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Research
Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa
  1. Marion Ravit1,
  2. Martine Audibert2,
  3. Valéry Ridde3,4,
  4. Myriam de Loenzien1,
  5. Clémence Schantz1,
  6. Alexandre Dumont1
  1. 1 Centre Population et Développement (Ceped), IRD, INSERM, Université Paris Descartes, Paris, France
  2. 2 CNRS, CERDI, Université Clermont Auvergne, Clermont-Ferrand, France
  3. 3 Institut de Recherche en Santé Publique de Montréal (IRSPUM), Montreal, Quebec, Canada
  4. 4 Ecole de santé publique de Montréal (ESPUM), Montreal, Quebec, Canada
  1. Correspondence to Marion Ravit, Centre Population et Développement (Ceped), IRD, INSERM Université Paris Descartes Paris France ; marion.ravit{at}gmail.com

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.

  • maternal health
  • health systems evaluation
  • obstetrics
  • public health

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000558

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors MR and AD designed the study and prepared the first draft of the manuscript. MR performed statistical analyses. All authors contributed to the data interpretation and the revisions of the manuscript and provided approval of the final submission. MR and AD are the guarantors.

    • Funding MR has a PhD grant from the French School of Public Health (EHESP). VR holds a CIHR-funded Research Chair in Applied Public Health (CPP-137901).

    • 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.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.