[Doing more to earn more: cesarean sections based on three cases of exemption from payment in Senegal]

In 2007, the number of caesarean sections performed in Senegal increased by 124% compared to the number of caesarean sections recorded before the introduction of a C-section funding initiative in 2006. The rate of increase varies in different regions and hospitals, with some hospitals performing caesarean sections in over 50% of deliveries. The purpose of this paper is to analyze the main reasons for high hospital caesarean section rates (i.e. above the national average) based on three cases of exemption from payment. The study is based on a qualitative method involving semi-structured interviews with healthcare and administrative staff and pregnant women in three healthcare institutions and interviews with central health authorities. Research indicates that high caesarean section rates are not directly linked to the C-section subsidy policy introduced in 2006. The perception of caesarean rates is more closely linked to the perception of population rates among healthcare professionals than to the perception of institutional (hospital) rates. Since population rates are very low, healthcare professionals tend to perform more caesarean sections. Among management staff, the financial returns of high caesarean section rates (in the three levels of exemption) represent a significant motivation for encouraging healthcare professionals to perform more C-sections. Despite these high rates, a normative discourse was found to be held by healthcare professionals, who tend to consider that their practices are aimed exclusively at saving the mother or the child. However, in the long term, high caesarean section rates may result in an increase of maternal deaths and go against MDG 5, aimed at reducing maternal mortality by 3/4 by 2015.