How Costly is the First Prenatal Clinic Visit? Analysis of Out-of-Pocket Expenditure in Rural Sri Lanka - A Country With Free Maternal Health Care

Background: This study aimed to determine the magnitude of and factors associated with out-of-pocket expenditure (OOPE) during the first prenatal clinic visit among pregnant women in Anuradhapura district, Sri Lanka, which provides free maternal healthcare. Methods: : The study design was a cross-sectional study, and the study setting was 22 Medical Officers of Health areas in Anuradhapura District, Sri Lanka. Data of 1,389 pregnant women were analyzed using descriptive statistics and non-parametric tests. Results: : The mean OOPE of the first prenatal clinic visit was USD 8.12, which accounted for 2.9% and 4.5% of the household income and expenditure, respectively. Pregnant women who used only government-free health services had an OOPE of USD 3.49. A significant correlation was recorded between household expenditure (r s =0.095, p=0.002) and the number of pregnancies (r s =-0.155, p<0.001) with OOPE. Conclusion: Despite having free maternal services, the OOPE of the first prenatal clinic visit is high in rural Sri Lanka. One-fifth of pregnant women utilize private health services, and pregnant women who used only government-free maternal health services also spend a direct medical cost.