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Sri Lanka provides health care service free-of-charge, including maternal health care. This study aimed to examine the magnitude of and factors associated with out-of-pocket expenditure (OOPs) during the first prenatal clinic visit by pregnant women in Anuradhapura district, Sri Lanka. Findings showed that the mean OOPs 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 free government health services had an OOPs of USD 3.49 and, thus, free maternal health care provision could significantly reduce the OOPs during the first prenatal clinic visit.