Maternal Care Costs Reached Catastrophic Levels for Most Women Needing Surgery
Direct patient charges for maternity services at two faith-based hospitals in rural southern Madagascar frequently crossed levels that would exhaust a household budget. In this secondary analysis of program data, women using maternal healthcare services between 1 March 2019 and 7 September 2020 faced a striking burden of out-of-pocket spending, with the highest costs concentrated among those who required surgical care, most often caesarean section. The pattern is clinically familiar and economically severe: uncomplicated delivery may be relatively affordable, but obstetric complications can transform a birth into a financial shock for an entire family.
The analysis included 957 women, although the cost calculations were based on invoice and record data available for 890 women. Using regional average annual household consumption as the benchmark, investigators defined catastrophic health expenditure at two thresholds: 10% and 25% of household consumption. At the 10% threshold, 486 of 890 women, or 54.6%, crossed into catastrophic spending. At the stricter 25% threshold, 366 of 890 women, or 41.1%, still exceeded the limit. Those proportions are not marginal. They indicate that for a large share of families, routine access to maternal care was financially destabilizing rather than protective.
The burden was even more severe when complications required operative management. Among women who underwent surgical care, almost all experienced catastrophic expenditure: 279 of 280 women, or 99.6%, crossed the 10% threshold, and the same proportion crossed the 25% threshold. In practical terms, surgery did not merely increase cost; it nearly guaranteed financial catastrophe in this setting. Because caesarean delivery often carries additional expenses for operating theatre use, anesthesia, medications, supplies, inpatient monitoring, and longer length of stay, the result is biologically and logistically predictable. Obstetric surgery saves lives, but in systems with heavy out-of-pocket payment, it can also expose women to expenses that exceed what households can absorb.
The contrast with spontaneous delivery was stark. Among women who delivered spontaneously, the rate of catastrophic health expenditure at the 10% threshold was 5.7% (14/247). Even this lower figure is important, because it shows that uncomplicated birth is not cost-free for many families. Transport, accommodation, clinical fees, and other direct payments can still push vulnerable households over the edge, especially in rural regions where access to care often requires travel and time away from work. Yet the distance between spontaneous delivery and surgical care is enormous, and it reveals how obstetric complications can convert a medical necessity into a financial emergency.
Out-of-Pocket Payment Can Suppress Care-Seeking When Obstetric Risk Rises
The setting matters. These were two faith-based, secondary-level hospitals serving rural communities in southern Madagascar, not tertiary referral centers with broad public subsidy or universal insurance coverage. In that context, patient invoices become more than administrative records. They are a direct measure of how health system financing shapes whether women can seek care early, return for treatment when complications develop, or accept referral for surgery when it is urgently needed. When the expected cost of care is high, families may delay presentation until disease is advanced, and obstetric delay is especially dangerous because hemorrhage, obstructed labor, infection, and fetal distress can evolve quickly.
This financing structure also has implications for health equity. Maternal complications do not fall evenly across households, and the ability to pay often determines the timing and location of care. Faith-based hospitals may provide essential services in rural regions where alternatives are limited, yet the financial model still matters. If women know that surgical delivery is likely to impose catastrophic spending, they may avoid seeking care until the last possible moment, even when prompt intervention would reduce maternal and neonatal risk. The result is a cycle in which higher clinical acuity and higher financial burden reinforce each other.
The data also suggest that financial risk protection policies cannot stop at public facilities alone. Any strategy aimed at lowering maternal mortality or improving universal health coverage in Madagascar has to account for where women actually receive care. Faith-based hospitals are part of the obstetric safety net in rural areas, and excluding them from reimbursement or subsidy programs leaves a gap precisely where complications are most expensive. Since surgical care accounted for nearly universal catastrophic expenditure, targeted support for caesarean delivery and complication management would likely have the greatest immediate impact on household financial protection.
The 10% and 25% thresholds used in the analysis help frame the severity of the burden, but the lived consequence is simpler than any threshold calculation. A family that must pay for maternal surgery in this setting may be forced to borrow money, sell assets, or postpone other essential spending. Those downstream effects can compound food insecurity, reduce the ability to seek future healthcare, and deepen poverty after what should have been a normal life event.
Why Surgical Birth Drove the Economic Shock
Obstetric surgery is a high-resource intervention even in well-funded systems. It requires equipment, trained personnel, medications, postoperative observation, and the capacity to manage complications. In lower-resource rural hospitals, each of those components can translate into a charge on the patient invoice. When payments are made directly at the point of care, there is little buffering between the clinical need and the household balance sheet.
The findings fit a broader public health reality: maternal health financing is not only about whether services exist, but whether women can actually use them without disastrous cost. Universal coverage depends on more than physical availability of obstetric care. It depends on a financing model that protects families from the expenses generated by routine delivery and by the unpredictable complications that make maternal care life-saving. In this study, direct payments at faith-based hospitals consistently failed that test for women requiring surgery.
The analysis was limited to direct patient costs captured through invoices and records, and it focused on two rural hospitals within one region. Even so, the signal is hard to ignore. Catastrophic health expenditure was common overall, and it was overwhelming in the surgical subgroup. For policymakers, the most actionable implication is straightforward: maternal financial protection in Madagascar must include faith-based hospitals, especially for women whose pregnancies end in operative delivery or other complications.