difficult to know how much time had been spent waiting and how much actually seeing the doctor. Therefore, we combined them into one category.

In our study, opportunity cost is considered from the point of view that if women reduce the number of consultations, they will have more time to spend on other activities. Therefore, we asked our study subjects what they would have done if they had not seen their doctor that day. In this case we found that 50.59% of the women in the intervention group, and 55.88% in the control group, responded they would have been “doing nothing.”  16.4% of women in the intervention group, and 24.1% of those in the control group responded that they would have been doing household chores.

The percentage of these women who responded that they would have been working at their jobs was 14.7% for the intervention group and 11.7% for the control group. This question was asked to find out whether working women were on maternity leave at that point of their pregnancy, mainly those in the last weeks of their pregnancy. There were 8 women in this situation.  An interesting fact is that 61.2% of the women were not workers, while 38.8% of them worked. That is, at least 40% of the women studied were workers.

It is important to highlight that researchers who try to find out about people’s income are usually confronted with laconic or evasive answers, or no answer. It happens all over the world, and Cuba is no exception.

To identify expenses related with doctor’s visits, data of major interest included the purchase of medications. It is one among the several possible types of expense, in absolute terms, resulting from attending prenatal exams. Comparisons regarding medication costs between the two groups studied (control and intervention) showed that those in the intervention group spent less money on medications, almost half of what the ones in the control group spent. This can be dependent upon the women selected for each group.

This also varied among the polyclinics. A control group reported more doctor’s visits on the pregnant women’s initiative. The association between the number of visits and the medications prescribed coincided in this polyclinic.

In general, it is possible that this behavior results from the fact that the WHO’s intervention research methodology establishes that if any of the women in the intervention group acquires a disease for which she has to be included in a risk group, has to leave the program; although this was not so for the control group, who could remain in the program, since the number of doctor’s visits was not affected. Particularly in Cuba, the Obstetrics Procedure Manual, establishes that pregnant women should attend as many follow-up consultations as are necessary.15

It is also necessary to comment that one third of the women who reported receiving prescriptions for medications at their doctor’s visit stated that they were for the treatment of vaginal infections—a disorder for which women were not required to leave the study.

We calculated the mean and the standard deviation for absolute values and, based on the results obtained, we calculated t and p. We found no statistically significant difference. This finding brought about various questions, such as whether women in the intervention group had been properly classified, and whether the prescription of medications was justified.

We found no significant differences for the patterns compared, although there were differences regarding the absolute values of some of the types of expenses studied. An important fact is observed: prenatal care for pregnant women with no risks does not bring about enormous expenses. Moreover, it is practically without expense for Cuban women.

Opportunity cost, in spite of being related to collateral activities, can also be calculated using an economic representation of time. For this, we found the way of doing it in our research methodology. Following are the results obtained:

Regarding the monetary calculation of opportunity cost for travel time and waiting and consultation time spent by pregnant women and their companions, we found that waiting and consultation time is twice as much in women who had a companion and who waited for them, than in those who did not. In this case, in which such time was almost one hour, healthcare providers in the health areas studied have to analyze the possibility of  examing the existing breaches in the implementation of actions and procedures, which make pregnant women wait.

Although we decided to allot a monetary value to some of the opportunity costs studied, some specialists affirm16 that sometimes, for this type of time-related costs, it is not the best way of expressing the opportunity cost in a health service cost assessment. This is due to the fact that it would be more evident if we said that the time unnecessarily used on an activity in a certain program could have been devoted to another program.

In the case of women who reported that if they had not have been at the consultation they would have been doing something else, it is obvious that time is being used on doing something, which can sacrifice another activity.

Time and opportunity loss Assessment 

This assessment was carried out using the two variables we considered to be the most sensitive ones: “cost of transportation” and “waiting and consultation time.”  Regarding the cost of transportation, we considered three possibilities: (a) that all women had gone to their consultations by foot, (b) that all women had used public transport to go to their consultations, and (c) that all women had used private taxies .

In Cuba, the existence of polyclinics in every neighborhood and of family doctor’s offices in every community, has brought health services closer to the population. As a result, the alternative of going to consultation by foot has become a reality. If a service organization decided to consider the possibility of having consultations at places that have to be reached by public transportation, this alternative should be carefully evaluated, keeping in mind the current availability of transportation and the anxiety this brings about, rather than the analysis of the monetary cost for the program.

For the loss assessment regarding waiting and consultation time, we considered two possibilities: (a) that waiting time had been 10 minutes and consultation (examination) time 30 minutes—a minimum of 40 minutes, and (b) that waiting time had been one hour and consultation time 30 minutes—a total of 1 hour and 30 minutes per women.

For the control group, waiting and consultation time was 59 minutes, if the alternative of adjusting the pace of service to a minimum amount of time with the purpose of reducing waiting time is applied.  Time for this group still has a reserve potentiality of 19.2 minutes, and 20 minutes for the intervention group.

If the time had been 1 and a half hours, the time for the control group would have increased up to 31 minutes, and 30 minutes for the intervention group. In both cases, the increase is almost the same, given the homogeneity of this variable.

For the healthcare system, the analysis of these alternatives should be useful, given the possibility of identifying existing breaches of the time wasted waiting to see the doctor. Loss assessments give more credibility to the results obtained, since they presuppose objectivity.

Conclusions

Pocket expenses for doctor’s visits by pregnant women in the two groups studied showed no statistically significant difference, demonstrating the accessibility of health services. The average time used by pregnant women per visit was approximately one hour; and no statistically significant difference was found between the two groups. If existing breaches are solved, consultation time and travel time can be reduced. The distance between pregnant women’s home and their family doctor’s office does not make them feel the need to take advantage of their trip to carry out collateral activities.

No variation was found for each group concerning the pregnant women’s expenses regarding attendance at follow-up consultations; therefore, in each program this cost will increase with the number of doctor’s visits. This shows how convenient it is, from pregnant women’s point of view, to apply the new program, provided its effectiveness is proven. In the case of opportunity cost savings, it will be beneficial both for pregnant women and for the healthcare system.

References