The Impact of Removing User Fees on Maternal and Child Health Services: A Systematic Review of Quasi-Experimental Studies

User fee removal is emerging as a leading strategy to expand access to financial services for maternal and child health (MCH) services. However, whether such policies improve downstream outcomes or equity remains unclear. We conducted a systematic review of quasi-experimental studies evaluating the effects of user fee removal on the MCH continuum of care, mortality outcomes, and equity, guided by PRISMA and an original conceptual framework linking financial barriers to service use, quality, system readiness, and health outcomes. We searched PubMed and Web of Science in August 2025 for studies that used experimental or quasi-experimental designs evaluating user fee removal. Of the 933 records screened, 14 studies met the inclusion criteria; all were quasi-experimental. Narrative synthesis followed SWiM (Systematic Review Without Meta-analysis) guidelines due to heterogeneity, and risk of bias was assessed using ROBINS-I. Free health care policies consistently improved access to antenatal care, facility-based delivery, and skilled birth attendance. Effects on postnatal care and caesarean section were mixed. These improvements did not correspond to significant reductions in maternal mortality, stillbirths, or neonatal mortality. Removing user fees had no immediate effect on the initiation of early antenatal care but showed long-term gains. Some policies closed equity gaps while some unintentionally widened health disparities. Removing user fees significantly increased MCH utilisation, with limited or inconsistent effects on mortality and equity. Our framework clarifies how fee removal brings both benefits and system pressures. Future research should address quality and system readiness to achieve equitable outcomes.