BACKGROUND : Improving maternal health outcomes by reducing barriers to accessing maternal health services is a
key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for
rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.
METHODS : Data from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years
preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a
difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54
rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this
policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy
announcement in April 2006.
RESULTS : The difference-in-difference estimates point to statistically insignificant changes in the proportion of women
giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based)
facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have
their children born.
CONCLUSION : The removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities.
User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore,
abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving
service quality, may have a greater impact.