Do free caesarean section policies increase inequalities in Benin and Mali?

Abstract

Background: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced.

Methods: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries.

Results: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present.

Conclusions: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Keywords: Benin; Caesarean section; Health equity; Health policy; Low-income countries; Mali; Maternal health; User fees.

Fig. 1

Dates of birth data available by country and survey. DHS surveys (http://dhsprogramme.com/). C-section = caesarean section. In Benin: Period 1 = September 1996 to November 2001; Period 2 = December 2001 to March 2009; and Period 3 = April 2009 to March 2012. In Mali: Period 1 = February 1996 to May 2001; Period 2 = June 2001 to December 2004; and Period 3 = January 2005 to January 2013

Fig. 2

Trends in C-section rates in Benin and Mali by category and period. DHS surveys (http://dhsprogram.com/). CS = caesarean section. In Benin: Period 1 = September 1996 to November 2001; Period 2 = December 2001 to March 2009; and Period 3 = April 2009 to March 2012. In Mali: Period 1 = February 1996 to May 2001; Period 2 = June 2001 to December 2004; and Period 3 = January 2005 to January 2013

Fig. 3

Concentration curves for C-section and facility based delivery in Mali and Benin between the late 1990s and early 2010s. FBD: facility based delivery In Benin: Period 1 = September 1996 to November 2001; Period 2 = December 2001 to March 2009; and Period 3 = April 2009 to March 2012. In Mali: Period 1 = February 1996 to May 2001; Period 2 = June 2001 to December 2004; and Period 3 = January 2005 to January 2013