Celebrate Solutions: Free caesarean policy increases utilization in Mali, but challenges remain

By: Rati Bishnoi, Special Projects Intern at Women Deliver

Mali_mother.jpgThe government of Mali in 2005 began offering free caesarean sections in public hospitals, health clinics, and army hospitals. The policy change was driven by the reality that high maternal costs often prevent women from giving birth in health care facilities—and catastrophic costs, such as for caesareans, have the “potential to plunge a household into poverty.” Six years later, the policy is associated with a steady increase in caesarean rates, a drop in maternal and neonatal mortality, and a rise in institutional deliveries in the West African nation, according to a recent report by USAID’s Health System 20/20.

A one-in-15 risk of maternal death
In the landlocked country of 14.5 million people, maternal health is a persistent and deeply destabilizing problem. Mali has a high maternal mortality ratio of 460 women dying to every 100,000 live births. Across a lifetime, this translates into a one in 15 chance of dying in pregnancy—a stark contrast to the 1 in 2,800 lifetime risk in developed countries. Although on the rise, less than one-half of women give birth in a health care facility, less than one-half of births include a skilled birth attendant, and 14 percent of women give birth with no support. Emergency obstetric care, such as caesareans, is considered one of the greatest obstacles to safe motherhood.

Removing the user free for caesareans
Under the new policy, the government paid for  all the direct costs of a caesarean procedure, including pre-operative examinations, a caesarean kit, surgical costs, and post-operative treatment and hospitalization. Health care facilities receive 30,000 FCFA (U.S. $60) and 42,000 FCFA (U.S. $84) for a simple and complicated procedure, respectively. Under the policy, caesareans can only be performed when a health provider determines that they are necessary. In addition, the government provides no monetary or other incentives to providers for performing caesareans. It is important to note that transportation costs, other indirect costs, or normal deliveries, which themselves can be difficult for families to pay, are not covered. Overall, the government has spent 5.9 trillion FCFA (U.S. $11.7 million), increasing annual investment by 40 percent every year since 2005.

Evaluation finds increase in procedure, decrease in maternal and neonatal deaths
Researchers from Health Systems 20/20 analyzed caesarean rates between 2005 and 2009 using government information, survey data from nearly 4,000 women, interviews, and focus group discussions.  

Rate of caesareans increases: Researchers found that the estimated population-based caesarean rate in Mali more than doubled from 0.9 percent in 2005 to 2.3 percent in 2009 across all of the country’s nine regions after the policy was implemented. Although four regions saw their rates triple, Mali nonetheless is still well below recommended international standards of 5 percent to 15 percent of caesareans.

Fewer neonatal deaths: In addition, the share of caesarean procedures ending in death declined as well from 2 percent in 2006 to 1.3 percent in 2009. Similarly, neonatal death following caesareans also improved, from 14 percent to 12 percent. Researchers suggested this improvement may be attributed to families no longer spending time trying to gather money or may be deciding to go to facilities more quickly—improving the survival chances for both mother and child.

However, many challenges remain
Despite these gains, the evaluation identified many obstacles that still stand in the way of Malian women giving birth safely.

  • Almost one-half of women receiving caesareans belong to the richest third of the population, with only 23.9 percent of Mali’s poorest women obtaining services.
  • Most people know about the policy, but do not know all the services it covered.
  • Medical professionals complain about inadequate amount of drugs to do all procedures. Underfunding of referral and emergency transport is the greatest obstacle to receiving timely care. Dangerous road conditions also limit access, especially during rainy season.   

Although there are many challenges  that remain, community members and health care providers view the free caesarean policy as a positive change. According to one man interviewed during a focus group discussion, “Before the policy, a caesarean would be considered disastrous news to the family. Now with the free initiative, everyone can benefit from caesareans even if they do not possess the means.”

Photo via Nathan Laurell

Entry Comments

    • May 24
    • .(JavaScript must be enabled to view this email address)

    Maybe I’m misreading something, and I don’t want to be unduly critical but missing in this report seems to be the reason for performing the caesarean sections.
    It’s probably just a wording issue and I expect they are all justified on clinical grounds, but the fact that they are predominantly being accessed by wealthy women paints a worrying picture.
    Drops in maternal and neonatal mortality are of course to be celebrated and investing in women, their health and other services must be encouraged and maintained by governmenents.
    Raising the caesarean section rate to save lives is excellent, but the WHO standard of up to 15 percent (which has now been withdrawn as a recommendation) was, I thought, there to discourage this top limit being exceeded by countries with too much of a tendency to intervene in normal birth, and not as a target to be hit. 
    The more normal birth we have, the better, albeit within a framework of a working infrastructure, well qualified midwives and effective back-up health facilities.
    Much needs to be done and I’ve never been to Mali so perhaps have no right to contribute.  I just get worried when I see a focus of a solution set on hospital intervention rather than on safely facilitating normal birth.  I appreciate a well placed caesarean section is a life-saving necessity.  However, I wholeheartedly believe that a focus on normal birth is immensely valuable, as and reduce the need for caesarean sections and all their associated costs and risks.

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