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

Abstract

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.