Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho

Objective Lesotho has one of the highest maternal mortality rates in the world. While at primary health care (PHC) level maternity care is free, at hospital level co‐payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital (SJH) in Roma, Lesotho. Methods We compared utilisation of delivery services, stillbirths and maternal and neonatal mortality for the periods before (1 July 2012 to 31 December 2013) and after (1 January 2014 to 30 June 2015) user fee removal through a retrospective chart review and estimated additional costs attributed to user fee removal from provider (hospital) and patient perspectives. Results Of 4715 deliveries 3855 were at SJH and 860 at PHC centres. Of women delivering at SJH 684 (18.5%) were ≤19 years and 894 (23.6%) were HIV positive. After user fee removal hospital deliveries increased by 49% — from 1547 to 2308 — and neonatal mortality decreased from 4.8 to 1.3 per 1000 live births (P = 0.033). Extrapolating costs to the entire country, 1 USD per capita per year would allow user fee removal at hospital level, the provision of free transport to/from and accommodation at hospital. Conclusion Removing user fees for hospital delivery care in Lesotho is feasible and affordable, and has the potential to improve maternal and neonatal outcomes by removing financial barriers to skilled birth attendants and increasing coverage of institutional deliveries. Objectif Le Lesotho a l'un des taux de mortalité maternelle les plus élevés au monde. Alors qu'au niveau des soins de santé primaires (SSP), les soins de maternité sont gratuits, au niveau de l'hôpital, une participation aux frais est requise des patientes. Nous décrivons l'utilisation des services et les résultats des accouchements après élimination des frais d'utilisation et la qualité des soins d'accouchement, ainsi que les coûts associés, à l'hôpital St Joseph (SJH) de Roma, au Lesotho. Méthodes Nous avons comparé l'utilisation des services d'accouchement, les mortinaissances et la mortalité maternelle et néonatale pour les périodes avant (1er juillet 2012 au 31 décembre 2013) et après (1er janvier 2014 au 30 juin 2015) la suppression des frais d'utilisation à travers une analyse graphique rétrospective et avons estimé les coûts supplémentaires imputés à la suppression des frais d'utilisation selon les perspectives du prestataire (l'hôp