Amazons in Mali? Women's experiences of breast cancer and gender (re)negotiation.

Breast cancer is the second most common cancer, with more than 2.31 million cases diagnosed worldwide in 2022. Cancer medicine subjects the body to invasive procedures in the hope of offering a chance of recovery. In the course of treatment, the body is pricked, burned, incised and amputated, sometimes shattering identity and often changing the way women perceive the world. In sub-Saharan Africa, incidence rates are steadily increasing and women are particularly young when they develop breast cancer. Despite this alarming situation, the scientific literature on breast cancer in sub-Saharan Africa is poor and largely dominated by medical literature. Using a qualitative approach and a theoretical framework at the intersection of the sociology of gender and the sociology of the body, we explore the discourse strategies of women with breast cancer in Mali regarding their relationship to the body and to others. Based on 25 semi-directive interviews, we analyse the experiences of these women. Using the image of the Amazon woman, whose struggle has challenged gender because of its masculine attributes, we explore whether these women's fight against their breast cancer could be an opportunity to renegotiate gender relations. The experience of these women is characterised by the deconstruction of their bodies, pain and suffering. The masculinisation of their bodies and their inability to perform certain typically female functions in society (such as cooking or sexuality) challenges their female identity. The resistance observed through the sorority, discreet mobilisation and display of their bodies does not seem to be part of a renegotiation of gender relations, but it does play an active role in women's acceptance of the disease and their reconstruction.

Access to oncology care in Mali: a qualitative study on breast cancer.

BACKGROUND: Breast cancer is the most common cancer in terms of incidence and mortality among women worldwide, including in Africa, and a rapid increase in the number of new cases of breast cancer has recently been observed in sub-Saharan Africa. Oncology is a relatively new discipline in many West African countries, particularly Mali; thus, little is known about the current state of cancer care infrastructure and oncology practices in these countries. METHODS: To describe the challenges related to access to oncology care in Mali, we used a qualitative approach, following the Consolidated Criteria for Reporting Qualitative Research (COREQ). Thirty-eight semistructured interviews were conducted with health professionals treating cancer in Mali (n = 10), women with breast cancer (n = 25), and representatives of associations (n = 3), and 40 participant observations were conducted in an oncology unit in Bamako. We used the theoretical framework on access to health care developed by Levesque et al. a posteriori to organise and analyse the data collected. RESULTS: Access to oncology care is partly limited by the current state of Mali's health infrastructure (technical platform failures, repeated strikes in university hospitals, incomplete free health care and the unavailability of medicines) and exacerbated by the security crisis that has been occurring the country since 2012. The lack of specialist doctors, combined with limited screening campaigns and a centralised and fragmented technical platform in Bamako, is particularly detrimental to breast cancer treatment. Women's lack of awareness, lack of information throughout the treatment process, stereotypes and opposition to amputations all play a significant role in their ability to seek and access quality care, leading some women to therapeutically wander and others to want to leave Mali. It also leaves them in debt and jeopardises the future of their children. However, the high level of trust in doctors, the involvement of international actors, the level of social support and the growing influence of civil society on the issue of cancer also represent great current opportunities to fight cancer in Mali. CONCLUSION: Despite the efforts of successive Malian governments and the commitment of international actors, the provision of health care is still limited in the country, entrenching global inequalities in women's bodies.

"A vaccine that nonetheless remains apart": Papillomavirus and vaccination in France / « Un vaccin qui reste quand même à part ¼ : Papillomavirus et vaccination en France

Introduction: Vaccination against the human papillomavirus (HPV) is currently not widespread in France, where the vaccination rate is one of the lowest in Europe. However, this virus is encountered by 80% of the population and causes 3000 new cases of cancer per year. This vaccination constitutes a real lever for action. Purpose of research: Using a qualitative approach (semi-directive interviews), we documented the perceptions, reluctance, and obstacles of sixteen general practitioners in Ile de France. The objective was to understand the low vaccination rate and to propose sustainable solutions to increase adherence to this vaccine. Results: The HPV vaccine is different from other vaccines, which makes it more difficult for the public to understand. Firstly, because it affects the privacy of patients from a very young age. Secondly, because it has long been dedicated to a female public and the opening of vaccination to boys of the same age leads to a change in discourse and a break with its gendered image. Finally, this vaccination is taking place in a context where there is a marked reluctance to vaccinate in France, with a rapid circulation of more or less reliable information that often places the medical profession in difficulty. Conclusions: Health professionals play a key role in convincing and encouraging patients to adhere to the vaccine, and a majority of doctors are still in favor of vaccination. Relying on a wider group of health professionals could help to increase adherence to the vaccine in France.

Introduction: La vaccination contre le papillomavirus humain (HPV) est aujourd'hui peu répandue en France où le taux vaccinal est l'un des plus faibles d'Europe. Pourtant, ce virus est rencontré par 80 % de la population et entraine 3 000 nouveaux cas de cancers du col de l'utérus par an. Cette vaccination constitue un réel levier d'action, notamment par le biais des médecins généralistes. But de l'étude: L'objectif était de comprendre le faible taux vaccinal en France et de proposer des solutions durables pour augmenter l'adhésion à ce vaccin. Avec une approche qualitative, nous avons documenté les perceptions, réticences et obstacles de seize médecins généralistes en Île de France. Résultats: Le vaccin anti-HPV présente des particularités qui rendent son abord plus délicat auprès de la population. D'abord, parce qu'il touche à l'intimité des patients et ce, dès un très jeune âge. Ensuite, parce qu'il a longtemps été dédié à un public féminin ; l'ouverture de la vaccination aux garçons du même âge entraine donc une modification des discours et une rupture avec son image genrée. Enfin, cette vaccination s'inscrit dans un contexte où l'hésitation vaccinale est marquée en France, avec une circulation rapide d'informations plus ou moins fiables venant souvent mettre en difficulté le corps médical. Conclusions: Les professionnels de santé détiennent un rôle clé pour convaincre et entrainer l'adhésion des patients, et une majorité des médecins reste favorable à cette vaccination. S'appuyer sur un ensemble de professionnels de santé plus large pourrait permettre d'augmenter l'adhésion vaccinale en France.

Radiothérapie et lutte contre les cancers : défis de maintenance de l'unique accélérateur linéaire à l'Hôpital du Mali.

Cancer incidence and mortality rates are increasing in West Africa. Cancer is a recent discipline in Mali and the means available to treat patients are insufficient. Mali has only one radiotherapy machine for the country and its malfunctions are regularly reported in the media. In order to understand the recurrent dissatisfactions linked to access to radiotherapy in Mali, we retraced the history of this machine and described its functioning. Based on semi-directive interviews with patients’ associations and health professionals involved in cancer care in Bamako, we describe how radiotherapy in Mali reveals global health issues through the intervention of numerous international cooperations. In addition, based on data collection from medical registers and institutional reports, we report that the average time to get a radiotherapy appointment is 3 to 6 months in Mali, but also that the radiotherapy machine has experienced 198 breakdowns between April 3, 2014 and September 24, 2021, which represents more than 54 weeks of cumulative downtime. Radiotherapy is a crucial element in the treatment of cancer and the lack of access to this treatment worsens the vital diagnosis of patients. While the Malian government is committed to universal health coverage reforms, strengthening cancer treatment facilities should also be considered a public health priority for Mali.

Les violences gynécologiques et obstétricales : construction d'une question politique et de santé publique.

The concept of “gynecological and obstetric violence”, which emerged in the early 2000s in Latin America in activist and scientific circles, has been debated since the 2010s in French and European feminist and political circles. We show here how this concept is defined, what realities and practices it covers and by whom and in what context it is used in the public space in France and internationally, and in academic research. This concept allows for a new approach to medical care in gynecology and obstetrics that takes into account the experiences, both objective and subjective, of women and medical practices that are now technical, sometimes impersonal and disrespectful. Although there is a growing body of work in the social sciences that uses this conceptual approach, it focuses more on childbirth and less on strictly gynecological medical care.

Normal delivery: physiologic support and medical interventions. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF).

OBJECTIVE: To define for women at low obstetric risk methods of management that respect the rhythm and the spontaneous course of giving birth as well as each woman's preferences. METHODS: These clinical practice guidelines were developed through professional consensus based on an analysis of the literature and of the French and international guidelines available on this topic. RESULTS: Labor should be monitored with a partograph (professional consensus). Digital cervical examination should be offered every 4 h during the first stage of labor, hourly during the second. The choice between continuous (cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring should be left to the woman (professional consensus). In the active phase of the first stage of labor, dilation speed is considered abnormal if it is less than 1 cm/4 h between 5 and 7 cm or less than 1 cm/2 h after 7 cm. In those cases, an amniotomy is recommended if the membranes are intact, and the administration of oxytocin if the membranes are already broken and uterine contractions are judged insufficient (professional consensus). It is recommended that pushing not begin when full dilation has been reached; rather, the fetus should be allowed to descend (grade A). Umbilical cord clamping should be delayed beyond the first 30 s in newborns who do not require resuscitation (grade C). CONCLUSION: The establishment of these clinical practice guidelines should enable women at low obstetric risk to receive better care in conditions of optimal safety while supporting physiologic birth.

Reasons for rejecting hormonal contraception in Western countries: A systematic review.

Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading "hormonophobia", i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

In the era of humanitarian crisis, young women continue to die in childbirth in Mali.

Maternal mortality occurs mostly in contexts of poverty and health system collapse. Mali has a very high maternal mortality rate and this extremely high mortality rate is due in part to longstanding constraints in maternal health services. The central region has been particularly affected by the humanitarian crisis in recent years, and maternal health has been aggravated by the conflict. Sominé Dolo Hospital is located in Mopti, central region. In the last decade, a high number of pregnant or delivering women have died in this hospital.We conducted a retrospective and exhaustive study of maternal deaths occurring in Mopti hospital. Between 2007 and 2019, 420 women died, with an average of 32 deaths per year. The years 2014-2015 and the last 2 years have been particularly deadly, with 40 and 50 deaths in 2018 and 2019, respectively. The main causes were hypertensive disorders/eclampsia and haemorrhage. 80% of these women's deaths were preventable. Two major explanations result in these maternal deaths in Sominé Dolo's hospital: first, a lack of accessible and safe blood, and second, the absence of a reference and evacuation referral system, all of which are aggravated by security issues in and around Mopti.Access to quality hospital care is in dire need in the Mopti region. There is an urgent need for a safe blood collection system and free of charge for pregnant women. We also strongly recommend that the referral/evacuation system be reinvigorated, and that universal health coverage be strengthened.

Dépasser la tension éthique de la césarienne sur demande maternelle.

INTRODUCTION: In a legal context focused on the right and autonomy of the patient, some women wish to be able to choose their mode of childbirth. As midwives are primary care-givers for pregnant women with a physiological pregnancy, we wanted to find out whether it was ethically acceptable for them to accompany a woman in her decision to have a caesarean section. PURPOSE OF RESEARCH: This survey is an ancillary study of the CESARIA research program validated by the Comité de Protection des Personnes Sud Méditerranée IV and declared to the CNIL. Thirty-seven semi-directive interviews were conducted with midwives and women. RESULTS: The majority of women and midwives share a vision of childbirth as “natural” and consider the request for caesarean section as a pathology. When formulated, this request places midwives in a situation of ethical tension. On the one hand, midwives wish to refer women to vaginal birth as the norm, and this choice embodies the ethical principles of beneficence and non-maleficence. On the other hand, midwives express a desire to respect patient choice and freedom, illustrating the ethical principle of respect for autonomy. CONCLUSIONS: The ethical issue of caesarean section on demand lies not so much in the decision to accept or not to accept a caesarean section but rather in listening to the request. Taking into consideration a medical indication more broadly than the simple obstetrical indication makes it possible to ethically support these requests while respecting the pregnant woman’s autonomy.

'A caesarean section is like you've never delivered a baby': A mixed methods study of the experience of childbirth among French women.

The experience of childbirth has been technologized worldwide, leading to major social changes. In France, childbirth occurs almost exclusively in hospitals. Few studies have been published on the opinions of French women regarding obstetric technology and, in particular, caesarean section. In 2017-2018, we used a mixed methods approach to determine French women's preferences regarding the mode of delivery, and captured their experiences and satisfaction in relation to childbirth in two maternity settings. Of 284 pregnant women, 277 (97.5%) expressed a preference for vaginal birth, while seven (2.5%) women expressed a preference for caesarean section. Vaginal birth was also preferred among 26 women who underwent an in-depth interview. Vaginal birth was perceived as more natural, less risky and less painful, and to favour mother-child bonding. This vision was shared by caregivers. The women who expressed a preference for vaginal birth tended to remain sexually active late in their pregnancy, to find sexual intercourse pleasurable, and to believe that vaginal birth would not enlarge their vagina. A large majority (94.5%) of women who gave birth vaginally were satisfied with their childbirth experience, compared with 24.3% of those who underwent caesarean section. The caring attitude of the caregivers contributed to increasing this satisfaction. The notion of women's 'empowerment' emerged spontaneously in women's discourse in this research: women who gave birth vaginally felt satisfied and empowered. The vision shared by caregivers and women that vaginal birth is a natural process contributes to the stability of caesarean section rates in France.

Caesarean section in Benin and Mali: increased recourse to technology due to suffering and under-resourced facilities.

In line with policies to combat maternal mortality, the medicalization of childbirth is increasing in low-income countries, while access to healthcare services remains difficult for many women. High caesarean section rates have been documented recently in hospitals in Mali and Benin, illustrating an a-priori paradoxical situation, compared with low caesarean section rates in the population. Through a qualitative approach, this article aims to describe the practice of caesarean section in maternity wards in Bamako and Cotonou. Workshops with obstetricians and midwives; participant observation inside labour rooms; and in-depth interviews with caregivers, patients and policy makers have indicated increased recourse to caesarean section due to women's and caregivers' suffering and under-resourced facilities. Within these procedures, two types of caesarean section were documented: 'maternal distress caesarean section' and 'preventive caesarean section'. The main reasons for these caesarean sections are maternal fear and pain, and a lack of resources. Inadequately resourced facilities lead to staff suffering and ethical breakdowns, and encourage the inappropriate use of technology. The policy of access to free caesarean section procedures exacerbates the issue of non-medically-justified caesarean sections in these countries. The overuse of caesarean section is particularly alarming in countries with high fertility as it constitutes a danger to both mothers and babies in the short and long term. Currently, conditions are in place in Benin and Mali for an increase in non-medically-justified caesarean sections. In the short term, such an increase could constitute a new burden for these two sub-Saharan countries, where maternal mortality is high.

[Moving beyond the ethical tension of caesarean section on maternal request]. / Dépasser la tension éthique de la césarienne sur demande maternelle.

INTRODUCTION: In a legal context focused on the right and autonomy of the patient, some women wish to be able to choose their mode of childbirth. As midwives are primary care-givers for pregnant women with a physiological pregnancy, we wanted to find out whether it was ethically acceptable for them to accompany a woman in her decision to have a caesarean section.Purpose of research: This survey is an ancillary study of the CESARIA research program validated by the Comité de Protection des Personnes Sud Méditerranée IV and declared to the CNIL. Thirty-seven semi-directive interviews were conducted with midwives and women. RESULTS: The majority of women and midwives share a vision of childbirth as “natural” and consider the request for caesarean section as a pathology. When formulated, this request places midwives in a situation of ethical tension. On the one hand, midwives wish to refer women to vaginal birth as the norm, and this choice embodies the ethical principles of beneficence and non-maleficence. On the other hand, midwives express a desire to respect patient choice and freedom, illustrating the ethical principle of respect for autonomy. CONCLUSIONS: The ethical issue of caesarean section on demand lies not so much in the decision to accept or not to accept a caesarean section but rather in listening to the request. Taking into consideration a medical indication more broadly than the simple obstetrical indication makes it possible to ethically support these requests while respecting the pregnant woman’s autonomy.

Magnitude and correlates of caesarean section in urban and rural areas: A multivariate study in Vietnam.

Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs.

How is women's demand for caesarean section measured? A systematic literature review.

BACKGROUND: Caesarean section rates are increasing worldwide, and since the 2000s, several researchers have investigated women's demand for caesarean sections. QUESTION: The aim of this article was to review and summarise published studies investigating caesarean section demand and to describe the methodologies, outcomes, country characteristics and country income levels in these studies. METHODS: This is a systematic review of studies published between 2000 and 2017 in French and English that quantitatively measured women's demand for caesarean sections. We carried out a systematic search using the Medline database in PubMed. FINDINGS: The search strategy identified 390 studies, 41 of which met the final inclusion criteria, representing a total sample of 3 774 458 women. We identified two different study designs, i.e., cross-sectional studies and prospective cohort studies, that are commonly used to measure social demand for caesarean sections. Two different types of outcomes were reported, i.e., the preferences of pregnant or non-pregnant women regarding the method of childbirth in the future and caesarean delivery following maternal request. No study measured demand for caesarean section during the childbirth process. All included studies were conducted in middle- (n = 24) and high-income countries (n = 17), and no study performed in a low-income country was found. DISCUSSION: Measuring caesarean section demand is challenging, and the structural violence leading to demand for caesarean section during childbirth while in the labour ward remains invisible. In addition, the caesarean section demand in low-income countries remains unclear due to the lack of studies conducted in these countries. CONCLUSION: We recommend conducting prospective cohort studies to describe the social construction of caesarean section demand. We also recommend conducting studies in low-income countries because demand for caesarean sections in these countries is rarely investigated.

State of midwifery research in France.

OBJECTIVE: We describe French midwives' experience and perception of research and publication as well as their publications in scientific and professional journals. DESIGN: We conducted an online cross sectional survey of midwives from June to November 2016; complemented by a bibliometric analysis of their publications in any language. SETTING: This study was conducted in France, where it is necessary to question some midwifery and obstetrical practices. PARTICIPANTS: 146 midwives working/residing in France or holding/studying in France for a PhD or a Masters' degree at the time of the study; or having already published articles in any scientific or professional journal. FINDINGS: Of the 146 eligible midwives, 91.8% were female; 15 (10.3%) had a PhD degree, 26 (17.8%) and 80 (54.8%) were preparing a PhD and a Master's degree, respectively. A total of 140 midwives (95.8%) were working in midwifery and 54 (37.0%) respondents reported having already participated in midwifery research programs. Publication experience was reported by 73 midwives, including 26 (17.8%) who have published at least one article on midwifery in a journal accessible online and peerreviewed. 97.2% of midwives with publication experience consider it useful to publish but 75.7% consider that it is a difficult process. Lack of time, not mastering scientific writing and English language are their main barriers to publication. We identified 218 articles published by these midwives before January 2016, including 180 (82.6%) on maternal and perinatal health. Of their 134 unique articles on midwifery accessible online, 77 (57.5%) dealt with bio-medical topics, 49 (36.6%) with health system issues, and 17 (12.7%) used human and social sciences approaches. Pregnancy and birth were the two most studied reproductive life phases. Eighty-nine (28.4%) of these 314 articles were about midwifery practices or interventions. Since 1990, 93 articles have been published on midwifery in peer-reviewed journals, including 32 in the French language. The number of publications increased significantly with time with a progression coefficient at +1.18% per year, in particular in scientific journals (+0.78% per year). KEY CONCLUSIONS AND IMPLICATION: We evidenced that even though midwives in France have a still limited experience of research, and few of them have completed a PhD degree, or receive a salary for doing research, they publish an increasing number of scientific articles on midwifery topics. However, very few research programs in France examine aspects of midwifery. This scarcity is a major barrier to the involvement of midwives in research. Scientific publications about midwifery in French language are limited mainly due to the lack of adequate and specialized journal in French. However, publishing in French would facilitate the access to knowledge and evidence of midwifery practitioners in Frenchspeaking countries, including French-speaking Africa, where maternal mortality ratios can be very high. We suggest and discuss a number of approaches to increase access to scientific knowledge on midwifery in France and French-speaking countries.

Do free caesarean section policies increase inequalities in Benin and Mali?

BACKGROUND: Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS: We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS: We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS: Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.

Why are caesarean section rates so high in facilities in Mali and Benin?

OBJECTIVE: To assess new estimates of caesarean section (c-section) rates in facilities in two sub-Saharan countries using the Robson classification. METHODS: This study is a retrospective study. Workshops were organized in Mali and Benin in 2017 to train health care professionals in the use of the Robson classification. Nine health facilities in Mali and Benin were selected to participate in the study. Data for deliveries performed in 2014, 2015, and 2016 were included. RESULTS: A total of 12,472 deliveries were included. The overall c-section rate was high in facilities in both countries: 31.0% in Mali and 43.9% in Benin. Women classified as high-risk (groups 6-10) were small relative contributors to the overall c-section rate (19.3% in Mali and 25.3% in Benin), while low-risk women (groups 1-4) were high relative contributors (55.4% in Mali and 45.2% in Benin). C-section rates in women who had undergone a previous c-section were especially high in both countries (84.0% in Mali; 82.5% in Benin). This group was the largest contributor to the overall c-section rates in both countries. CONCLUSIONS: We found high c-section rates in facilities in Mali and Benin, particularly for low-risk women and for women with a previous c-section. Further investigations should be carried out to understand why the c-section rates are so high in these facilities. Strategies must be implemented to avoid unnecessary c-sections, which potentially lead to further complications, particularly in countries with high fertility rates.

Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa.

INTRODUCTION: Mali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household. METHODS: We use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality. RESULTS: We analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001). CONCLUSION: This study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.