Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?

Objective: To investigate, the impact of maternity-related fee payment policies on the uptake of skilled birth care amongst the poor in Ghana.

Methods: Population data representing 12 288 births between November 1990 and October 2008 from four consecutive rounds of the Ghana demographic and health surveys were used to examine the impact of four major maternity-related payment policies: the full-cost recovery 'cash and carry' scheme; 'antenatal care fee exemption'; 'delivery care fee exemption' and the 'National Health Insurance Scheme (NHIS)'. Concentration curves were used to analyse the rich-poor gap in the use of skilled birth care by the four policy interventions. Multilevel logistic regression was used to examine the effect of the policies on the uptake of skilled birth care, adjusting for relevant predictors and clustering within communities and districts.

Findings: The uptake of skilled birth care over the policy periods for the poorest women was trivial when compared with their non-poor counterparts. The rich-poor gap in skilled birth care use was highly pronounced during the 'cash and carry' and 'free antenatal care' policies period. The benefits during the 'free delivery care' and ' NHIS' policy periods accrued more for the rich than the poor. There exist significant differences in skilled birth care use between and within communities and districts, even after adjusting for policy effects and other relevant predictors.

Conclusions: The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care.