ArticlePloS one2021
Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.
Article in PloS one, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 13 papers, 1 of them a synthesis that pooled it.
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Who cites it
13 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis.Bulletin of the World Health Organization · 2022Pooled it
- Assessing intervention effects on healthcare-related financial protection in low- and middle-income countries: a rapid evidence review.Health policy and planning · 2026Review
- Catastrophic health expenditure associated to bellwether surgery care in Northcentral Ethiopia.BMC surgery · 2026Observational
- Household costs, catastrophic out-of-pocket payments and impoverishment related to accessing surgical care in rural Ethiopia.PloS one · 2026Article
- Repositioning Primary Health Care in Sierra Leone: From Geographic Access to Effective Coverage.Annals of global health · 2026Article
- A Systematic Review of Government-Led Free Caesarean Section Policies in Low- and Middle-Income Countries from 2009 to 2025.Healthcare (Basel, Switzerland) · 2025Review
- Article
- Evaluating Access Improving Interventions: An Economic Evaluation of Surgical Task-Shifting for C-Sections in Sierra Leone.Applied health economics and health policy · 2025Article
- The impact of surgical task-sharing in Sierra Leone: a nationwide longitudinal observational study on surgical workforce and volume, 2012-2023.BMJ global health · 2025Observational
- Long-term maternal outcomes 5 years after cesarean section in Sierra Leone: A prospective cohort study.International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics · 2025Observational
- Exploring the concept of surgical transition: surgical activity in the light of economic development in Sierra Leone, Liberia, Ghana and India.Frontiers in surgery · 2025Article
- Inequalities in maternal healthcare use in Sierra Leone: Evidence from the 2008-2019 Demographic and Health Surveys.PloS one · 2022Article
- Access and Financial Burden for Patients Seeking Essential Surgical Care in Pakistan.Annals of global health · 2022Article
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Authors and funding
10 authors.
Funding
Abstract
backgroundUtilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI.
methodsWomen who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed.
resultsFor the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure.
conclusionMany women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.
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