摘要：Lack of access to quality care is the main obstacle to reducing maternal mortality in low-income countries. In many settings, women must pay out-of-pocket fees, resulting in delays, some of them fatal, and catastrophic expenditure that push households into poverty. Various innovative approaches have targeted the poor or exempted specific services, such as cesarean deliveries. We analyzed 8 case studies to better understand current experiments in reducing financial barriers to maternal care. Although service utilization increased in most of the settings, concerns remain about quality of care, equity between rich and poor patients and between urban and rural residents, and financial sustainability to support these new strategies. LACK OF ACCESS TO QUALITY care is the main obstacle to reducing maternal mortality in low- and middle-income countries. 1 Two types of barriers are critical: physical and financial. 2 – 4 Poor countries often have few and widely spaced health facilities that are adequately equipped and staffed with competent, available, and committed personnel. 5 Many women prefer to deliver at home rather than embark on a long, expensive, and painful journey to underequipped health centers and poorly functioning district hospitals. 4 When women or their families in these countries decide to seek health care, the next obstacle is out-of-pocket payment for the services. Access to a cesarean delivery is directly affected by household wealth. In a study of Demographic and Health Survey data for 42 developing countries, cesarean birth rates were extremely low among the very poor: less than 1% for the poorest quintile of the population in 20 countries and less than 1% for 80% of the population in 6 countries. 2 Childbirth can be costly for households in countries that do not provide universal health care. If mother or child suffers complications, costs can skyrocket. 6 There is increasing recognition that maternal costs, especially when complications occur, can plunge a household into poverty or force it to rely on risky coping strategies. 7 , 8 A recent review by the World Health Organization found that the direct costs of maternal health care ranged between 1% and 5% of total annual household expenditures, rising to between 5% and 34% if the woman suffered a complication. 9 The Economic Commission for Africa has called for the elimination of user fees for basic health services as a “quick win” that can diminish health inequities related to poverty and gender discrimination. 10 (p15) In recent years, Nepal and several countries in sub-Saharan Africa have introduced policies that eliminate fees for maternal health care. 11 Social health insurance subsidized by taxation at the national level is considered to be the best way to fund health care, but most countries in sub-Saharan Africa and South Asia do not have the means to organize it. Social health insurance presents challenges in rural areas because of low incomes, limited formal sector employment, and minimal health care infrastructure. 12 Countries are therefore pursuing more specific approaches through different pooling and targeting mechanisms. However, published evaluations of these attempts to reduce financial barriers to obstetric care are still scarce. We aimed to contribute to a better understanding of current experiments in reducing financial barriers to maternal care by analyzing results from 8 case studies, which are published elsewhere. 13 The initiatives described in these studies varied broadly in mechanism (from fee exemption to cash assistance), structure (some local and others national), location (ranging across Africa, Asia, and Latin America), and population target (from all pregnant women to only those from poor households). This breadth allowed us to extract some preliminary lessons for policymakers about likely challenges in different contexts.
