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Objective  Lesotho has one of the highest maternal mortality rates in the world. While at primary health care ( PHC ) level maternity care is free, at hospital level co‐payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital ( SJH ) in Roma, Lesotho.    Methods  We compared utilisation of delivery services, stillbirths and maternal and neonatal mortality for the periods before (1 July 2012 to 31 December 2013) and after (1 January 2014 to 30 June 2015) user fee removal through a retrospective chart review and estimated additional costs attributed to user fee removal from provider (hospital) and patient perspectives.    Results  Of 4715 deliveries 3855 were at  SJH  and 860 at  PHC  centres. Of women delivering at  SJH  684 (18.5%) were ≤19 years and 894 (23.6%) were  HIV  positive. After user fee removal hospital deliveries increased by 49% — from 1547 to 2308 — and neonatal mortality decreased from 4.8 to 1.3 per 1000 live births ( P  = 0.033). Extrapolating costs to the entire country, 1  USD  per capita per year would allow user fee removal at hospital level, the provision of free transport to/from and accommodation at hospital.    Conclusion  Removing user fees for hospital delivery care in Lesotho is feasible and affordable, and has the potential to improve maternal and neonatal outcomes by removing financial barriers to skilled birth attendants and increasing coverage of institutional deliveries.

Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho