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

Author

Listed:
  • Marion Ravit

    (CEPED - UMR_D 196 - Centre population et développement - IRD - Institut de Recherche pour le Développement - UPD5 - Université Paris Descartes - Paris 5)

  • Martine Audibert

    (CERDI - Centre d'Études et de Recherches sur le Développement International - UCA [2017-2020] - Université Clermont Auvergne [2017-2020] - CNRS - Centre National de la Recherche Scientifique)

  • Valery Ridde

    (Ecole de Santé Publique [Montreal, Canada] - UdeM - Université de Montréal, CEPED - UMR_D 196 - Centre population et développement - IRD - Institut de Recherche pour le Développement - UPCité - Université Paris Cité)

  • Myriam de Loenzien

    (CEPED - UMR_D 196 - Centre population et développement - IRD - Institut de Recherche pour le Développement - UPD5 - Université Paris Descartes - Paris 5)

  • Clémence Schantz

    (CEPED - UMR_D 196 - Centre population et développement - IRD - Institut de Recherche pour le Développement - UPD5 - Université Paris Descartes - Paris 5)

  • Alexandre Dumont

    (CEPED - UMR_D 196 - Centre population et développement - IRD - Institut de Recherche pour le Développement - UPD5 - Université Paris Descartes - Paris 5)

Abstract

Introduction Mali and Benin introduced a user feeexemption policy focused on caesarean sections in 2005and 2009, respectively. The objective of this study is toassess the impact of this policy on service utilisation andneonatal outcomes. We focus specifically on whether thepolicy differentially impacts women by education level,zone of residence and wealth quintile of the household.Methods We use a difference-in-differences approachusing two other western African countries with no feeexemption policies as the comparison group (Cameroonand Nigeria). Data were extracted from Demographic andHealth Surveys over four periods between the early 1990sand the early 2000s. We assess the impact of the policy onthree outcomes: caesarean delivery, facility-based deliveryand neonatal mortality.Results We analyse 99 800 childbirths. The freecaesarean policy had a positive impact on caesareansection rates (adjusted OR=1.36 (95% CI 1.11 to 1.66;P≤0.01), particularly in non-educated women (adjustedOR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those livingin 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). Thepolicy contributes to the increase in the proportion offacility-based delivery (adjusted OR=1.68; 95% CI 1.48 to1.89; P≤0.001) and may also contribute to the decreaseof neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to0.85; P≤0.001).Conclusion This study is the first to evaluate the impactof a user fee exemption policy focused on caesareansections on maternal and child health outcomes withrobust methods. It provides evidence that eliminating feesfor caesareans benefits both women and neonates in sub-Saharan countries.

Suggested Citation

  • Marion Ravit & Martine Audibert & Valery Ridde & Myriam de Loenzien & Clémence Schantz & Alexandre Dumont, 2018. "Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa," Post-Print hal-01682919, HAL.
    • Handle: RePEc:hal:journl:hal-01682919
    DOI: 10.1136/bmjgh-2017-000558
    Note: View the original document on HAL open archive server: https://hal.science/hal-01682919
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    References listed on IDEAS

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    1. Paul J. Gertler & Sebastian Martinez & Patrick Premand & Laura B. Rawlings & Christel M. J. Vermeersch, 2016. "Impact Evaluation in Practice, Second Edition," World Bank Publications - Books, The World Bank Group, number 25030, December.
    2. Cristina Cirillo & Raquel Tebaldi, 2016. "Social Protection in Africa: inventory of non-contributory programmes," Joint Publications 004, International Policy Centre for Inclusive Growth.
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    1. Martine Audibert & Emmanuel Bonnet & Alexandre Dumont & A. N'Landu & Bertille Raffalli & Andrainolo Ravalihasy & M. Ravit & Valéry Ridde & Flore Apolline Roy, 2019. "Impacts du forfait obstétrical en Mauritanie sur l'offre, le recours et les inégalités d'accès aux soins : synthèse du rapport final," Post-Print hal-03834803, HAL.

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