Giving birth at a health-care facility in rural China: is it affordable for the poor?

Objective To investigate changes in the expenditure of giving birth in health-care facilities in rural China during 1998-2007, to examine the financial burden on households, particularly poor ones, and to identify factors associated with out-of-pocket expenditure. Methods Cross-sectional data on births between 1998 and 2007 were obtained from national household surveys conducted in 2003 and 2008. Descriptive statistics and log-linear models were used to identify factors associated with out-of-pocket expenditure on delivery. Findings During 1998-2007, the proportion of facility-based deliveries increased from 55% to 90%. In 2007, 60% of births occurred at county-level or higher-level facilities. The Caesarean delivery rate increased from 6% to 26%. Total expenditure on a facility-based delivery increased by 152%, with a marked rise from 2002 onwards with the introduction of the New Cooperative Medical Scheme. In 2007, out-of-pocket expenditure on a facility-based delivery equalled 13% of the mean annual household income for low-income households. This proportion had decreased from 18% in 2002 and differences between income groups had narrowed. Regression models showed that Caesarean delivery and delivery at a higher-level facility were associated with higher expenditure in 2007. The New Cooperative Medical Scheme was associated with lower out-of-pocket expenditure on Caesarean delivery but not on vaginal delivery. Conclusion Expenditure on facility-based delivery greatly increased in rural China over 1998-2007 because of greater use of higher-level facilities, more Caesarean deliveries and the introduction of the New Cooperative Medical Scheme. The financial burden on the rural poor remained high.