BACKGROUND: Increasing the percentage of maternal health service utilization in health facilities, through costremoval
policy is important in reducing maternal deaths. The Cross River State Government of Nigeria introduced
a cost-removal policy in 2009, under the umbrella of “PROJECT HOPE” where free maternal health services are
provided. Since its inception, there has been no formal evaluation of its effectiveness.
AIM: This study aims to evaluate the effect of the free maternal health care program on the health care-seeking
behaviours of pregnant women in Cross River State, Nigeria.
METHOD: A mixed method approach (quantitative and qualitative methods) was used to describe the effect of
free maternal health care intervention. The quantitative component uses data on maternal health service
utilisation obtained from PROJECT HOPE and Nigeria Demographic Health Survey. The qualitative part uses
Focus Group Discussions to examine women's perception of the program.
RESULTS: Results suggest weak evidence of change in maternal health care service utilization, as 95%
Confidence Intervals overlap even though point estimate suggest increase in utilization. Results of quantitative
data show increase in the percentage of women accessing maternal health services. This increase is greater than
the population growth rate of Cross River State which is 2.9%, from 2010 to 2013. This increase is likely to be a
genuine increase in maternal health care utilisation. Qualitative results showed that women perceived that there
have been increases in the number of women who utilize Antenatal care, delivery and Post Partum Care at health
facilities, following the removal of direct cost of maternal health services. There is urban and rural differences as
well as between communities closer to health facility and those further off. Perceived barriers to utilization are
indirect cost of service utilization, poor information dissemination especially in rural areas, perceived poor quality
of care at facilities including drug and consumables stock-outs, geographical barriers, inadequate health work
force, and poor attitude of skilled health workers and lack of trust in the health system.
CONCLUSION: Reasons for Maternal health care utilisation even under a cost-removal policy is multi-factorial.
Therefore, in addition to fee-removal, the government must be committed to addressing other deterrents so as to
significantly increase maternal health care service utilisation.