The Hidden Costs of a Free Caesarean Section Policy in West Africa (Kayes Region, Mali)

Abstract

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.

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

“…Second, this study did not consider the level of implementation of the free C-section policy in both countries. Previous studies showed that the cost of C-sections was still high in many hospitals in Benin after the policy was introduced [ 15 ] and that 91% of women still paid for their C-sections in a rural area of Mali during the period 2008–2011 [ 51 ]. The impact of this policy on socioeconomic inequalities might have been more important than the observed impact if C-sections were truly free for every woman.…”

From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies

“…These results take into account factors that might influence that probability, such as the women's ages, the district, clinical indications, history of caesareans, and existence of a referral-evacuation system. However, women continue to pay a heavy financial price for caesareans, and between 20% and 50% of households still face catastrophic expenses [ 58 , 59 ]. These few examples testify to the currently limited impacts of exemption policies in Africa.…”

Exemption from Health Care Fees Influences Indications of Caesarean Section in a Urban Health District Hospital in Benin

“…In a study in Mali, Diallo [17] reported that mechanical dystocia was the most frequent caesarean section indication with 18.81% before the implementation of the PCSFE and 56.43% during the implementation of the PCSFE (p < 0.05). The main indications for Caesarean section at the Douala General Hospital in 2012 were: fetal distress (17.00%), scarred uterus (12.56%) and seat presentation (11.49%) [21]. In the present study, the increase in the frequency of placenta preaviea and excessive uterine height may be explained by improved access to maternal care assuming that these conditions were previously managed with failure at home or at first line health care facilities.…”