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The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

Guidelines must be developed that will facilitate standardization of the management of postpartum infection and other less common complications for which healthcare workers show low competence. Strategies to increase use of these guidelines will be necessary.

IntroductionSeveral countries have instituted fee exemptions for caesareans to reduce maternal and newborn mortality.ObjectivesTo evaluate the effect of fee exemptions for caesareans on population caesarean rates taking into account different levels of accessibility.MethodsThe observation period was from January 2003 to May 2012 in one Region and covered 11.7 million person-years. Exemption fees for caesareans were adopted on June 26, 2005. Data were obtained from a registration system implemented in 2003 that tracks all obstetrical emergencies and interventions including caesareans. The pre-intervention period was 30 months and the post-intervention period was 83 months. We used an interrupted time series to evaluate the trend before and after the policy adoption and the overall tendency.FindingsDuring the study period, the caesarean rate increased from 0.25 to 1.5% for the entire population. For women living in cities with district hospitals that provided caesareans, the rate increased from 1.7% before the policy was enforced to 5.7% 83 months later. No significant change in trends was observed among women living in villages with a healthcare centre or those in villages with no healthcare facility. For the latter, the caesarean rate increased from 0.4 to 1%.ConclusionsAfter nine years of implementation policy in Mali, the caesarean rate achieved in cities with a district hospital reached the full beneficial effect of this measure, whereas for women living elsewhere this policy did not increase the caesarean rate to a level that could contribute effectively to reduce their risk of maternal death. Only universal access to this essential intervention could reduce the inequities and increase the effectiveness of this policy.

Birth seasonality responds to a variety of environmental and socio-cultural factors. The present study was carried out to quantify the trends in seasonal variation in birth rate in seven districts in the Kayes region of Mali between 2007 and 2010 and to attempt to link climatic- and agricultural-cycle-dependent factors with birth seasonality. Lagged regression analysis based on time series analysis techniques was used to investigate seasonality of births registered in health facilities and its association with climate, labour migration, agriculture workload, malaria infection and food supply. There was a clear bimodal pattern in month-to-month institutional delivery rate variation, and this seasonal pattern repeated each year over the study period. The data showed that rates of health-facility-attended deliveries were high at the end of the dry season (April-June), fell rapidly in the first half of the rainy season, rose again during the later part of the rainy season (August-October) and fell to their lowest values after the rains. The first peak observed in spring (April-June) corresponded to conception nine months earlier during the rainy season (between July and September), while the second peak observed in the third quarter of the year (August-October) corresponded with conception at the beginning of the dry season right after the harvest period (between November and January). Between these peaks was an abrupt trough in July. The findings support a causal process through which climate change influences conception/birth seasonality in two direct and indirect pathways. On one side climate change influences conception/birth seasonality from the effects on fetal loss (changes in annual rainfall leading to changes in malaria incidence) and on the other side by affecting fecundability (changes in agricultural cycles leading to changes in food production, agricultural workload and socio-cultural events, which in turn influence energy balance and sexual behaviour). Labour migration, which is closely linked with the agricultural cycle, influences sexual intercourse and thus marital fertility. Finally, the model emphasizes an eco-systemic approach to the study of birth seasonality.