Summary objectives: To determine changes in the proportion of deliveries at health facilities and the proportion attended by health professionals after delivery fee exemption implementation.
Design: Pre and post intervention implementation cluster-sampled household survey.
Setting: Central and Volta regions of Ghana.
Participants: Women who had delivered in these regions during the fee exemption policy and an equivalent period of time prior to it.
Main outcome measures: Place of delivery and person attending.
Results: After fee exemption implementation the likelihood of delivering in a health facility increased significantly in Central (OR 1.83, p<0.001) and Volta (OR 1.34, p<0.05) regions when accounting for the mothers' education and poverty levels and the clustered data. Results from Central Region showed increases in facility deliveries mainly occurred in health centres (from 13.7% to 22.3% of deliveries), and were attended by midwives (from 49.0% to 59.7%). There was evidence that after implementation some inequalities in the uptake of facility deliveries decreased. The greatest increase in the proportion of deliveries taking place in facilities occurred among women with the lowest levels of education (Central Region) and wealth (Volta Region). These changes reduced the differentials observed.
Conclusions: After the implementation of fee exemption the proportion of deliveries in health facilities increased in both regions. Although changes cannot be directly attributed to delivery fee exemption, results demonstrating that the greatest increases in facility-based deliveries occurred among the poorest and least educated women are consistent with the expectation that the policy would particularly benefit women with the greatest financial barrier to health care and at the greatest risk of maternal mortality.
Keywords: Women's health; delivery service utilization; fee exemption; programme evaluation.