Direct and Indirect Effects of Free Cesarean Section Access on Maternal and Infant Outcomes

Background Maternal and infant mortality remain pressing health challenges in Sub-Saharan Africa, where financial barriers often restrict access to lifesaving obstetric care. In 2008, Benin implemented a nationwide policy eliminating user fees for cesarean sections. This paper assesses both the direct and indirect effects of the reform on maternal and infant outcomes. Methods Using Demographic and Health Surveys (2001, 2006, 2011) from seven West African countries and national census microdata, I estimate a difference-in-differences model comparing Benin (treatment group) with neighboring countries (control group). Outcomes include infant mortality, maternal mortality among surviving children, fertility behavior, and maternal labor supply. Results The policy reduced stillbirths and infant mortality by an average of 18.8%, with the largest gains among older women, those without formal education, and those in lower wealth quintiles. However, maternal mortality among surviving children rose by approximately 5.2%, indicating potential health risks for mothers. The policy also contributed to smaller family sizes and a 25.8% decline in women’s labor force participation following childbirth. Conclusions While Benin’s free cesarean section policy substantially improved neonatal survival, it also produced unintended negative consequences for maternal health and postnatal employment. Complementary investments in obstetric quality, maternal recovery care, and follow-up support are essential to ensure that financial access translates into lasting health and economic benefits for women.