Topic:

Determinants and experiences of out of pocket and health insurance payments for

antenatal services among pregnant women in selected general hospitals in Lagos state
Chapter 1

Introduction

Operational definition of terms:

Out of Pocket Payment (OOP): Out of Pocket Payment (OOP)refers to all payments made

directly by the pregnant woman for ANC and delivery services. It includes consultation fees,

medicines, hospital/antenatal clinic charges and other medical expenditure.

Health Insurance: Health insurance refers to financial protection against the cost of medical care

arising from attending ANC and using delivery services. These include government-based health

insurance (Social health Insurance Scheme – popularly known as NHIS

Literature Review

Maternal health is the wellbeing of women before, during pregnancy, at childbirth, and post-

delivery. It entails the provision of pregnancy-related services to women, and this includes

Antenatal Care (ANC), Delivery Care, and Postnatal Care (PNC) (Sanni et al., 2013). Antenatal

Care (ANC) helps to identify risks in pregnancy and to manage pregnancy related diseases as

well as educate prospective mothers on proper health practices during pregnancy (KAAF

Maternity, 2024). It helps to optimize their health and promote positive pregnancy outcomes for

the mothers and newborns. These services encompass a range of healthcare assessments,

screening for potential risk factors, vaccinations, nutritional supplementation (such as folic acid

and iron). Antenatal care will have at least 8-10 visits (KAAF Maternity, 2024). However, due to

financial barriers, few expectant mothers attend the recommended eight or more visits advised by

the World Health Organization (Ogbonna and Zarihun, 2026). Pregnant women are at risk of

developing complications such as pregnancy-induced hypertension, anemia, severe persistent

nausea, vomiting, and gestational diabetes (Agboaye et al., 2022).

Access to maternal care services remains a major developmental challenge around the world, and

in sub-Saharan Africa in particular, it has been documented that financial challenge is a barrier to

accessible healthcare services for the vulnerable, particularly women (Sanni et al., 2013). In

Nigeria, the consistently high maternal mortality rates (MMR) are closely associated with

inadequate prenatal care, whether as a result of low attendance or subpar service quality

(Ogbonna and Zarihun, 2026). As a result, the maternal mortality rate (MMR) remains unacceptably

high while ANC rates are significantly below the WHO recommendations. For example, Nigeria had an

MMR of 993 deaths per 100,000 live births in 2023, according to a World Bank (2023) estimate. This
figure is substantially greater than the global target outlined in the Sustainable Development Goals

(SDGs), which aims to cut MMR in 2030 to less than 70 deaths per 100,000 live births. Among the many

other factors that have been found in prior research to be the main cause of maternal mortality, lack of

or insufficient ANC is one of the key variables in the incidence of maternal death (Mahmood et al., 2021;

Motappa et al., 2024).

One of the recommended interventions for attaining optimal maternal and child healthcare is the

provision of antenatal care. The WHO states that “Every pregnant woman should have at least four visits

for antenatal care during which they receive interventions such as tetanus toxoid and malaria

prevention” (NPCICF, 2019). However, this recommended provision of ANC remains largely underfunded

in most developing nations, including the sub-Saharan African states (Okedo-Alex et al., 2019)

The United Nations reported in 2019 that an estimated 1.9 million families in Africa spend more

than 40% of their non-food, out-of-pocket expenses on Maternal Health Services each year,

which makes the cost of childbirth services catastrophic. When families cut corners to reduce

maternal health care costs, both mothers and their babies suffer. (Esan et al., 2023). The high

cost and effect of out-of-pocket payments for health care on households in developing countries

such as Nigeria have led to the use of community-based health insurance (CBHI) as a viable

alternative for health care funding (Agbo et al., 2019).

Notably, Nigeria bears a disproportionately high burden of global maternal and neonatal

mortalities, accounting for over 28% of maternal deaths (> 82,000 in 2020) and ranking second

in the absolute number of neonatal deaths with over 270,000 reported deaths in 2019 (Adewuyi

et al., 2024)

A World Health Organisation (2022) document publication notes that over 50 per cent of the

global population faces barriers in accessing vital healthcare services, with disparities in both
affordability and availability of such healthcare services persisting worldwide. The World Health

Organization (WHO) report of 2015 revealed that over 90 million individuals faced financial

difficulties due to paying for healthcare expenses out of their pockets, about 150 million people

suffer financial catastrophe because of out-of-pocket expenditure on health services (WHO,

2016). Between 2000 and 2022, impoverishing out-of-pocket (OOP) health spending declined

mainly because fewer people were further impoverished by health payments (falling from 26.6%

to 18.6%), while the share pushed into poverty remained largely unchanged at 1.9–2.8%.

However, poverty reduction occurred faster than reductions in impoverishing OOP spending,

resulting in a growing concentration of people pushed into or further into poverty by health costs

among those already poor. The proportion of the population not covered by essential health

services decreased by about 20% between 2000 and 2023, indicating that in 2023, about 4.6

billion people were not fully covered. (WHO, 2025)

A major number of people who are driven into poverty reside in developing countries in

Sub Saharan Africa (SSA) with weak health care systems and lack of health insurance

schemes (Carrin et al., 2005; World Health Organization, 2005).

The burgeoning recognition and paramount importance of health in the domains of human well-

being and economic progress is gaining momentum on a global scale. Consequently, nations are

augmenting their commitments and allocations towards initiatives and systemic modifications

that aim to ameliorate health outcomes and advance societal progress (Health Policy

Commission, 2023).

Universal Health Coverage (UHC) can simply be described as access to quality healthcare free of

financial burden. UHC is defined as health coverage in which individuals and communities

receive health services needed without suffering financial hardship.

universal. For example, countries such as China which has a population of over 1.3 billion

people ensures health insurance coverage for its populace. Several countries including the USA,

Taiwan, and France have all instituted national health insurance. In sub-Saharan Africa (SSA),

countries like Ghana and Nigeria have health insurance (Agboagye et al., 2022).

While worldwide efforts toward Universal Health Coverage (UHC) have seen significant

momentum, sub-Saharan Africa remains a notable exception. According to the WHO and World

Bank (2023), the global service coverage index rose from 54 to 71 between 2000 and 2021;

however, the index for sub-Saharan Africa only reached 43 during that timeframe. Consequently,

more than 50% of the region's inhabitants still lack access to fundamental healthcare services

(Porgo et. al., 2024),

In 2021, Nigeria’s UHC service coverage index stood at 38—well below the regional average

and lagging behind several peer countries, including Ghana, Senegal, and Côte d’Ivoire (WHO,

2025; Population Reference Bureau, 2025). This low level of coverage implies that a large share

of the population continues to face barriers in accessing essential health services (Yakoob and

Salman, 2026).

HealthCare Financing

Health care financing involves the means by "funds are generated, allocated and utilized for

health care. The functions of health systems financing include revenue collection, pooling of

resources and purchase of services (Abdus-salam et al., 2021). It consists of tax-revenue

financing, OOP payments, donor funding and health insurance.

they need. One of the primary ways this is achieved is through payments made by those utilizing

the services. Healthcare financing is an important component of birth preparedness and

complication readiness. In obstetric emergency, lack of adequate funds for healthcare plays a

vital role in all the level of delays contributing to maternal mortality (Pacgnella et al., 2014)

The proportion of the population not covered by essential health services decreased by about

20% between 2000 and 2023, indicating that in 2023, about 4.6 billion people were not fully

covered. (WHO 2025)

In 2022, 2.1 billion people faced financial hardship, including 1.6 billion people living in poverty

or pushed deeper into it due to out-of-pocket health expenses. This equates to 26% of the

population, a drop from 34% in 2000 (WHO 2025). According to the World Bank, OOP

payments for health services determine whether a household would end up being poor or not.

Most low- and middle-income countries (LMICs) including Nigeria are battling the problem of

poverty (Aregbesola and Khan., 2010). Financial protection ensures that households do not face

financial hardship and become impoverished as a result of seeking healthcare. Current statistics

indicate less than 5% of Nigerians are enrolled in NHIS, while 70% still finance their healthcare

independently. Major issues include inefficient service delivery, inadequate healthcare

infrastructure, and poor resource management, leading to substandard care quality (Eze et al.,

2024)

Financial hardship from health spending also varies by age, household composition, and place of

residence – rural populations experience a median hardship rate 14% higher than urban
populations, and people in multigenerational households, especially those with adults over 60,

face greater financial strain. (WHO, 2025)

The World Health Organization continues to emphasize the critical role of health financing in

strengthening health systems and improving overall human wellbeing, financial inclusion in

healthcare remains relatively inadequate in Sub-Saharan countries, Nigeria included (Dele-Dada

et al., 2024)

The National Health Insurance Scheme

The National Health Insurance Scheme (NHIS) of Nigeria was established and the objective of

the scheme was to enhance access to quality healthcare for all and minimize catastrophic health

expenditures. However, since inception, the population coverage has been less than ten percent

of the total. The development of health insurance has been a gradual process marked by various

initiatives over the years, albeit with their positives and setbacks (Eze et al., 2024). In 1988, the

then health minister, Professor Olikoye Ransome Kuti, appointed a committee that recommended

a template for the NHIS. As a result of administrative clumsiness, the law that established the

scheme was signed in May, 1999 but it became operational in 2005. The NHIS was officially

launched in 2005 with the goal of achieving universal coverage for all Nigerians by 2015. (Eze et

al., 2024). The NHIS partners with other actors in both the public and private sectors, such as

health care providers and health maintenance organizations (HMOs), in its operations (Adewole,

2025). To mitigate high out-of-pocket (OOP) health expenditures and improve healthcare access,

the Nigerian Federal Government launched the National Health Insurance Scheme (NHIS) in

2005, aimed at providing financial risk protection for households (Onyedibe et al., 2018). The

NHIS outlines objectives including universal access to quality healthcare for Nigerians,

protection of families from crippling medical expenses, containment of rising healthcare costs,
equitable distribution of healthcare expenses across income groups, even distribution of

healthcare facilities within the nation, and ensuring funds for improved services (Abiola et al.,

2019).

Despite the establishment of the NHIS, the financial burden of healthcare on Nigerian

households has continued to rise, and a significant portion of the population in the informal

sector remains excluded from the scheme. As of recent estimates, only about 5% of Nigerians

have health insurance, and 70% still finance their healthcare through out-of-pocket (OOP)

expenditure. Expenditure on health care is sufficient to tip households into poverty causing

them to forego consumption of other items that are necessary for their wellbeing such as

food or education (Agbo et al., 2019). Despite having the NHIS available, there has been a

low health insurance coverage in Nigeria which has led to impairing access to antenatal care

and prompt emergency obstetric care due to their unavailability to pay out of pocket ((Abdus-

salam et al., 2021).

Out of Pocket Payment

The World Bank defines out-of-pocket expenditures as any direct expenditure by households,

including gratuities and payments in-kind, to health practitioners and suppliers of

pharmaceuticals, therapeutic appliances, and other goods and services which primarily contribute

to the restoration or enhancement of health status (Ogundare et al., 2022). Generally, it involves

payment for healthcare services at the point of care and this accounts for the highest health

expenditure in Nigeria (Abdus-salam et al., 2021). Access to affordable, high-quality maternal

health services (MHS) is a fundamental human right of all women irrespective of their age,

residence, and socioeconomic status.

for over one-quarter (28.3%) of all estimated global maternal deaths, with approximately 8,200

maternal deaths and a maternal mortality ratio of 1,047 per 100,000 livebirths (WHO, 2023 :

Dogbanya, 2025)

Theoretical framework

Conceptual Framework
Chapter 3

3.0 Methodology

3.1 Description of the Study area

This cross-sectional study will be carried among pregnant women attending antenatal

services in selected general hospitals in Lagos state. Lagos State is located in the South-

West geopolitical zone of Nigeria. Lagos has a unique healthcare landscape characterized by

high-volume public secondary health facilities known as General Hospitals As of early 2026,

Lagos State operates approximately 30 to 31 state-owned secondary health facilities (General

Hospitals, Maternal and Child Care Centers, and specialized centers). These facilities serve a

diverse demographic, providing a rich data set of women using both National/Lagos State Health

Insurance Schemes (NHIS/LASHMA) and those paying out-of-pocket

3.2 Research Design

The mixed- approach method would be used:

Quantitative study: To identify the determinants (socio-economic factors, distance, etc.) of

payment methods.

Qualitative study: To explore the live experiences of pregnant women regarding the ease or

burden of these payments

3.3 Duration of study

The study will be done between the months of September and October, 2026.

3.4 Study population

General Hospitals in Lagos state are the target population. They consist of female adults within

the age range of 18-50 years from different ethnic, religious and cultural background. Pregnant

women at various stages of gestation (first, second, or third trimesters) who are accessing care

during the period of data collection alongside being present at the ANC clinics of the specific

selected hospitals on the days of the survey. Currently, each general hospital in Lagos state

should have about fifty women registered for antenatal services weekly.

3.5 Sample size calculation

The sample size (n) that will be used will be estimated using the single population

proportion formula:

N= (1.96)2pq
D2
Where;
n = required sample size

p = proportion of the population of pregnant women attending antenatal services in Lagos state

from previous study

q =1-p and

d = the degree of precision

For the calculation, a 95% confidence interval, a p value of 0.14, i.e, a prevalence rate of

14% from previous study by Pennap et al., (2010) and margin of error (d) set at 0.05 was used to

determine the minimum sample size required. To minimize errors arising from the likelihood of

non-compliance, 10% of the sample size was added giving a final sample size of 200.
3.6 Sample size

A total of 200 questionnaires will be administered randomly from consenting 200

Pregnant women at different selected General Hospitals in Lagos State.

3.7 Sampling Technique

Purposive Sampling: Selection of specific General Hospitals based on their high patient volume

and the availability of both NHIS/LASHMA (insurance) and OOP payment desks.

Proportionate Allocation: Assigning a specific number of questionnaires to each hospital based

on their average monthly ANC registration.

Systematic Random Sampling: Selecting every pregnant woman (e.g., every 3rd woman) on

the clinic register until the required sample size for that facility is met.

3.8 Ethical consideration

Ethical clearance will be obtained from the Babcock University Health Research Ethics

Committee (BUHREC) before the commencement of the study.

3.9 Eligibility of Subjects

3.9.1 Inclusion Criteria

 Consenting pregnant women between the ages 18-50

 Pregnant women registered and receiving ANC services at the selected hospitals

 Women who have made at least one payment (either through insurance or out-of-pocket)

for services such as registration, tests, or drugs during the current pregnancy term

3.9.2 Exclusion criteria

 Pregnant women with health challenges or complications are excluded.

 Women visiting the hospitals that are not pregnant

3.10 Consent

Informed consent will be obtained from each participant. The purpose and nature of the

study, as well as method of sample collection will be explained to them properly before

administering the questionnaire. Afterwards, participants are obliged at free will to voluntarily

complete the consent form in their own handwriting and endorse by their signatures as proof of

willingness to provide accurate data for the research.

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