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

Abstract

BackgroundBenin 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.MethodsWe 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.ResultsWe 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.ConclusionsUrban/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.

Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review

“…Among included studies, national legislation or policy adoption promoting the access to and utilisation of SRH services spanned the period from 1996 to 2013, with a concentration of studies conducted between 2000 and 2009 (Supplemental Figure 4). Most studies analysed SRH service utilisation from one to eight years before and one to eight years after legislation/policy adoption (23,25,27,30,31,33,38,(42)(43)(44)(45)(46)(47)(48) and between 1 and 14 years after legislation/policy adoption (26,28,29,32,34,37,40,41,(49)(50)(51)(52)(53)(54). Two studies examined service utilisation two to four years before legislation/ policy adoption at time point 1 and the same year at time point 2 (24,39).…”

“…Four other studies examined the effects of a reproductive health programme (35), performance-based financing (40), national health insurance (32), and exemption fees (32) or free health care (29) for pregnant women and lactating mothers on family planning and contraception. Five studies considered policy pertaining to caesarean sections (33,34,45,47,53). To a lesser extent, postnatal care (35,43,44,52) and PMTCT (29,39) were studied.…”

Urban–Rural Disparities of Facility-Based Childbirth in Indonesia

“…A study found that there are differences in health, access to and quality of healthcare between rural and urban areas in the United States [1] [2] [3]. Several studies in Africa and the European Union also revealed the same thing [4][5] [6] [7]. Thus it can be concluded that the disparity in health services between urban and rural areas is still a global problem.…”

How do supply- and demand-side interventions influence equity in healthcare utilisation? Evidence from maternal healthcare in Senegal

“…For instance, in the context of maternal health, Ghana introduced free facility deliveries in 2003 (Bosu et al, 2007), Senegal in 2005 (Witter et al, 2010) and Burkina Faso subsidised user fees in 2007 (Ridde et al, 2015). Mali removed user fees for only caesarean deliveries in 2005, followed by Benin andMorocco in 2009 (Dossou et al, 2018;Ravit et al, 2018;Witter et al, 2016). Evidence from these schemes show that demand-side interventions that reduce barriers to access by reducing or eliminating user fees at health facilities make healthcare more equitable as poor households are now more likely to access healthcare (Peters et al, 2008;Ridde & Morestin, 2011); albeit the poorest are still often the least likely to utilise facility-based care (Ridde et al, 2015).…”