Impact of Ghana's fee exemption policy on maternal health service utilisation: an inverse probability of treatment weighting analysis of pooled national data.

Background: Fee exemption policies are key strategies for reducing the barriers to accessing maternal health services and improving maternal and child health outcomes. This study used pooled national data to determine the impact of Ghana's user fee exemption policy on maternal health service utilisation since it was implemented in 2008.

Methods: Using four rounds of cross-sectional data from national surveys on women with live births, we conducted an inverse probability of treatment weighting analysis to evaluate the causal effects of Ghana's user fee exemption policy intervention on the timing of first antenatal care (ANC) visit, completion of four or more ANC visits and facility-based delivery as indicators of maternal health service utilisation.

Results: The average treatment effect of the fee exemption policy was an increase of 8, 9, and 21% in the utilisation of timely first ANC visit, completion of the recommended number of ANC visits, and facility-based delivery, respectively. Wealth index categorisation showed a clear stepwise increase in the likelihood of facility-based delivery. Compared to the poorest group, the odds were 1.48 times higher for the poorer group adjusted odds ratio (aOR) = 1.48 (95% confidence interval (CI) = 1.33-1.66), 2.27 times higher for the middle group aOR = 2.27 (95% CI = 1.95-2.64), 3.84 times higher for the rich group aOR = 3.84 (95% CI = 3.13-4.69), and 5.96 times higher for the richest group aOR = 5.96 (95% CI = 4.43-8.02). Women who reside in the Upper East region were more likely to utilise maternal health services.

Conclusions: Ghana's fee exemption policy positively impacts maternal health service utilisation among pregnant women. However, there still exist disparities across geographical regions and wealth indexes.