The role of the private sector in delivery in low-income and middle-income countries: a retrospective, observational analysis of Demographic and Health Surveys from 57 countries

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BackgroundMaternal mortality rates have decreased worldwide in recent decades but remain offtrack for the Millennium Development Goals. Strategies to achieve equitable maternal outcomes will need to effectively reach the most socioeconomically vulnerable women. We assessed the role of the private sector in the provision of institutional delivery care, and compare equity and quality of private sector care with the public sector. MethodsWe used data from the 57 countries in the Demographic and Health Survey 2000–12 to analyse delivery care for the most recent birth among 337 208 women. We created weighted estimates for each geographical region, using wealth quintile for equity analysis. We used the presence of a skilled birth attendant and caesarean section as proxies for cross-sector comparisons of delivery care quality. FindingsThe proportion of women delivering in health facilities varied widely between regions (from 201 057 [42%] in south and southeast Asia, to 25 193 [79%] in north Africa, west Asia, and Europe) and increased with wealth quintile in every region. The largest difference in the proportion of births delivered in a facility between poorest and richest quintiles was in south and southeast Asia (67%) and the lowest was in the north Africa, west Asia, and Europe region (41%). The proportion of all facility deliveries occurring in private sector facilities ranged from 10% in Latin America and the Caribbean to 57% in south and southeast Asia. Depending on region, the wealthiest women were 4–13-times more likely to deliver in private facilities than were the poorest. Inequalities based on wealth also existed for the care women received in facilities. Among women delivering in public sector facilities in all countries (n=95 547), 94% in the poorest and 98% in the richest quintile delivered with a skilled birth attendant. In private sector facilities, 86% of the poorest and 98% of the richest women had a skilled birth attendant. In every region, the proportion of deliveries by caesarean section increased with rising wealth and caesarean section was more common in the private sector than in the public sector. The difference for the proportion of caesarean sections between the two sectors was smallest in sub-Saharan Africa (2%) and largest in north Africa, west Asia, Europe (21%). InterpretationThis study is the largest analysis of the role of the private sector in delivery care. More information is needed about whether the role of the private sector in various countries is a reaction to the failures within the public health system or a substitution effect. Future research should describe countries that achieved rapid improvements in facility delivery rates and assess the contribution of the private sector to this trend. FundingMSD for Mothers.