Rationale for the study: The Maternal Mortality Ratio was estimated to 690 /100 000 in 2005. This lies above the average for the other countries with comparable income. (8) To reduce the MMR it is vital to increase the proportion of births attended by skilled health personnel. Currently, there is a significant difference in the socio economic status of the women who deliver with a skilled attendant, and those who do not. The total user costs may affect the use of health services and in order to improve the women’s access to maternity care, it is essential both to identify what these costs are and to investigate means of reducing the cost for the most vulnerable in the Gambia.Objectives: The objectives were to estimate the total household cost for deliveries in a health facility, to explore to what extent households opt out of institutional delivery services due to high cost, to look into the characteristics of the households that opted out of public delivery services due to cost and to look into the financial strategies of households to cope with health emergencies.Materials and methods: This is a quantitative and observational study with both analytical and exploratory components. The study was conducted in Upper River Division and Central River Division of the Gambia between August and November 2007. Interviews were held of 323 women that had delivered a baby between January to July the same year and that lived in the catchment area of 4 preselected health centres. A total of 17 villages were selected by convenience and all eligible women in the village were interviewed using a structured questionnaireResults: The median total cost when the user fee and transport is included was estimated at 112 Dalasi. The user fee is about 45% of this cost and transport is the second major expense at 22%. Removing the user fee as is now done in the Gambia will thus clearly change the price of utilizing the health facilities for deliveries. ‘Poor’ households frequent the health facilities less than households with a higher consumption capacity. However, only 13% of home deliveries claimed they did not use the health facility due to cost. Other risk factors for delivering at home were distance, previous experience with perinatal death and low education. More than half of the women that delivered in a health facility did not have cash available when leaving for the facility, and mostly borrowed money to be able to pay – the ‘poorer’ families more than the others.Conclusion: Removing the user fee is a great step towards improving access to maternity services. However, efforts should still be made on getting delivery services ‘closer’ to the population- either by improving the availability of low cost transport or by further decentralizing appropriate obstetric care facilities.