User fees are gaining widespread use in government health programs as a means of alleviating pressure on constrained budgets as demand for services increases. Concerns that fees reduce access to services among the poor have led to the promotion of fee exemption mechanisms in order to protect those unable to pay for services. The exemptions, however, may not effectively ensure access among the poor because (1) informal fees and other costs associated with seeking and receiving services are not alleviated by most exemption mechanisms and (2) exemption mechanisms are poorly implemented. The low proportion of formal fees to total costs to the consumer and the unpredictable nature of informal fees and other costs of access may actually work against formal fee exemption mechanisms. Even though little is known about how well fee and waiver mechanisms function for maternal health services, it is important to understand whether exemption mechanisms alone hold promise for protecting access for the poor or whether the mechanisms need to be supplemented with other strategies. This study was conducted simultaneously in five countries: Egypt, India (Uttaranchal), Kenya, Peru, and Vietnam. The objectives were to survey actual costs to consumers for antenatal and delivery care; survey current fee and waiver mechanisms; assess the degree to which these mechanisms function; assess the degree to which informal costs to consumers constitute a barrier to service; and review current policies and practices regarding the setting of fees and the collection, retention, and use of revenue. Methodology For purposes of the study, formal fees are defined as those charges to patients for health care goods and services as published in a health care facility’s policy or elsewhere in an official policy document. Informal fees are any other payments made by clients not formally sanctioned by the health care facility or other expenses clients must incur in order to receive care, including “under-the-table” payments made to any staff affiliated with the health care facility when such payments are a condition of receiving care. Informal fees and other costs to access services also include costs incurred by clients or their families for supplies or drugs that must be purchased outside and brought to the facility, costs for transportation and food, informal board charges, and costs of travel for an accompanying family member. The report presents data synthesized from several sources, including government policies, facility records, household surveys, facility surveys, focus group discussions, and key informant interviews. Results Despite government efforts and favorable policies aimed at improving service provision, utilization rates for maternal health services were low among the poor in the five countries of interest. In Peru, 31 percent of poor women had no antenatal care (ANC) during their last pregnancy, and 83 percent of poor women delivered at home. Similarly, 29 percent of poor women in Kenya had no antenatal care during their last pregnancy, and 85 percent of poor women delivered at home. Irrespective of poverty status, a large proportion of women rely on public sector services. In India (Uttaranchal), 29 percent of ANC clients and 18 percent of delivery clients who receive free services at public facilities fall into the nonpoor category, raising the question of whether subsidized government services are properly targeted to women most in need. The study also found that poor women incurred substantial maternal health expenses in both the public and private sectors. In India (Uttaranchal), poor women who paid for maternal health services in the public and/or private sector spent about US$1.90 on ANC, US$4.50 on home delivery, and up to US$66.90 on institutional delivery