Half a million women die during pregnancy and childbirth in the world’s poorest countries each year.
Many are unable to meet the cost of medical care which prevents them from seeking professional help during their pregnancy and delivery.
So-called ‘user fees’ for those requiring medical attention were introduced by many developing countries in the 1980s as a way of helping fund healthcare.
The abolition of such fees, especially for priority groups such as pregnant women, is currently being debated by governments, donors and maternal health stakeholders across the globe.
However not enough is known about the implementation and impact of fee removal for policymakers to make informed decisions about how to take these policies forward.
Now the University of Aberdeen is leading a €2.9 million international research project to assess the result of fee exemption on maternal health in West Africa and Morocco.
Immpact - the University’s global research initiative which aims to promote better health for mothers- to-be in developing countries - is heading the three-year study which will focus on Mali, Benin, Burkina Faso and Morocco.
In recent years these four countries have removed or reduced obstetric fees for deliveries and caesarean sections, and, in some cases, other complicated deliveries.
Dr Sophie Witter, a health economist with Immpact with more than 20 years’ experience in developing and transitional countries, is leading the collaboration. She said: “The burden of maternal and newborn deaths is really high in many countries in sub-Saharan Africa and while there are many reasons for this, a very important one is the cost of care, which is prohibitively expensive for many households in developing countries.
“Take Burkino Faso, until fees were removed the cost of a normal delivery was 43% of the annual per capita income in the poorest households, while a caesarean section was 138% of that income. This perhaps helps explain why an incredibly low number of women here received sections – some 0.5% overall, compared with an expected 5-15% globally.
“Women from the ‘richer’ 20% of the population in developing countries are more than three times more likely to give birth with medical help, while women with more money also have much less chance of dying from maternal causes than poorer women.
“Governments introduced user fees in developing countries to increase resources for the health sector and improve the general quality of health services delivery in these countries.
“However the objectives that were originally hoped for when the fees were introduced are not being met and millions are dying each year from preventable causes in the developing world. If you want to raise money, taking a lot of small payments from people who cannot afford to pay very much is not going to be effective, never mind fair.
“Our study will fill the gap in knowledge as to what happens when user fees are removed. We will be examining why and how these policies were adopted, how they are being financed, how they affect the local health system, and how they change the quality of care and health outcomes for women. We will also establish a ‘community of practice’ to feed back information to policy-makers on how to strengthen these policies.”
The World Bank and World Health Organization are amongst the many organisations increasingly offering to support Governments to reduce their dependence on user fees, but how this should be done and how the quality of health care can be protected and improved at the same time, requires high quality evidence.
A final aim of the research is to develop new practical research tools and methods which can be used to conduct other multidisciplinary evaluations and develop evidence for policy-makers and maternal health stakeholders. Plans to strengthen local research skills have also been incorporated into the research, which is divided into nine work streams.