Women and healthcare provider views on the acceptability of user fee exemptions for caesarean section to prevent maternal and perinatal complications in low and lower-middle-income countries: a qualitative evidence synthesis

doi:10.21203/rs.3.rs-4600591/v1

Background

Clinically indicated caesarean section (CS) can be a lifesaving procedure to minimise complications during childbirth. User fees are direct out-of-pocket costs for receiving a particular medical service and constitute a financial barrier to accessing care. Policies to remove user fees for CS in low and lower-middle-income countries (LLMIC) aim to improve timely access and prevent catastrophic expenditures. However, there is a need to understand the acceptability of these policies. This qualitative evidence synthesis aimed to explore the acceptability of user fee exemption policies for CS in LLMIC from the perspectives of women and healthcare providers.

Methods

Six electronic databases and relevant reference lists were systematically searched. Studies containing primary qualitative data including women and/or healthcare provider views on the acceptability of user fee exemptions for CS, undertaken in LLMIC, and published between 1990 and May 2024, were eligible for inclusion. Best-fit framework synthesis using the Sekon et al.’s theoretical framework of acceptability informed data analysis.

Results

We included five studies involving 315 women and healthcare providers. Studies were published between 2011 and 2020. Data aligned with Sekhon et al’s theoretical framework of acceptability and were presented in 5 domains: affective attitude, burden, ethicality and opportunity cost, perceived effectiveness and intervention coherence, and self-efficacy. The free CS policies were perceived to increase the utilisation of health facilities and CS and as a move towards more equitable maternity care. However, concern was expressed that the policies had encouraged medically unjustified CS and did not cover complications of vaginal births. Policies were reported to be poorly implemented and inadequately resourced, resulting in many women still paying for their CS and negatively impacting quality of care.

Conclusions

The findings demonstrate a mixed picture of the acceptability of removing user fees for CS. A broader policy that appropriately addresses all obstetric complications with adequate staffing and resources will likely increase acceptability and reduce maternal and perinatal complications.

Caesarean section

fee exemption

Low and lower-middle-income countries

Acceptability

Qualitative evidence synthesis

Clinically indicated caesarean sections (CS) can be lifesaving when a vaginal birth is not possible or safe for the mother or fetus.(1) However, CS poses higher risks of mortality and morbidity than vaginal birth.(2–4) These risks are higher in low and low-middle-income countries (LLMIC) due to more limited access to comprehensive obstetric care.(5) Additionally, CS increases the risk of adverse outcomes in future pregnancies, which is concerning considering the high fertility rates in many LLMIC.(4,6)

Inadequate access to timely and safe CS contributes to the underuse of CS in LLMIC.(5,7) 76% of low-income and 16% of middle-income countries have CS rates below 10%, which is suggested as unlikely to meet their clinical need.(8,9,10) Sub-Saharan Africa is the region with the lowest CS rates globally at approximately 5%.(10) However, overuse of CS is also harmful, particularly in LLMIC due to the significantly higher risk of maternal and perinatal complications. Moreover, it consumes finite resources needed to address underutilisation.(5,7)

The World Health Organisation recommend focusing on appropriate CS use rather than achieving a recommended rate (11), as national rates alone do not accurately reflect the unmet need for CS in LLMIC due to significant disparities in rates within countries and the complex reasons for these.(8, 10,12,13)

Financial barriers make timely CS inaccessible to many women in LMIC.(14–16) High costs are associated with facility-based birth, particularly when complications arise. If a CS is performed, costs can be up to ten times more than a vaginal birth.(17,18). When women access emergency care, it can result in catastrophic expenditures, plunging them and their families into poverty.(19,20) This can have lasting consequences on a family’s physical, social, and financial sustainability after birth.(15,21,22)

User fees are direct out-of-pocket costs for receiving a particular medical service and constitute a financial barrier to accessing care.(23) User fee exemption policies have been applied to varying degrees in several LLMIC, often focusing on a particular condition or population group.(14,24) In maternity care, these policies aim to increase the utilisation of facility-based birth and skilled birth attendance, reduce inequities in access to care and ultimately reduce maternal and perinatal morbidity and mortality.(25)

Qualitative evidence evaluating user fee exemptions in LLMIC and, specifically, free CS policies is limited. Available evidence aims to understand why and under which circumstances user fee exemptions for CS succeed or fail(26–28) and to identify remaining barriers to CS, particularly for poorer women.(29–31) Policies were generally well accepted; however, the findings identified several constraints to effective implementation. These included: inadequacy of trained healthcare personnel and resources,(26–29) a lack of awareness of the policies for women,(28,30) continuation of costs,(27,30,31) and persistence of inequities in access.(28–31) Furthermore, no study has sought to evaluate how perceived barriers and facilitators of free CS policies impact acceptability.

Although the importance of assessing the acceptability of interventions is well-established, acceptability is a difficult construct to assess, and evaluations are often vague and ill-defined.(32,33) This qualitative evidence synthesis (QES) will draw upon Sekhon et al.'s theoretical framework of acceptability (TFA), which defines acceptability as ‘a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention.’(32)

The acceptability of interventions can impact both uptake and adherence and is important to consider for successful implementation.(32,34) Insights into the acceptability of user fee exemptions could help identify the strengths and weaknesses of the policies, which could inform recommendations on appropriate implementation.(32) This QES aims to understand the acceptability of user fee exemption policies for CS in LLMIC from the perspective of women and healthcare providers (HCP).

We registered the protocol for this systematic review in the International Prospective Register of Systematic reviews (PROSPERO) available at https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023412943. We have reported this systematic review against the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework to improve the quality of reporting (Additional File 1).(35)

Our research question was articulated by the PerSPE(C )TiF (Perspective, Setting, Phenomenon of interest/problem, Environment, Comparison (optional), Time/Timing, Findings) framework.(36) This framework helped ensure that the QES captured both the wider context and immediate setting in addressing the acceptability of free CS policies. This framework informed the search strategy (Additional file 2) and eligibility criteria (Additional file 3).(36)

Inclusion and Exclusion Criteria

We included the following articles: published January 1990-May 2024; available in English and full text; concerning women and HCP views on the acceptability of free CS policies to prevent maternal and perinatal complications; undertaken in LLMIC; and containing primary qualitative data (from either qualitative or mixed methods studies) where direct participant quotes were available. 1990 was applied as a date limit to identify studies since the safer motherhood initiative, which was a global campaign to reduce maternal and perinatal morbidity and mortality, particularly for women living in LLMIC.(37)

The following studies were excluded: systematic reviews, editorials, conference abstracts, letters and studies that do not contain primary quotes and/or did not use qualitative methods for data

collection and data analysis. Non-English language studies were excluded due to time and resource limitations. Studies reporting other perspectives where data between included and excluded groups as well as between included groups cannot be disaggregated, were also excluded.

Search strategy

Search terms were developed using the PerSPE(C )TiF framework, knowledge of existing literature and advice from a clinical search specialist. They included controlled vocabulary and keyword terms combining four components: 1) CS AND 2) LLMIC AND 3) terms for women and HCPs, AND 4) terms to capture qualitative literature. (Additional file 2)

Systematic searches were conducted in February 2023 and updated in May 2024 in MEDLINE, CINAHL, EMBASE, Web of Science, PsycInfo and Global Index Medicus. The core search strategy was appropriately adapted for each database. Reference lists of included full-text studies were reviewed to capture additional relevant literature.

Selection of studies

Titles and abstracts then full texts were screened by two independent review authors (MH, AT or HN). Discrepancies in study eligibility were discussed to reach an agreement. A third party (AW) was consulted when there was uncertainty regarding eligibility and to resolve conflicts.

Quality appraisal

We assessed the methodological quality of the studies using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research by one review author (MH) (Additional file 4).(38) No studies were excluded based on methodological quality providing that they contributed to the conceptual richness of the synthesis.

Data extraction

One study author (MH) independently extracted contextual data and recorded it in a specifically designed data extraction proforma (Additional file 5). Study findings, including participant quotes, author interpretations, themes, and subthemes, were extracted into a second form from the ‘results’, ‘findings’, ‘discussion’ and ‘conclusion’ sub-headings in the primary studies. The findings data from included studies were imported into a qualitative data management system (NVIVO).(39)

Data synthesis

Studies were synthesised using the best-fit framework synthesis approach aligned with Sekhon et al.'s TFA (Table 1).(32,40) Sekhon et al.’s TFA is widely cited in the literature for assessing the acceptability of complex interventions, as it supports researchers in considering multiple aspects of acceptability to both deliverers and recipients.(32)

We decided that best-fit framework synthesis was a suitable data synthesis method as it works well in reviews of complex interventions by accommodating the complexity within the framework and including representation of theory.(40) Furthermore, the framework facilitated a clear mechanism for integrating qualitative evidence in an aggregative way, which could be sustained despite the potential thinness of available data.

The seven domains of Sekhon et al.'s TFA provided an a priori list of themes that were used to code data from primary studies deductively.(32) Sekhon et al.'s TFA provided a model to support data synthesis, which was adapted based on the data found. MH independently coded and analysed the data. However, findings were continually reviewed and discussed with AW and LJ as a method of investigator triangulation.(41)

Table 1

**The seven domains of Sekhon et al.'s theoretical framework of acceptability**

*(Adapted from)* (32)
Domain	Definition
Affective attitude	How an individual feels about the intervention
Burden	The perceived amount of effort that is required to participate in the intervention
Perceived effectiveness	The extent to which the intervention is perceived as likely to achieve its purpose
Ethicality	The extent to which the intervention has a good fit with an individual’s value system
Intervention coherence	The extent to which the participant understands the intervention and how it works
Opportunity costs	The extent to which benefits, profits or values must be given up to engage in the intervention
Self-efficacy	The participant's confidence that they can perform the behaviour(s) required to participate in the intervention

Assessment of confidence in the evidence

The confidence in review findings from the evidence synthesis was assessed using the GRADE-CERQual approach.(42,43) This was based upon four domains: methodological limitations of included studies, relevance of included studies to the review question, coherence of the review findings and adequacy of the data contributing to the review findings. These domains informed an overall confidence assessment for each review finding as either high confidence, moderate confidence, low confidence, or very low confidence.

Reflexivity statement

The research team comprised medical students (MH) (obstetricians (ST), midwives (AW, SD, FCS), and social scientists (LJ, CK, SD). Data synthesis was carried out by MH, AW and LJ in consultation with all authors. MH is a medical student intercalating in public health with prior knowledge of how financial barriers impact access to quality health services. MH believes that care should be given based on one's clinical need, not ability to pay. However, MH’s lack of experience in LLMIC maternity care on a clinical level provided a degree of professional distance, which likely limited bias regarding the acceptability of the free CS policies. AW and FCS are midwives, AW is also the C-Safe programme manager, and has experience in systematic reviews, qualitative synthesis and maternity care in LMIC settings. LJ is a White British cis gender woman who specialises in qualitative and mixed methods women’s health research. CK and SD are sociologists with expertise in qualitative primary research and extensive experience of reviews investigating optimal caesarean use globally, who believe CS should be available for all women in need. AT and HN are also medical students. ST is a consultant obstetrician and co-director of the WHO collaborating centre for global women's health and lead for maternal & reproductive health, and the chief investigator for C-Safe.

Reflexivity was maintained through discussions with the wider team (experienced women’s health researchers and midwives) regarding prior views and experiences, and a reflexive journal was kept throughout the analysis. Additionally, research bias was mitigated through independent screening by two review authors, second checking of data extraction and quality appraisal, and investigator triangulation during data analysis.(41)

Search and selection

The search produced 5547 results. After duplicates were removed, 3889 articles underwent title and abstract screening, and 95 articles underwent full-text screening. Three met the inclusion criteria and were eligible for this QES. An additional two eligible studies were identified from reference mining of the included studies. The study selection process is represented in a PRISMA flow diagram (Fig. 1).

Description of included studies

The included studies reported qualitative responses from a total of 315 women and HCPs. All five studies report women's perspectives, including women of reproductive age, older women and those who underwent a CS.(27,29,44–46) Three studies reported the views of HCPs, including obstetricians, midwives, and nurses.(27,45,46) Four studies were carried out in Benin(27,44–46) and two in Mali(29,46). Studies were published between 2011 and 2020. Most studies employed primary qualitative methods(27,44,46), and two used mixed methods.(29,45) All studies collected data using semi-structured interviews, and some used additional data collection methods such as focus group discussions(29) and observations(44–46). Study contextual characteristics are summarised in Table 2.

Table 2: Summary of Study Characteristics of the Included Studies

Authors/ (date)	Review Aim	Dates of study duration	Study setting	Country (World Bank status)(56,57)	Sample size and characteristics	Methods of data collection and analysis
Dossou et al. (45) (2018).	To understand how context impacts policy implementation in regard to the user fee exemption policy in Benin.	Data collection: 2012 - 2013	Public and private facilities implementing the free CS³ policy	Benin (lower-middle-income)	24 Policymakers, implementers, patients, and community representatives.⁴	Semi-structured interviews, observations in implementing facilities Thematic analysis
Dossou et al. (27) (2020).	To understand why and under which circumstances the implementation of Benin’s user fee exemption policy for CS succeeded or failed.	Data collection: March 2012- March 2013	Faith-based hospital (non-state-owned) and public hospital (state-owned)	Benin (lower-middle-income)	44 Faith-based hospital: 15 hospital managers and HCPs⁵, 6 community representatives⁶, 6 women who underwent CS. Public hospital: 8 hospital managers and HCPs, 3 community representatives, 6 women who underwent CS.	Semi-structured interviews. Thematic analysis
El-Khoury et al. (29) (2011).	To explore the effects of removing user fees on access to CS in Mali and to identify remaining barriers particular for poorer women.	Data collection: December 2009 -February 2010	Public facilities implementing the free CS policy	Mali (low-income)	162 54 married women (aged 15-49) who gave birth in a health facility, 38 married women (aged 15-49) who gave birth outside a health facility, 59 women aged over 50, 11 women who underwent CS	Focus group discussions, semi-structured interviews with women who underwent CS No data on the analysis method
Lange et al. (2016). (44)	To explore how the user fee exemption policy shaped health workers and patient’s perceptions with quality of care and to identify remaining barriers to treatment.	Data collection: 2012- July 2013	Five referral hospitals including 2 case study hospitals (A and B). Hospital A: Located in the north near the Nigerian border, in an urban centre. Draws patients from rural and urban areas hundreds of kilometres away and sometimes across the border. Hospital B: HCPs on strike during observations. The strike was officially “unlimited without a minimum service.”	Benin (lower-middle-income)	62 Women who underwent CS within the past 30 days in the five referral hospitals. 6 women per site 32 additional interviews with women from case study hospitals with women who had either a CS, near miss or uncomplicated birth	Semi-structured interviews, observations in maternity and labour wards. Thematic analysis
Schantz et al. (46) (2020).	To understand how and why CS are performed under the user fee exemption policies in Benin and Mali.	Data collected: January 2017 - July 2017	Four health facilities in Benin, 5 facilities in Mali – with a diversity of contexts: district/provincial, rural/urban and private/public facilities.	Mali (low-income) and Benin (lower-middle- income)	23 6 midwives, 11 obstetricians, 6 women who underwent CS	Participant observation, semi-structured interviews Thematic analysis

Context of Benin and Mali

All studies identified were conducted in Benin and Mali, as these were the only countries to implement free CS policies not part of a broader user fee exemption policy.(24) Benin and Mali are countries with high maternal mortality ratios of 397 and 562 per 100,000 births and high total fertility rates of 5 and 6, respectively.(6,47) In both countries, the free CS policies were motivated by improving access to facility-based births and emergency obstetric care.(29,45) Additionally, in Benin, the policy was pushed forward after the President in 2008, Boni Yayi, drew attention to women detained for weeks and months in hospitals when they could not afford their CS fees.(45,46)

The free CS policy in Mali was broader, including all facility-based costs for CS.(24,29) However, CS in Benin were more generously reimbursed. In Benin, reimbursement was the same regardless of the actual costs of the procedure, the socioeconomic status of women or the indication for CS. In Mali, complicated CS were reimbursed at a higher rate.(29) Details of the free CS policies in both countries are summarised in Table 3.

Table 3: Summary of the Free Caesarean Section Policies in Benin and Mali

Country

Date introduced

Participating facilities

Costs covered by the free CS¹ policy

Reimbursement

Benin

2009

Public and private hospitals capable of performing CS.

Includes: check-up costs before CS, drugs, kits, surgery, blood, and hospitalisation for seven days.

Excludes: antenatal care, transport, vaginal births, check-up costs prior to intervention and other obstetric and neonatal complications.

Hospitals receive a fixed sum of 100,000 CFA² (Approx. £134) for each CS.

Mali

2005

Public hospitals capable of performing CS.

Includes: All facility-based costs for CS – including hospitalisation, surgery, and treatment of complications.

Excludes: antenatal care, transport, vaginal births.

Hospitals receive 30,000 CFA (Approx. £40) for simple CS and 42,000 CFA (Approx. £56) for complicated CS.

Quality assessment

All studies clearly stated their research aims and a qualitative methodology was appropriate to address these. Two studies did not describe how participants were recruited and why the methods were appropriate.(27,29) Reflexivity was absent in all studies; therefore, it was not possible to assess the extent to which the researcher’s worldviews may have influenced the research methods and analysis. All studies showed evidence of ethical approval; however, some did not discuss how they obtained participant consent or maintained confidentiality.(45,46) One study did not state their analysis method.(29) Whilst all studies were clear on how data was collected, and most stated their analysis method, there was limited justification for why these methods were appropriate and a lack of detail in how they were carried out. All studies had a clear statement of findings that were discussed in relation to the original research question; however, some failed to discuss the credibility of findings.(29,44,46) The results of the quality appraisal are summarised in Table 4.

Table 4

**Summary of Quality Appraisals Using the Critical Appraisal Skills Programme (CASP) checklist for Qualitative Studies** (38)
Authors (Date)	Aim	Method	Design	Recruitment	Data Collection	Bias	Ethics	Analysis	Findings	Value
Dossou et al. (2018). (45)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Dossou et al. (2020). (27)	Yes	Yes	Yes	Unclear	Yes	No	Yes	Yes	Yes	Yes
El-Khoury et al. (2011). (29)	Yes	Yes	Yes	Unclear	Yes	No	Yes	Unclear	Yes	Yes
Lange et al. (2016). (44)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Schantz et al. (2020). (46)	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes

Findings

The data are presented within the domains of Sekhon et al.'s TFA.(32) Interpretations are supported by “participant quotes” in italics and author interpretations in normal text. In addition, to help contextualise the viewpoint, participant characteristics and country are included after each quote where available.

Affective attitude

Affective attitude describes how women and HCPs feel about the free CS policies. The policies and their intention to provide free CS was generally received positively by women and HCPs. The policies were perceived to remove a crucial financial barrier in access to CS and as a step towards more equitable maternity care. Women welcomed the reduction in costs as, unlike before, they believed if a CS was performed, they would not face as significant or debilitating costs. Women from poorer families were perceived to benefit, resulting in a reported increase in their utilisation of health services.

“With the free policy, many women are visiting health facilities. The change is very noticeable. Women who deliver at home usually do because of a short labor. We always tell our daughters-in-law that we prefer that they deliver at health facilities” Woman, Mali(29)

HCPs expressed relief that they did not have to impose perceived catastrophic expenditures for CS, a potentially lifesaving intervention. In the past, HCPs described that when prescribed a CS, women and their families would disappear to try to collect funds causing delays in treatment with some women not returning. The free CS policies meant HCPs could perform a CS depending on a woman's medical indications without considering their financial means.

Whereas once they dreaded having to tell a woman or her family that she would need a CS, since the policy initiation, midwives now felt a sense of relief.(44)

However, some women expressed not everyone would benefit from the policies equally and barriers to access would persist. For example, high transportation costs, the sparsity of healthcare facilities and poor transport infrastructure mean many women, particularly from low-income or rural households, will not be able to access a health facility where they could benefit from the free CS policies.(29)

Additionally, one study reported that the free CS policies might create wider inequities in women who receive different management of their birth complications.(44) Near-miss vaginal births can amount to substantial costs resulting in perilous financial situations; however, these are not included in the policies.

Furthermore, for many women, CS was still overwhelmingly feared due to the threat of complications, loss of life and implications on future pregnancies. Therefore, despite the free CS policies, CS was seen as a procedure to avoid whenever possible.

“When one speaks of CS, its about fear for the stomach, because…[silence]…because birth is something you should do yourself and you’re told that you can’t that they have to open your belly with a knife! Aah! A woman is not a chicken that you can slice open every time! You could die during the operation because the health workers are just humans and can make mistakes too” Woman, Benin(44)

For some women, the cultural stigma around CS and facility-based birth continues to affect women's judgement of their need to seek healthcare. CS was perceived as a failure of womanhood and could negatively impact how women were viewed and treated in the community, particularly by their elders. Therefore, although the free CS policies may have removed some financial barriers to access, cultural barriers to CS remain.

“Here in our culture, giving birth at home is synonymous to bravery… it shows that the mother is physically strong. On the other hand, giving birth at a facility is perceived to be a sign of weakness. Thus for us, unless the woman is ill, she does not deliver at a health facility.” Woman, Mali(29)

Burden

HCPs expressed concern that the free CS policies had encouraged an increase in medically unjustified CS. Unnecessary CS resulting from the policies resulted in a ‘burden’ for women and HCPs.

“Yes [there are excessive caesarean sections], of course. More than excessive, abusive! Well, in theory [the policy of free access cannot increase the number of abusive caesarean sections], but in reality, yes.” Obstetrician, Benin(46)

HCPs reported that "abusive"(46) use of free CS policies resulted in both short- and long-term complications for mothers and their babies, for example, uterus scarring, which can cause infertility problems and adverse outcomes in future pregnancies. HCPs feared these complications would be particularly challenging to manage due to high fertility rates and would directly contribute to maternal deaths.

“And they do not see the consequences! Placenta accreta, all these factors contribute to maternal deaths” Midwife, Benin(46)

Staff motivation, perceived financial gain, lack of equipment for fetal surveillance and increased demand from women were all cited as contributing to the increase in CS.(44,46) In addition, as the free CS policies reimbursed hospitals for each CS performed, this became a source of income for hospitals, encouraging them to perform medically unjustified CS.

“Doctors are less rigorous now in terms of caesarean section because, for hospitals, it is a source of money, so doctors are more inclined to do caesareans more easily (…) For hospitals, when the state pays the costs of caesarean section, it’s a breath of fresh air for them; so today, indications for caesarean section are nothing.” Obstetrician, Benin(46)

HCPs cited increased maternal requests for CS as another reason for the increase in unnecessary CS. Some HCPs believed that women perceived CS as an easier alternative when experiencing prolonged or painful labour.

“As soon as the contractions begin, they come to the hospital. They say, ‘operate on me, operate on me, operate on me.’ You see they scream, and they say ‘Go ahead and operate; I cannot push any more’ I see a lot of women saying that” Obstetrician, Mali(46)

However, one study noted that maternal preference for CS was rarely expressed before birth.(46) During observations, women were often subject to poor labour conditions and sub-optimal care by HCPs. In this environment, women underwent ‘maternal distress CS’ due to perceptions that CS would relieve their suffering and pain.

Ethicality and Opportunity cost

Ethicality in the context of this QES refers to the extent to which the free CS policies fit with an individual's value system. Opportunity cost describes the extent to which benefits, profits or values need to be given up for individuals to engage with the free CS policies. These domains were merged in the analysis, as HCP values and beliefs (ethicality) influenced the extent to which they could give up profits (an opportunity cost) to effectively deliver the free CS policies.

HCPs were reported to charge for services supposedly included in the free CS policies, often exploiting women who did not know their entitlements. These unofficial payments undermined women’s trust in HCPs and the policies.

“She [the midwife] only placed a catheter but she told me to get at least 50,000 CFA (Central African Francs) ready before our trip to the hospital. My husband said that he didn't have the money, and so she told him to give her 30,000 CFA instead. She'd give 5000 to the doctor and the same to the others who would care for me. At that time, my husband didn't know that one shouldn't pay anything. He only knew afterwards, when he heard the CS was free and had already given the money e it hurt him a lot …” Woman, Benin(44)

However, even women informed of the policies and their entitlements often felt they had little agency to challenge HCPs due to fears of negligence or poorer care quality if they did not pay. Women reported being left in distressing and vulnerable conditions to force them to pay for services such as postoperative pain relief.

“When the effect of the anaesthesia waned, we started feeling uncomfortable and women started crying from everywhere. We were obliged to call the midwives and beg them and ask if they would not have a drug that can reduce our pain. They replied [the managers] said caesarean section is free, and if we want pain relief, we must pay for it. Then we begged them to put something in our infusion” Woman, Benin(27)

Some HCPs justified charging for aspects of care despite the free CS policies due to concerns over loss of profits (an opportunity cost). Some providers did not trust the government to reimburse them or felt the reimbursement was insufficient compared to the actual costs of care. However, one study highlighted continuation of under-the-table payments despite the government effectively reimbursing facilities.(27) One midwife stated that bribery is deeply embedded in the hospital landscape and is fundamental to its continuation, regardless of the free CS policies.

“The hotelier lives off the hotel…he tastes every soup before serving it…healthcare won’t exist without it [informal payments] “Midwife, Benin(44)

Perceived effectiveness and Intervention coherence

Coherence refers to the extent women and HCPs understand the free CS policies. Perceived effectiveness describes to what extent individuals believe that the free CS policies are likely to achieve their purpose. These domains were merged in the analysis as the extent to which individuals understood the free CS policies influenced perceptions of effectiveness.

Most women were aware of the free CS policies and the core message that CS was now free. Women heard about the policies through various mediums, including TV, radio and from other community members and HCPs.(27,29) However, women had significant variability in their understanding of what aspects of care were covered by the policies and which facilities could perform CS.

Although the free caesarean policy is becoming increasingly well-known, information about the specific components of the policy remains fragmented. Mali(29)

Furthermore, implementation at different health facilities was inconsistent. Individual hospitals seemed to dictate to what extent they followed the free CS policies, with some continuing to charge for services such as drugs and consumables supposedly included in the policies. Although national policy guidance was standardised, the policies were not effectively enforced on a facility level leading to variability in practice.

Variability in adherence to the free CS policies by hospitals, coupled with unofficial payments made by HCPs, created uncertainty for women around what services they should pay for. Furthermore, some HCPs were also poorly informed regarding the services included in the policies likely exacerbating inconsistencies in implementation.

Confusion around which materials and services should be paid for apparently both on the part of the staff as well as the patients created some sense of tension amongst clients who were confronted with unclear charges. Benin(44)

As a result, women’s 'perceived effectiveness' of the free CS policies was variable. In general, women reported that CS costs had decreased, but most were still paying for aspects of their care to the extent that, for some women, costs seemed unchanged from before the policies.

“Yes CS is free,” she said, but nevertheless, she had budgeted between 50,000 and 60,000 CFA for the procedure, saving money over the last months for potential complications. Adding up medications, materials and special payments to the midwives, there was nothing free about this procedure, she sighed. Woman, Benin(44)

An informed patient voice was important for promoting adherence to the policies and ensuring quality of care. As many women had a low coherence of their entitlements within the policies, they had little agency to demand removal of charges. Without pressure from women claiming their entitlements, hospitals dictated their own terms of the free CS policies, resulting in low perceived effectiveness. Where women's voices were informed and had channels through which they could express their opinions, HCPs felt more obliged to adhere.

Several providers reported being surprised and put under pressure to comply with the policy, since the population was informed and was expecting immediate benefits. Benin(45)

HCPs cited hospital management as a key determinant of whether the free CS policies were effectively implemented on a facility level. Managers were vital in ensuring staff were equipped to perform safe CS and enforce policy adherence by providing supervision support, sanctioning staff who continued to take informal payments and reimbursing women who were wrongly charged.

Hospital A, benefiting from this strong leadership and the financial comfort of being able to profit from the CS policy rather than clocking losses, was able to institute the policy without increasing under-the-table-payments. Benin(44)

Self-efficacy

Lack of equipment and consumables impacted HCPs self-efficacy to perform safe and appropriate CS. HCPs reported equipment was often degraded and not replaced. For example, in one study, observations found a lack of maternal and fetal monitoring equipment, which directly led to inappropriate CS.(46) Frequent shortages of drugs, aseptic equipment and blood meant that CS were performed in unsafe environments, leading to maternal complications.

Due to stock-out of their regular steriliser, health workers were using iodine to clean the wounds during this period, considered by medical staff to be less effective antiseptic that may have contributed to an increase in infections.(44)

HCPs reported the CS kits supplied as part of the policies were inadequate. Kits were not regularly replaced and contained insufficient medical supplies and medications. One HCP explained that implementers encouraged compliance with the kits even if it was detrimental to patient outcomes. There was evidence that the policies were inadequately resourced and encouraged HCPs to deviate from clinical guidelines.

“Doctors, when they treat women who have been referred with meconium-stained fluid, prescribe strong antibiotics to avoid infection, but they (the implementing agency supervisors) said ‘No, nothing other than ampicillin should be prescribed (the antibiotic provided for free within the policy’. Now that we do not prescribe anything else, we see surgical wounds become infected.” Midwife, Benin(45)

Insufficient resources to provide high quality care impacted staff motivation and morale creating a sense of hopelessness and regression. This further catalysed the increase in unsafe and unnecessary CS.

Assessment of confidence according to GRADE CERQual

Key findings under each theme were assessed using the GRADE CERQual approach.(42,43) Overall confidence in the review findings was either moderate or low, with two findings receiving a very low confidence rating.

Regarding methodological limitations the confidence in the evidence was limited by two studies one with moderate(27) and one with serious methodological limitations.(29) Consequently, most findings were assessed to have moderate methodological limitations.

Most studies had no or very minor concerns about coherence. Confidence was reduced in findings under the theme of affective attitude due to conflicting opinions on the policies presented within and between studies.

Concerning data adequacy most findings had adequate richness of data, moderate concerns were noted when there were significantly unequal contributions from supporting studies. Furthermore, the paucity of included studies reduced confidence that could be placed in the findings.

There were no concerns regarding relevance except one finding that was supported by a study with only partial relevance. The study aimed to understand how context impacts policy implementation which had only partial relevance to the acceptability of user fee exemption policies for CS for women and HCPs.(45)

A summary of the GRADE CERQual assessments are presented in Table 5. An evidence profile containing the rationale for the assessment of each finding is provided in Additional file 6.

Table 5 Summary results of GRADE CERQual assessments

Finding	Contributing studies	Methodological limitations; quality of the studies which are contributing to finding	Coherence; extent of support for review finding from the underlying data	Adequacy; richness of data; depth and quantity contributing to the findings	Relevance; the extent to which the data supporting a review finding is applicable to the context. (Women and HCPs perspective, acceptability, user fee exemptions for CS)	Overall confidence
Theme 1: Affective attitude
Women and healthcare providers perceived the free CS⁷ policies as a move towards more equitable maternity care	(27,29,44)	Moderate methodological limitations	Moderate concerns	Minor concerns	No or very minor concerns	Low
Women expressed that the policies did not benefit everyone equally as several barrier to access persisted e.g high transport costs, scarcity of health facilities, high cost of complications in vaginal birth	(29,44)	Moderate methodological limitations	Moderate concerns	Minor concerns	No or very minor concerns	Low
The free CS policies did not necessarily change women’s health seeking behaviours for CS	(29,44,46)	Moderate methodological limitations	Minor concerns	Minor concerns	No or very minor concerns	Moderate
Theme 2: Burden
The free CS policies were perceived to encourage CS for medically unjustified reasons	(44,46)	Minor methodological limitations	Minor concerns:	Moderate concerns	No or very minor concerns	Moderate
Theme 3: Ethicality and opportunity cost
Bribery and corruption by healthcare providers was reported to be commonplace	(27,44)	Moderate methodological limitations	Minor concerns	Minor concerns	No or very minor concerns	Moderate
Theme 4: Perceived effectiveness and intervention coherence
Women and healthcare providers were generally aware of the policies but were not well-informed of the specific aspects of care included under the free CS policies and which facilities it applied to	(27,29)	Serious methodological limitations	Moderate concerns	Moderate concerns	No or very minor concerns	Very low
Implementation of the free CS policies was variable between health facilities	(27,44)	Moderate methodological limitations	Minor concerns	Minor concerns	No or very minor concerns	Moderate
Despite the free CS policies, women were still paying for aspects of care e.g prescriptions, transport costs, informal payments to healthcare providers	(27,29,44)	Moderate methodological limitations	Minor concerns:	Minor concerns:	No or very minor concerns:	Moderate
Healthcare providers cited hospital management as a key determinant of whether the free CS policies were effectively implemented on a facility level	(27,44)	Moderate methodological limitations:	Minor concerns	Moderate concerns:	No ore very minor concerns	Low
Theme 5: Self-efficacy
The free CS policies did not significantly impact (or increase) the perceived quality of care.	(29,44–46)	Moderate methodological limitations	Moderate concerns	Minor concerns	Moderate concerns	Very Low
Health facilities were often insufficiently resourced regarding staff, consumables, and equipment to perform CS safely and to ensure the quality of care.	(27,44,46)	Minor methodological limitations	Minor concerns	Minor concerns	No or very minor concerns	Moderate

Main findings

This QES presents variation in the perceived acceptability of the free CS policies for women and HCPs in Benin and Mali. The findings demonstrated that the policies could result in relief, comfort, and ease as well as distress, exploitation, and helplessness.

Both women and HCPs perceived the free CS policies as a move towards more equitable maternity care and expressed that the policies may encourage more women to give birth in health facilities. However, despite the implementation of the free CS policies, cultural and financial barriers to CS persisted for women, impacting their acceptability of these policies. Women reported a continuation of costs related to non-covered care aspects such as transportation and informal payments to HCPs, impacting the accessibility of CS for the poorest women. Moreover, CS was still overwhelmingly feared by many women so these policies did not necessarily alter health-seeking behaviours that may result in CS.

Inadequate service provisions, coupled with a perceived increase in unnecessary CS, diminished the acceptability of the free CS policies among HCPs. HCPs highlighted shortages in essential equipment and drugs necessary for safe CS. Insufficient resources to ensure safe vaginal birth combined with financial incentives for performing CS likely contributed to the perceived increase in unnecessary CS. Concerns were voiced by HCPs regarding the increased risks of complications for both mothers and babies associated with unsafe and unnecessary CS, as well as potential implications for future pregnancies.

Strengths and limitations

This is the first QES to explore the acceptability of user fee exemptions for CS from the perspectives of women and HCPs who are key stakeholders in the delivery and receipt of these policies, to the best of the authors knowledge.

The sensitive search strategy, wide range of databases systematically searched, and experienced team in global women’s health and qualitative research were a strength and facilitated the narrowing of the research focus during study selection. Non-English language studies were excluded due to time limitations and resources, which may have excluded relevant literature.

The paucity of included studies meant that available data were relatively thin, so findings were primarily descriptive rather than interpretative. It was not possible to perform an analysis comparing how acceptability differed between women and HCPs. The small number of studies also limited the confidence that could be placed in the findings.

All included studies were conducted in either Benin or Mali, where the free CS policies were a stand-alone policy. This limits the transferability of findings to other countries that implemented broader user fee exemption policies. However, it could be considered a strength that this review has delved deeper into the acceptability of the specific free CS policies as it is likely to differ from broader policies and may facilitate more focused recommendations to be made.

Finally, the perspectives of policymakers, managers, and other community members were beyond the scope of this review. These groups are as important in the planning, implementation, monitoring, and utilisation of the free CS policies.

Interpretation

This QES contributes to the expanding body of literature concerning the removal of user fees for health services in LLMIC(23,48,49) and in particular maternity care.(24,25,50) Our findings align with existing literature indicating that user fee exemption policies may encourage more women to give birth in health facilities.(24,25) While previous studies have found this may contribute to a reduction in maternal and perinatal complications, the supporting evidence is weak.(24,25)

A key barrier to the acceptability of these policies for women is the persistent financial burden despite the implementation of the free CS policies. Our findings and the wider literature highlight the role of poor policy implementation, transportation expenses, and informal payments to HCPs as contributing factors to these persistent costs. (24,25,48,49) Our findings may shed light on why studies have shown persistent urban/rural and socioeconomic inequalities in access to CS, despite the free CS policies and other user fee exemption policies in maternity care.(51–53) Policies need to be better implemented and other barriers addressed to increase the acceptability for women.

Our findings resonate with existing literature that user fee exemption policies can have undesired and potentially harmful effects with the perceived increase in unnecessary and unsafe CS highlighted in our review.(24,25,48,50) Previous reviews have highlighted that user fee exemption policies have had negative or inconclusive effects on the availability of essential healthcare resources, HCP workload and motivation, revenue loss for health centres and ultimately quality of care.(25,48) Policymakers should plan for and continually evaluate the impacts of exemption policies and ensure complementary measures are put in place to increase acceptability of these policies. It is paramount that alongside increased access, the quality of care is maintained to reduce maternal and perinatal complications.

Furthermore, one review which compared the user fee exemption policies in Benin, Mali, Burkina Faso and Morocco highlighted the problematic nature of policies that focus solely on exempting fees for CS while excluding vaginal births. Even with optimal implementation, they argued that such policies would have a limited impact on reducing maternal and perinatal complications.(24) Moreover, several studies have raised concerns that these policies may inadvertently encourage unnecessary CS.(24,25,50,54) Our findings further substantiate this concern demonstrating the distress and worry from some HCPs by the perceived increase in unnecessary CS resulting from the policies. Considering the growing evidence base for the harms caused by CS overuse, it is essential policies prioritise ensuring appropriate use of CS alongside enhancing access.(3–5,9,55)

Implications for future research

Future research could examine the acceptability of different user fee exemption approaches in maternity care. For example, more comprehensive service packages encompassing antenatal care and delivery or targeting specific population groups such as low-income women. Evaluations should include the perspectives of all relevant stakeholders to comprehensively understand how these interventions can most acceptably be implemented to their intended populations. Additionally, future assessments of acceptability should consider the impact of interventions on equity in access to maternity services as well as appropriate utilisation of interventions such as CS.

This QES examined the acceptability of removing user fees for CS in the context of the free CS policies in Benin and Mali. Overall, findings showed a mixed picture of the acceptability for women and HCPs. Perceived benefits were that women increased their utilisation of health facilities and reduced delays in receiving a CS, as decisions were less influenced by women's ability to pay. However, the policies could have been better formulated and implemented. For example, services included were inadequate for women who suffered complications in vaginal birth, and policies were perceived to promote unnecessary CS. Furthermore, the policies were poorly implemented at the facility level and were often inadequately resourced with negative implications on the quality of care. A broader policy that appropriately addresses all obstetric complications with adequate staffing and resources will likely increase acceptability and reduce maternal and perinatal complications.

CASP – Critical Appraisal Skills Programme

CS – Caesarean section

HCP – Healthcare provider

ENTREQ - Enhancing Transparency in Reporting the Synthesis of Qualitative Research

LLMIC – Low and lower-middle-income countries

PerSPE(C )TiF - Perspective, Setting, Phenomenon of interest/problem, Environment, Comparison (optional), Time/Timing, Findings

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses

QES – Qualitative evidence synthesis

TFA – Theoretical Framework of Acceptability

Ethics declarations

Ethics approval and consent to participate

Not applicable as this is a systematic review

Consent for publication

Not applicable as this is a systematic review

Competing interests

No interests of conflicts to declare

Availability of data and materials

All data are available in the manuscript or in the Additional files. The corresponding author can be contacted for additional information if required.

Funding

This study was funded by the Medical Research Council, research grant MR/V035282/1. The funding body had no input in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.

Author contributions

MH: conducted the search, independently screened studies for inclusion, assessed the quality of included studies, extracted and coded the data, performed GRADE-CERqual assessments, analytically synthesised the data, drafted manuscript. LJ: identification of the research question, discussed and agreed quality assessments and CERQUAL assessments, reviewed analysis, reviewed manuscript. SD: identification of research question, reviewed manuscript. CK: identification of research question, reviewed manuscript. FCS: reviewed manuscript. AT: independently screened studies for inclusion. HN: independently screened studies for inclusion. ST: reviewed manuscript. AW: identification of the research question, independently screened studies for inclusion, discussed and agreed quality assessments and CERQUAL assessments, reviewed analysis, reviewed manuscript.

Acknowledgements

I wish to acknowledge and thank the Yorke Williams Bequest for their support.

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CS – Caesarean Section
CFA – Central African Franc
CS – Caesarean section
The study did not report the sample size of women and healthcare providers within the 24 participants. However, the study was still eligible for inclusion as it was possible to disaggregate quotes from included/excluded participants.
HCP – Healthcare provider
The study did not report the sample size of healthcare providers or if community representatives were women or pregnant and birthing persons. However, the study was still eligible for inclusion as it was possible to disaggregate quotes from included/excluded participants.
CS – Caesarean section

No competing interests reported.

Women and healthcare provider views on the acceptability of user fee exemptions for caesarean section to prevent maternal and perinatal complications in low and lower-middle-income countries: a qualitative evidence synthesis

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Inclusion and Exclusion Criteria

Search strategy

Selection of studies

Quality appraisal

Data extraction

Data synthesis

Assessment of confidence in the evidence

Reflexivity statement

Results

Search and selection

Description of included studies

Table 2: Summary of Study Characteristics of the Included Studies

Context of Benin and Mali

Quality assessment

Findings

Affective attitude

Burden

Ethicality and Opportunity cost

Perceived effectiveness and Intervention coherence

Self-efficacy

Assessment of confidence according to GRADE CERQual

Discussion

Main findings

Strengths and limitations

Interpretation

Implications for future research

Conclusion

Abbreviations

Declarations

Ethics declarations

Ethics approval and consent to participate

Consent for publication

Competing interests

Availability of data and materials

Funding

Author contributions

Acknowledgements

References

Footnotes

Additional Declarations

Supplementary Files

Status:

Version 1