title: Effect of a policy to reduce user fees on the rate of skilled birth attendance across socioeconomic strata in Burkina Faso.
abstract: BACKGROUND
  In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata.
  
  
  METHODS
  We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES.
  
  
  RESULTS
  For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years.
  
  
  CONCLUSIONS
  Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa.
authors.affiliation: Alliance for Health Policy and Systems Research, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland, langloise@who.int.
authors.forename: Étienne V
authors.initials: ÉV
authors.lastname: Langlois
authors.affiliation: Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Kresge Building, Room K201 London, Ontario N6A 5C1, Canada and.
authors.forename: Igor
authors.initials: I
authors.lastname: Karp
authors.affiliation: Société d'études et de recherches en santé publique (SERSAP), BP 9150, Ougadougou 06, Burkina Faso.
authors.forename: Jean De Dieu
authors.initials: Jde D
authors.lastname: Serme
authors.affiliation: Société d'études et de recherches en santé publique (SERSAP), BP 9150, Ougadougou 06, Burkina Faso.
authors.forename: Abel
authors.initials: A
authors.lastname: Bicaba
mesh_terms: D000293:Adolescent; D000328:Adult; D002050:Burkina Faso; D036861:Delivery, Obstetric / Q000191:economics; D005251:Fees, Medical; D005260:Female; D005380:Financing, Government / Q000379:methods; D006291:Health Policy / Q000191:economics*; D006801:Humans; D008427:Maternal Health Services / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D011247:Pregnancy; D012923:Social Class; D055815:Young Adult
keywords: Health services utilization; maternal health; obstetric care; skilled birth attendance; subsidy policy; user-fee alleviation