Assessing regional variations in the effect of the removal of user fees on facility-based deliveries in rural Zambia

Background: Maternal health remains a concern in sub-Saharan Africa, where maternal mortality averages 680 per 100,000 live births and almost 50% of the approximately 350,000 annual maternal deaths occur. Improving access to skilled birth assistance is paramount to reducing this average, and user fee reductions could help. Objective. The aim of this research was to analyse the effect of user fee removal in rural areas of Zambia on the use of health facilities for childbirth. The analysis incorporates supply-side factors, including quantitative measures of service quality in the assessment. Method: The analysis uses quarterly longitudinal data covering 2003 (q1)-2008 (q4) and controls for unobserved heterogeneity, spatial dependence and quantitative supply-side factors within an Interrupted Time Series design. Results: User fee removal was found to initially increase aggregate facility-based deliveries. Drug availability, the presence of traditional birth attendants, social factors and cultural factors also influenced facility-based deliveries at the national level. Conclusion: Although user fees matter, to a degree, service quality is a relatively more important contributor to the promotion of facility-based deliveries. Thus, in the short-term, strengthening and improving community-based interventions could lead to further increases in facility-based deliveries.