Introduction Mali and Benin introduced a user feeexemption policy focused on caesarean sections in 2005and 2009, respectively. The objective of this study is toassess the impact of this policy on service utilisation andneonatal outcomes. We focus specifically on whether thepolicy differentially impacts women by education level,zone of residence and wealth quintile of the household.Methods We use a difference-in-differences approachusing two other western African countries with no feeexemption policies as the comparison group (Cameroonand Nigeria). Data were extracted from Demographic andHealth Surveys over four periods between the early 1990sand the early 2000s. We assess the impact of the policy onthree outcomes: caesarean delivery, facility-based deliveryand neonatal mortality.Results We analyse 99 800 childbirths. The freecaesarean policy had a positive impact on caesareansection rates (adjusted OR=1.36 (95% CI 1.11 to 1.66;P≤0.01), particularly in non-educated women (adjustedOR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those livingin rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76;P≤0.001) and women in the middle-class wealth index(adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). Thepolicy contributes to the increase in the proportion offacility-based delivery (adjusted OR=1.68; 95% CI 1.48 to1.89; P≤0.001) and may also contribute to the decreaseof neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to0.85; P≤0.001).Conclusion This study is the first to evaluate the impactof a user fee exemption policy focused on caesareansections on maternal and child health outcomes withrobust methods. It provides evidence that eliminating feesfor caesareans benefits both women and neonates in sub-Saharan countries.