The costs of ‘free’: Experiences of facility-based childbirth after Benin's caesarean section exemption policy
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.
Section snippets
Study setting
Almost nine out of ten pregnant women in Benin delivered in health facilities in 2012, contributing to a remarkably high facility childbirth rate for the region (UNICEF, 2013). Yet, the lifetime risk of maternal death remains problematic at 1 in 51 suggesting issues with quality of care (WHO et al., 2015).
Influenced by the Bamako Initiative's cost recuperation agenda, Benin's healthcare system, in addition to being funded by local government and foreign donors (SHOPS, 2013), also relies on its
Two hospitals, two contexts
The five hospitals are all referral facilities in the south, central and north of Benin. The two case study hospitals have distinct profiles.
Hospital A is in the north of the country, not far from the Nigerian border. It is located in an urban centre with a population of about 70,000, and draws patients from rural and urban areas hundreds of kilometres away, and sometimes from across the border. Many patients were either Bariba or from the Peulh ethnic group, historically a nomadic group from
Discussion
Our findings depict experiences of CS in maternity wards in Benin after the removal of fees as a contentious arena, creating further space for doubt, tension, fear, and discomfort as well as possibility, relief, joy and ease. The policy introduction has allowed health workers to prescribe CS with the knowledge that they are not creating impossible financial situations for women and their families, and women welcome paying much less for this potentially lifesaving procedure than they would have
Conclusion
Even with the cost barrier removed, a woman's experience of giving birth by CS in Beninese hospitals can be a challenging, if life-saving, experience, influenced by where she delivers. It is not enough for a policy to be implemented to meaningfully improve access to quality of care in maternal health. Instead, how it is implemented will make a crucial difference in the way the policy benefits women and families.
In this respect, policies need to be accompanied by measures that offer greater
Acknowledgements
The authors would like to thank the women, families and health workers in the fieldwork hospitals. We would also like to thank Nicole Dari and Arielle Fagbité for assistance with data collection, the rest of the FEMHealth team for discussions and support throughout this research, and two reviewers who provided helpful and engaging feedback. This research was funded through the European Union Seventh Framework Programme (FP7/2007-13) under grant agreement no 261449.
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