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

Date Published: June 11, 2019

Publisher: Public Library of Science

Author(s): Wenjuan Wang, Lindsay Mallick, Courtney Allen, Thomas Pullum, Mahfuzar Rahman.


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.

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.

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.

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.

Partial Text

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. Examining the quality of maternal and newborn healthcare services centers upon the idea that skilled care provided at delivery, supported by well-equipped facilities, is critical for identifying and addressing complications in time for women and newborns to receive treatment and to save lives.[2] Moving beyond the conventional measurement of crude coverage, effective coverage combines both use and quality into one measurement, which can be understood as the fraction of the maximum health gain actually delivered through the health system to the population in need.[3, 4]

Analyzing the distribution of facilities by type, we found that government health facilities are the major providers of delivery care in all six countries (Fig A in S1 Figs). About 80% or more of facilities offering delivery care in Bangladesh, Tanzania, Nepal, and Senegal are government health facilities. Private facilities, especially private not-for-profit facilities, represent a larger share in Haiti and Malawi than in other countries. Most of the countries rely on lower-level facilities such as health posts or sub-health posts and dispensaries for delivery care. Government hospitals have a small share ranging from 1% in Senegal to 11% in Haiti.

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. The reduction ranges from 20% in Nepal to 39% in Haiti. Even though Malawi has almost universal facility delivery, the effective coverage is only 66%. 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] Taken along with findings from studies in other health areas and settings, [8, 28, 29] these highlight the need for improving quality of care to achieve the health-related Sustainable Development Goals.




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