The costs of ‘free’: Experiences of facility-based childbirth after Benin's caesarean section exemption policy

Highlights

• Ethnographic study of childbirth in two hospitals after the introduction of Benin's c-section policy.

• C-sections, largely undesired in Benin, still carry a hefty personal and financial cost for women.

• The implementation of an exemption policy can exacerbate already existing poor practices in hospitals.

• Maternal health exemption policies should be accompanied by measures for external support and supervision.

Abstract

As one of many similar policies in the region, in 2009 Benin launched a free c-section policy in publicly funded hospitals intended to decrease the barriers to facility delivery and the heavy financial burdens on women and their families. We conducted a qualitative study for eight months between 2012 and 2014 to understand women's experiences of care in maternity wards. We carried out semi-structured interviews with 30 women who had delivered via c-section at five hospitals. Two of these hospitals became case study sites where in-depth research was undertaken that consisted of participant observation in each maternity ward and 32 further interviews with women who had complicated, vaginal and c-section deliveries.

Overall, women continue to pay for care, both in the form of under-the-table payments to health workers and prescribed payments for services not covered by the policy, though they consider the costs reasonable compared to what the charges were before. Lifting the fees has facilitated conditions for midwives to alert doctors that the procedure might be needed. Partly because c-sections are still feared by most women, in one hospital this led to some women perceiving them as a threat if their labour was progressing more slowly. Implementation of the policy differed greatly between the two case study hospitals. We conclude that some burdens on women's access to care have been addressed but deterrents remain to the improved perception of quality of care on the part of women. Findings detail how important context is to the implementation of the policy, and suggest that similar user-fee removal policies should be accompanied by other measures addressing staff management and quality of care.

Introduction

Despite their recent decline, maternal mortality levels remain high in sub-Saharan Africa at about 201,000 maternal deaths per year (WHO et al., 2015). Beyond this statistic are the burdens of reproductive health crises occurring during labour and childbirth which can lead to drastic consequences for the health and financial circumstances of women and their families (Fottrell et al., 2010, Borghi et al., 2003), in settings where insurance policies are rare and personal safety nets are not economically robust.

Key strategies to reduce maternal deaths include improving access to skilled birth attendance and emergency obstetric care by ensuring that more women can afford childbirth and surgery at well-equipped, adequately-staffed clinics. To achieve this, one widespread approach is to remove user fees or offer fee exemptions for women who deliver in health facilities (Meessen et al., 2011, Richard et al., 2013). In 2009, Benin launched a free caesarean section (CS) policy in its publicly funded hospitals, as part of efforts to reach the Millennium Development Goals and alleviate the financial burdens of care on pregnant women.

Though CS and other maternal health user fee policies are popular, not enough is known about the implementation processes of these policies (Ridde and Morestin, 2011), and there is a dearth of evidence that these policies contribute to reducing access inequity (Dzakpasu et al., 2013). If accompanying measures to cope with increased facility attendance are not incorporated, these policies may even have a negative effect on health provider motivation and quality of care (Hatt et al., 2013), though the evidence for this is weak (Witter et al., 2015). After the implementation of a similar CS policy in Mali, women continued to incur considerable expenses for treatment, medicines and transport (Ravit et al., 2015) largely due to prescription of medicines outside of those the policy covered, with almost a quarter of families still paying off related debts ten months after undergoing the CS (Arsenault et al., 2013). Poor, uneducated women were hardest hit.

In spite of these mixed results, policy makers at local and international levels have pushed for exemption policies and have replicated approaches without evidence that is context specific, a common trend in global health initiatives (Adams, 2013). Gaps in effective solutions to improve maternal health outcomes have been linked to a lack of political will and gender inequality (Grépin and Klugman, 2013). In research that speaks to circumstances beyond her study site, Chapman (2006) explains reproductive risk in Mozambique as being indelibly permeated by social and economic factors borne out of the historical marginalisation of women – with their reproductive choices and medical care consequently based on personal relationships, social status and stigma.

In addition to the financial impact of CS, surgery and childbirth together form a space of heightened vulnerability in West Africa with the exposure to risk and unfamiliar procedures (Jaffré, 2003, Holten, 2013). Encounters in medical facilities can create vulnerable moments for women during labour, occasioning uncomfortable interactions, disrespect and abuse (Bohren et al., 2015). Particularly in Benin, maternity wards have been places of tension, submission and negotiation between women and health workers as they navigate delivery care (Grossmann-Kendall et al., 2001, Saizonou et al., 2006, Behague et al., 2008, Hurni, 2011). Beninese women have their own ideas about what constitutes good quality of care, emphasising respectful care alongside positive medical outcomes, but are more likely than not to feel that they cannot demand improved treatment (Behague et al., 2008).

Hospitals themselves serve as a microcosm of the relationships and dynamics between all involved (Van der Geest and Finkler, 2004, Long et al., 2008) through the intersection of health, risk, technology, resources, and power dynamics. Relationships between health workers and patients are further impacted in low-resource settings when care giving is in part undertaken on the basis of “social recognition” and status of patients (Jaffré and Suh, 2016), due to scarcity of staff, energy and morale. As such, how externally imposed policies are enacted is particular to the settings into which they are introduced, and user fee exemption initiatives can be interpretated and in varying ways depending on their context.

What is it like to give birth by CS in the context of Benin's free CS policy? We undertook this study as part of a larger evaluation of user fee removal policies in Africa (FEMHealth) (Witter et al., 2016). This paper reports on the anthropological component which investigated women's experiences of CS in referral hospitals three to four years after the start of the exemption policy, while also bringing provider perspectives and other contextual factors of the hospitals into consideration. Specifically, we explored how the CS policy shaped health workers' and patients' perceptions of and experiences with quality of care. We also aimed to identify remaining barriers to treatment.