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Effect of delivery care user fee exemption policy on institutional maternal deaths in the Central and Volta regions of Ghana

By W.K. Bosu, Jacqueline S. Bell, Margaret Armar-Klemesu and Janet Ansong-Tornui


Background: To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees. Objective: To examine the effect of the exemption policy on delivery-related maternal mortality. Methods: Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15-49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR). Results: A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions. Conclusion: The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy. In late 2003, the Government of Ghana introduced a policy exempting women in the four poorest regions of the country (the three northern regions and the Central Region) attending public and private health facilities from paying user fees for delivery care. An amount of about USD 2 million was voted for this purpose. The ‘fee-free’ delivery policy aimed to improve levels of skilled attendance at birth and thereby reduce maternal morbidity and mortality. In 2005, the policy was extended to the remaining six regions of the country1. As part of a multi-component study evaluating this policy, we investigated the effect of the policy on institutional maternal mortality in two regions. The objectives of the study were to measure any effect of the intervention on hospital maternal mortality ratios (MMRs) for all maternal deaths, and focus, in particular, on delivery-related deaths, as these should be most influenced by the policy. Reported figures from the Central Region demonstrate a significant reduction in total institutional MMR from 2001 through to 20042,3. We anticipated, this trend could reverse if increasing numbers of complicated cases referred from lower level facilities or reported directly to the district hospitals in response to the free delivery care policy. We also analysed the change in the distribution of causes of the maternal death over the study period.This work was undertaken as part of an international research programme - Immpact. See:, funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

Topics: Exemption policy, maternal death, institutional maternal deaths, Central Region, Volta Region, Ghana
Publisher: Ghana Medical Association
Year: 2007
OAI identifier:

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  1. (2004). Discontinuation of cost sharing in Uganda. Bull World Health Org
  2. (2005). Economic and welfare impact of the abolition of health user fees: evidence from Uganda. doi:10.1093/ jae/ejh034. doi
  3. (2006). Effect of Universal Fee exemption on Quality of Care in Hospitals.
  4. (2006). Evaluation of the free delivery policy in Ghana: Population estimates of changes in delivery service utilisation. Final draft report.
  5. (1997). Examination of attendance patterns before and after introduction of South Africa's policy of free health care for children aged under 6 years and pregnant women. BMJ doi
  6. (2006). Funding and Sustainability of the Delivery Exemptions Policy in Ghana.
  7. (2004). Health Directorate. Annual Report doi
  8. (2007). Implementation and provision of fee exempSeptember
  9. (2006). Implementation and provision of fee exemption for delivery care in Ghana. doi
  10. (2006). Maternal Outcomes Work Programme. Rapid Ascertainment Process for Institutional Deaths (RAPID) in the Central Region.
  11. (2006). Ministry of Health. The Ghana Health Sector Annual
  12. (1993). Organization. International statistical classification of diseases and related health problems, 10th revision. doi
  13. (2004). Public Health Division. Annual Report
  14. (2005). Removing user fees for primary care in Africa: the need for careful action. Br Med J doi
  15. (2004). SPSS for Windows Version 13 [program].
  16. (1997). Upgrading obstetric care at the health center level, doi
  17. Version 6: A word-processing, database and statistics program for public health on IBM-compatible microcomputers. [program]. 6.04d version.
  18. (2004). Volta Regional Health Directorate. Annual Report

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