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Background: In the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care. Despite the risk of catastrophic expenditures (CE), 94% of births in Lubumbashi are attended by skilled personnel. We aimed to identify risk factors for CE associated with obstetric and neonatal care in this setting, to document coping mechanisms employed by households to pay the price of care, and to identify consequences of CE on households., Methods: We used mixed methods and conducted both a cross-sectional study and a phenomenological study of women who delivered at 92 health care facilities in all 11 health zones of Lubumbashi. In April and May 2015 we followed 1,627 women and collected data on their health care and household expenses to determine whether they experienced CE, defined as payments that reached or exceeded 40% of a household's capacity to pay. Two months after discharge, we conducted semi-structured interviews with 58 women at their homes to assess the consequences of CE., Results: In all, 261 of 1,627 (16.0%) women experienced CE. Whether a woman or her infant experienced complications was an important contributor to her risk of CE; poverty, younger age, being unmarried, and delivering in a parastatal facility or with more highly trained personnel also increased risk. Among a subset of women with CE interviewed 2 months after discharge, those who were in debt or who had lost their trading income or goods were unable to pay their rent, their children's school fees, or were obliged to reduce food consumption in the household; some had become victims of mistreatment such as verbal abuse, disputes with in-laws, denial of paternity, abandonment by partners, financial deprivation, even divorce., Conclusions: We found a higher proportion of CE than previously reported in the DRC or in other urban settings in Africa. We suggest that the government and funders in DRC support initiatives to put in place mutual-aid health risk pools and health insurance and introduce and institutionalize free maternal and infant care. We further suggest that the government ensure decent and regular payment of providers and improve the financing and functioning of health care facilities to improve the quality of care and alleviate the burden on users.

Objective: In the Democratic Republic of the Congo, insufficient state financing of the health system produced weak progress toward targets of Millennium Development Goals 4 and 5. In Lubumbashi, almost all women pay out-of-pocket for obstetric and neonatal care. As no standard pricing system has been implemented, there is great variation in payments related to childbirth between health facilities and even within the same facility. This work investigates the determinants of this variation., Methods: We conducted a cross-sectional study including women from admission through discharge at 92 maternity wards in Lubumbashi in March 2014. The women's payments were collected and validated by triangulating interviews of new mothers and nurses with document review. We studied payments related to delivery from the perspective of women delivering. The total was the sum of the payments linked to seeking and accessing care and transport of the woman and companion. The determinants were assessed by multilevel regression., Results: Median payments for delivery varied by type: for an uncomplicated vaginal delivery, US$45 (range, US$17-260); for a complicated vaginal delivery US$60 (US$16-304); and for a Cesarean section, US$338 (US$163-782). Vaginal delivery was more expensive at health centers than in general referral hospitals or polyclinics. Cesarean sections done in corporate polyclinics and hospitals were more expensive than those done in the general referral hospitals. Referral of delivering women, use of more highly trained personnel, and a longer stay in the maternity unit contributed to higher expenses. A vaginal delivery in the private sector was more cost-effective than in the public sector., Conclusion: To guarantee universal coverage of high-quality care, we suggest that the government and funders in DRC support health insurance and risk pool initiatives, and introduce and institutionalize free mother and infant care., Competing Interests: The authors have declared that no competing interests exist.

Background: While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi., Methods: This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards., Results: The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one. In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities., Conclusion: Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.