Abstract
BackgroundThe persistence of preventable maternal and newborn deaths highlights the importance of quality of care as an essential element in coverage interventions. Moving beyond the conventional measurement of crude coverage, we estimated effective coverage of facility delivery by adjusting for facility preparedness to provide delivery services in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania.MethodsThe study uses data from Demographic and Health Surveys (DHS) and Service Provision Assessments (SPA) in Bangladesh (2014 DHS and 2014 SPA), Haiti (2012 DHS and 2013 SPA), Malawi (2015–16 DHS and 2013–14 SPA), Nepal (2016 DHS and 2015 SPA), Senegal (2016 DHS and 2015 SPA), and Tanzania (2015–16 DHS and 2014–15 SPA). We defined effective coverage as the mathematical product of crude coverage and quality of care. The coverage of facility delivery was measured with DHS data and quality of care was measured with facility data from SPA. We estimated effective coverage at both the regional and the national level and accounted for type of facility where delivery care was sought.FindingsThe findings from the six countries indicate the effective coverage ranges from 24% in Haiti to 66% in Malawi, representing substantial reductions (20% to 39%) from crude coverage rates. Although Malawi has achieved almost universal coverage of facility delivery (93%), effective coverage was only 66%.vSuch gaps between the crude coverage and the effective coverage suggest that women delivered in health facility but did not necessarily receive an adequate quality of care. In all countries except Malawi, effective coverage differed substantially among the country’s regions of the country, primarily due to regional variability in coverage.InterpretationOur findings reinforce the importance of quality of obstetric and newborn care to achieve further reduction of maternal and newborn mortality. Continued efforts are needed to increase the use of facility delivery service in countries or regions where coverage remains low.
Highlights
Despite global increases in coverage of facility delivery, the reduction in maternal and neonatal deaths remains limited.[1]
After taking into account facilities’ preparedness to provide delivery care services, the effective coverage in all countries studied is much lower than the crude coverage
Our results indicate that women who delivered in a health facility did not necessarily receive the quality of care needed to avoid preventable maternal and newborn mortality.[27]
Summary
Despite global increases in coverage of facility delivery, the reduction in maternal and neonatal deaths remains limited.[1] Crude coverage describes the use of care services, but does not provide information about the quality of care received. In Ghana, linking facility data to population data by districts, two-thirds of all births occurred in a health facility, but only one in every four births occurred in a high-quality facility.[7] in Tanzania, using a high quality standard that facilities have 90% of required items, the estimate of effective coverage reduced crude coverage from 80% to zero.[8] In a study of 17 countries, using a stringent quality measurement cut-off of 20 or more out of 23 essential items, median coverage of facility delivery fell from 42% to 28%.[9]. Moving beyond the conventional measurement of crude coverage, we estimated effective coverage of facility delivery by adjusting for facility preparedness to provide delivery services in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania
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