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

Marion Ravit (1) , Martine Audibert (2) , Valery Ridde (3, 1) , Myriam de Loenzien (4, 1) , Clémence Schantz (1) , Alexandre Dumont (1)

1 CEPED - UMR_D 196 - Centre population et développement
2 CERDI - Centre d'Études et de Recherches sur le Développement International
3 Department of Social and Preventive Medicine
4 IRD - Institut de Recherche pour le Développement

Background: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveriesamong all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study wasto observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access toC-sections and facility based deliveries after the free C-section policy was introduced.Methods: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011–2012 inBenin and 2001, 2006 and 2012–13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections andfacility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facilitybased deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the mostadvantaged categories (urban, educated and richest women). Concentration curves were used to observe the degreeof wealth-related inequality in access to C-sections and facility based deliveries.Results: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significantdifference 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 significantchange in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the freeC-section policy.In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of thepolicy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation ofthe policy, but wealth-related inequalities were still present.Conclusions: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after thecountries implemented free C-section policies. User fee exemption is not enough. We recommend switching tomechanisms that combine both a universal approach and targeted action for vulnerable populations to address thisissue and ensure equal health care access for all individuals.

Mots clés: Caesarean section; Low-income countries; Mali; Benin; Health policy; User fees; Health equity; Maternal health

Domaines: Economies et finances

Marion Ravit, Martine Audibert, Valery Ridde, Myriam de Loenzien, Clémence Schantz, et al.. Do free caesarean section policies increase inequalities in Benin and Mali?. International Journal for Equity in Health, 2018, 17 (1), ⟨10.1186/s12939-018-0789-x⟩. ⟨hal-01811304⟩