Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania

BACKGROUND: The 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. METHODS: The 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. FINDINGS: The 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. INTERPRETATION: Our 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.