Inequalities in access to birth by caesarean section in the context of user fee exemption for maternal health services in southwest and north central Nigeria

BACKGROUND: User fee exemption for maternal healthcare services was introduced with a focus on providing free maternal health services, including caesarean sections (CS), in Nigeria. This policy has had a positive impact on access to facility-based delivery; however, the extent to which inequality in access to CS exists in the context of user fee exemption is unclear. The objective of this study was to examine inequalities in access to birth by CS 5 y after the implementation of the user fee exemption policy. METHODS: Data were obtained from 1227 women who gave birth between 2011 and 2015 and were selected using cluster random sampling between May and August 2016 from two of the six main regions of the country. Adjusted and unadjusted binary logistic regression models were performed. RESULTS: An overall CS rate of 6.1% was found, but varied by income, education and place of residence. Women who earned a monthly income of ≤20 000 naira (US [Formula: see text] 150) were 50% less likely to have a birth by CS compared with those who earned more. Compared with women who were educated to the tertiary level, women who had a secondary education or less were 51% less likely to give birth by CS. CONCLUSIONS: This study shows that inequality in access to CS persists despite the implementation of free maternal healthcare services.