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. 2018 Jan 3;3(1):e000558.
doi: 10.1136/bmjgh-2017-000558. eCollection 2018.

Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa

Marion Ravit  1 , Martine Audibert  2 , Valéry Ridde  3   4 , Myriam de Loenzien  1 , Clémence Schantz  1 , Alexandre Dumont  1
Affiliations

Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa

Marion Ravit et al. BMJ Glob Health. .

Abstract

Introduction: Mali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household.

Methods: We use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality.

Results: We analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001).

Conclusion: This study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.

Keywords: health systems evaluation; maternal health; obstetrics; public health.

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Conflict of interest statement

Competing interests: VR has served as a consultant on the issue of user fee abolition to non-governmental organizations in West Africa. VR is a BMJ Global Health associate editor.

Figures

Figure 1
Figure 1
Flow chart for comparison countries selection. DHS, Demographic and Health Surveys.
Figure 2
Figure 2
Trends in adjusted predicted prevalence of caesarean section with 95% confidence interval by period and by country. CS, caesarean section; FBD, facility-based delivery.
See this image and copyright information in PMC

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