title: The free caesareans policy in low-income settings: an interrupted time series analysis in Mali (2003-2012).
abstract: BACKGROUND
  Several countries have instituted fee exemptions for caesareans to reduce maternal and newborn mortality.
  
  
  OBJECTIVE
  To evaluate the effect of fee exemptions for caesareans on population caesarean rates taking into account different levels of accessibility.
  
  
  METHODS
  The observation period was from January 2003 to May 2012 in one Region and covered 11.7 million person-years. Exemption fees for caesareans were adopted on June 26, 2005. Data were obtained from a registration system implemented in 2003 that tracks all obstetrical emergencies and interventions including caesareans. The pre-intervention period was 30 months and the post-intervention period was 83 months. We used an interrupted time series to evaluate the trend before and after the policy adoption and the overall tendency.
  
  
  RESULTS
  During the study period, the caesarean rate increased from 0.25 to 1.5% for the entire population. For women living in cities with district hospitals that provided caesareans, the rate increased from 1.7% before the policy was enforced to 5.7% 83 months later. No significant change in trends was observed among women living in villages with a healthcare centre or those in villages with no healthcare facility. For the latter, the caesarean rate increased from 0.4 to 1%.
  
  
  CONCLUSIONS
  After nine years of implementation policy in Mali, the caesarean rate achieved in cities with a district hospital reached the full beneficial effect of this measure, whereas for women living elsewhere this policy did not increase the caesarean rate to a level that could contribute effectively to reduce their risk of maternal death. Only universal access to this essential intervention could reduce the inequities and increase the effectiveness of this policy.
authors.affiliation: Research Center of the University of Montreal Hospital (CR-CHUM), Montreal, Canada; School of Public Health, University of Montreal, Montreal, Canada.
authors.forename: Pierre
authors.initials: P
authors.lastname: Fournier
authors.affiliation: Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Dumont
authors.affiliation: Research Center of the University of Montreal Hospital (CR-CHUM), Montreal, Canada.
authors.forename: Caroline
authors.initials: C
authors.lastname: Tourigny
authors.affiliation: Research Center of the University of Montreal Hospital (CR-CHUM), Montreal, Canada.
authors.forename: Aline
authors.initials: A
authors.lastname: Philibert
authors.affiliation: Research Center of the University of Montreal Hospital (CR-CHUM), Montreal, Canada.
authors.forename: Aliou
authors.initials: A
authors.lastname: Coulibaly
authors.affiliation: Unité de recherche et de formation en santé de la mère et de l'enfant (URFOSAME), Referral health center of the Commune V, Bamako, Mali.
authors.forename: Mamadou
authors.initials: M
authors.lastname: Traoré
mesh_terms: D002585:Cesarean Section / Q000191:economics* / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D005260:Female; D006291:Health Policy; D054625:Healthcare Disparities; D006801:Humans; D065186:Interrupted Time Series Analysis; D008302:Mali; D017057:Medically Uninsured; D007744:Obstetric Labor Complications / Q000453:epidemiology / Q000601:surgery*; D010342:Patient Acceptance of Health Care; D011203:Poverty; D011247:Pregnancy; D012424:Rural Population; D014505:Urban Population