Dzakpasu, Susie, Timothy Powell-Jackson, and Oona M.R. Campbell. “Impact of User Fees on Maternal Health Service Utilization and Related Health Outcomes: A Systematic Review.” Health Policy and Planning 29, no. 2 (2014): 137-150.  doi: 10.1093/heapol/czs142

URL: heapol.oxfordjournals.org/content/29/2/137.abstract.html?etoc

Abstract

Objective To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes.

Findings Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied.

Conclusion Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.

Dzakpasu et al. conduct a meta-analysis of studies which examine whether eliminating cost-sharing or user fees for pregnant women increases their use of healthcare facilities for prenatal care, labor and delivery. The authors conclude that the data supporting the elimination of user fees for pregnant women is weak and make specific recommendations for improving data quality. Her Dignity Network strongly supports rigorous efforts to ensure that interventions designed to improve maternal and child health outcomes are effective.