DHS ANALYTICAL 

STUDIES 65

EFFECTIVE COVERAGE OF FACILITY 

DELIVERY IN BANGLADESH, HAITI, 

MALAWI, NEPAL, SENEGAL, AND 

TANZANIA

August 2018

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Wenjuan Wang, Lindsay Mallick, Courtney Allen, and Tom Pullum.

DHS Analytical Studies No. 65

Effective Coverage of Facility Delivery in Bangladesh, Haiti, 

Malawi, Nepal, Senegal, and Tanzania

Wenjuan Wang

Lindsay Mallick

Courtney Allen

Tom Pullum

ICF

Rockville, Maryland, USA

August 2018

Corresponding author: Wenjuan Wang, International Health and Development, ICF, 530 Gaither Road, 

Suite 500, Rockville, MD 20850, USA; phone: 301-572-0950; fax: 301-572-0999; email: 

wenjuan.wang@icf.com
Acknowledgments:

We thank Dr. William Weiss and Dr. Robert Cohen who provided insight and expertise that helped shape 

the design of this study. We thank our ICF colleague Tom Fish for assistance with developing the maps. 

We are immensely grateful to our three reviewers – Dr. Hanna Leslie, Dr. Gheda Temsah, and Dr. Hamdy 

Moussa – for their thorough review, thoughtful comments, and useful suggestions that greatly improved 

the report.

Editor: Bryant Robey

Document Production: Joan Wardell

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government.

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about The DHS Program can be obtained 

from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA; telephone: +1 301-572-0200, fax: 

+1 301-572-0999, email: info@DHSprogram.com, internet: www.DHSprogram.com.

Recommended citation:

Wang, Wenjuan, Lindsay Mallick, Courtney Allen, and Tom Pullum. 2018. Effective Coverage of Facility 

Delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. DHS Analytical Studies No. 65. 

Rockville, Maryland, USA: ICF.
iii

CONTENTS

TABLES........................................................................................................................................................ v

FIGURES .................................................................................................................................................... vii

PREFACE .................................................................................................................................................... ix

ABSTRACT.................................................................................................................................................. xi

1 INTRODUCTION.............................................................................................................................. 1

2 DATA AND METHODS ................................................................................................................... 5

2.1 Data..................................................................................................................................... 5

2.2 Defining Components of Effective Coverage...................................................................... 6

2.2.1 Coverage of facility delivery ................................................................................... 6

2.2.2 Facility readiness to provide delivery care............................................................. 6

2.3 Effective Coverage Estimates............................................................................................. 8

3 RESULTS ...................................................................................................................................... 11

3.1 Bangladesh ....................................................................................................................... 11

3.1.1 Facility distribution by type................................................................................... 11

3.1.2 Facility readiness to provide delivery care........................................................... 11

3.1.3 Coverage of facility delivery ................................................................................. 14

3.1.4 Effective coverage ............................................................................................... 14

3.2 Haiti ................................................................................................................................... 15

3.2.1 Facility distribution by type................................................................................... 15

3.2.2 Facility readiness to provide delivery care........................................................... 15

3.2.3 Coverage of facility delivery ................................................................................. 16

3.2.4 Effective coverage ............................................................................................... 18

3.3 Malawi ............................................................................................................................... 19

3.3.1 Facility distribution by type................................................................................... 19

3.3.2 Facility readiness to provide delivery care........................................................... 19

3.3.3 Coverage of facility delivery ................................................................................. 22

3.3.4 Effective coverage ............................................................................................... 22

3.4 Nepal................................................................................................................................. 23

3.4.1 Facility distribution by type................................................................................... 23

3.4.2 Facility readiness to provide delivery care........................................................... 23

3.4.3 Coverage of facility delivery ................................................................................. 26

3.4.4 Effective coverage ............................................................................................... 26

3.5 Senegal ............................................................................................................................. 28

3.5.1 Facility distribution by type................................................................................... 28

3.5.2 Facility readiness to provide delivery care........................................................... 28

3.5.3 Coverage of facility delivery ................................................................................. 29

3.5.4 Effective coverage ............................................................................................... 31

3.6 Tanzania ........................................................................................................................... 32

3.6.1 Facility distribution by type................................................................................... 32

3.6.2 Facility readiness to provide delivery care........................................................... 32

3.6.3 Coverage of facility delivery ................................................................................. 35

3.6.4 Effective coverage ............................................................................................... 35

3.7 Comparison of Countries .................................................................................................. 36
iv

4 DISCUSSION AND CONCLUSION............................................................................................... 39

REFERENCES............................................................................................................................................ 45

APPENDICES............................................................................................................................................. 51
v

TABLES

Table 1 Description of SPA and DHS surveys included in the study.................................. 6

Table 2 Coverage, readiness score, and estimated effective coverage by division, 

Bangladesh .......................................................................................................... 15

Table 3 Coverage, readiness score, and estimated effective coverage by region, 

Haiti ...................................................................................................................... 18

Table 4 Coverage, readiness score, and estimated effective coverage by region, 

Malawi .................................................................................................................. 22

Table 5 Coverage, readiness score, and estimated effective coverage by province, 

Nepal.................................................................................................................... 27

Table 6 Coverage, readiness score, and estimated effective coverage by region, 

Senegal ................................................................................................................ 31

Table 7 Coverage, readiness score, and estimated effective coverage by zone, 

Tanzania .............................................................................................................. 36

Table 8 Estimated effective coverage of facility delivery in all six countries..................... 37

Appendix Table 1 Harmonized facility categories and reported categories in SPA and DHS.......... 51

Appendix Table 2 Obstetric and newborn care readiness indicators and definitions ....................... 53

Appendix Table 3 Weights based on expert ratings ......................................................................... 55

Appendix Table 4 Effective coverage of facility delivery: equal weight versus expert ratingsbased weight ........................................................................................................ 56

Appendix Table 5 Percentage of health facilities with structural tracer items, Bangladesh SPA 

2014 ..................................................................................................................... 57

Appendix Table 6 Service readiness scores for CEmOC facilities and non-CEmOC facilities......... 59

Appendix Table 7 Percentage of health facilities with structural tracer items, Haiti SPA 2013 ........ 60

Appendix Table 8 Percentage of health facilities with structural tracer items, Malawi SPA 

2013-14 ................................................................................................................ 62

Appendix Table 9 Percentage of health facilities with structural tracer items, Nepal SPA 

2015 ..................................................................................................................... 63

Appendix Table 10 Percentage of health facilities with structural tracer items, Senegal SPA 

2015 ..................................................................................................................... 65

Appendix Table 11 Percentage of health facilities with structural tracer items, Tanzania SPA 

2014-15 ................................................................................................................ 67

vii

FIGURES

Figure 1a Distribution of facilities with delivery care by facility type, Bangladesh SPA 

2014 ..................................................................................................................... 11

Figure 1b Readiness score of delivery services by facility type and division, 

Bangladesh SPA 2014......................................................................................... 13

Figure 1c Percentage delivered in a health facility by facility type and division, 

among births in the two years preceding the survey, Bangladesh DHS 2014 .... 13

Figure 1d Readiness versus coverage by division, Bangladesh.......................................... 14

Figure 1e Effective coverage of facility delivery by division, Bangladesh............................ 14

Figure 2a Distribution of facilities with delivery care by facility type, Haiti SPA 2013 .......... 15

Figure 2b Readiness score of delivery services by facility type and region, Haiti SPA 

2013 ..................................................................................................................... 17

Figure 2c Percentage delivered in a health facility by facility type and region, 

among births in the two years preceding the survey, Haiti DHS 2012 ................ 17

Figure 2d Readiness versus coverage by region, Haiti ....................................................... 18

Figure 2e Effective coverage of facility delivery by region, Haiti.......................................... 18

Figure 3a Distribution of facilities with delivery by facility type, Malawi SPA 2013-14......... 19

Figure 3b Readiness score of delivery services by facility type and region, Malawi 

SPA 2013-14........................................................................................................ 21

Figure 3c Percentage delivered in a health facility by facility type and region, 

among births in the two years preceding the survey, Malawi DHS 2012 ............ 21

Figure 3d Readiness versus coverage by region, Malawi ................................................... 22

Figure 3e Effective coverage of facility delivery by region, Malawi...................................... 22

Figure 4a Distribution of facilities with delivery by facility type, Nepal SPA 2015-16........... 23

Figure 4b Readiness score of delivery services by facility type and province, 

Nepal SPA 2015-16 ............................................................................................. 25

Figure 4c Percentage delivered in a health facility by facility type and province, 

among births in the two years preceding the survey, Nepal DHS 2015 .............. 25

Figure 4d Readiness versus coverage by province, Nepal.................................................. 26

Figure 4e Effective coverage of facility delivery by province, Nepal.................................... 27

Figure 5a Distribution of facilities with delivery by facility type, Senegal SPA 2015 ............ 28

Figure 5b Readiness score of delivery services by facility type and region, Senegal 

SPA 2015 ............................................................................................................. 30

Figure 5c Percentage delivered in a health facility by facility type and region, 

among births in the two years preceding the survey, Senegal DHS 2016 .......... 30

Figure 5d Readiness versus coverage by region, Senegal ................................................. 31

Figure 5e Effective coverage of facility delivery by region, Senegal.................................... 31

Figure 6a Distribution of facilities with delivery by facility type, Tanzania SPA 2014-15 ..... 32

Figure 6b Readiness score of delivery services by facility type and zone, Tanzania 

SPA 2014-15........................................................................................................ 34

Figure 6c Percentage delivered in a health facility by facility type and zone, 

among births in the two years preceding the survey, Tanzania DHS 2015-16 ... 34

Figure 6d Readiness versus coverage by zone, Tanzania .................................................. 35

Figure 6e Effective coverage of facility delivery by zone, Tanzania .................................... 35

Figure 7 National readiness score versus coverage and regional variations .................... 36

ix

PREFACE

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services.

One of the objectives of The DHS Program is to analyze DHS data and provide findings that will be useful 

to policymakers and program managers in low- and middle-income countries. DHS Analytical Studies serve 

this objective by providing in-depth research on a wide range of topics, typically including several 

countries, and applying multivariate statistical tools and models. These reports are also intended to illustrate 

research methods and applications of DHS data that may build the capacity of other researchers.

The topics in this series are selected by The DHS Program in consultation with the U. S. Agency for 

International Development.

It is hoped that the DHS Analytical Studies will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries.

Sunita Kishor

Director, The DHS Program

xi

ABSTRACT

This report uses data from Demographic and Health Surveys (DHS) and Service Provision Assessments

(SPA) to estimate effective coverage of health facility delivery in Bangladesh, Haiti, Malawi, Nepal, 

Senegal, and Tanzania—the six countries with both an SPA and a DHS survey occurring within two years 

of each other. Effective coverage can be considered as crude coverage—the conventional measure of the 

percentage of births delivered in a health facility—adjusted for the quality of care provided. In our analysis, 

quality of care for health facility delivery was measured using facility readiness scores, based on availability 

of items necessary for a facility to provide comprehensive delivery care.

Results show that the estimates of effective coverage were substantially lower than the levels of crude 

coverage for facility delivery in all six countries—from 20% lower in Nepal to 39% lower in Haiti. 

Although Malawi has achieved almost universal coverage of facility delivery, at 93% of births, effective 

coverage was lower, at 66%. Senegal was the only other country with effective coverage higher than 50%. 

These findings suggest that many women who deliver in a health facility may not receive an adequate

quality of care.

Within a country, we estimated effective coverage for each region, accounting for facility type. Effective 

coverage estimates differed significantly among regions in every country with the exception of Malawi. 

Because facility readiness scores differed little across regions, the largest factor explaining regional 

differences in effective coverage was the prevalence of facility delivery for recent births.

This study offers refined methods of producing effective coverage estimates of delivery care due to its

adjustment for facility types and composition of a readiness score based on international guidance and 

empirical evidence. The fact that estimates of effective coverage—which account for a facility’s 

preparedness to provide the care—are substantially lower than the estimates using conventional measures 

of facility coverage provides insight into why maternal and neonatal mortality rates in many countries are 

not declining as rapidly as expected.

KEY WORDS: Facility delivery, effective coverage, health facilities, quality of care, service readiness, 

SPA, DHS, Bangladesh, Haiti, Malawi, Nepal, Senegal, Tanzania

1

1 INTRODUCTION

Despite a reduction in maternal and neonatal mortality around the world, progress has been slow (Lawn et 

al. 2014). The global maternal mortality ratio was 216 maternal deaths per 100,000 live births in 2015, three 

times the level of fewer than 70 deaths per 100,000 births called for in the global Sustainable Development 

Goals (United Nations Economic and Social Council 2017). While the neonatal mortality rate has decreased 

globally, there were 2.6 million newborn deaths in 2016, and the majority occurred in Central and Southern 

Asia and in sub-Saharan Africa (UNICEF et al. 2017). Although globally in 2016 three in every four live 

births were attended by a skilled health provider, increases in coverage of facility delivery and skilled 

attendance at birth have resulted in only limited reductions in maternal and neonatal deaths (Marchant et 

al. 2016; Winter et al. 2017). This incongruous finding is believed to relate to the inadequate level of care 

that many women and children receive in health facilities (Graham, McCaw-Binns, and Munjanja 2013; 

Hodgins and D’Agostino 2014; Nguhiu, Barasa, and Chuma 2017).

The persistence of preventable maternal and newborn deaths highlights the importance of quality of care as 

an essential element in coverage interventions. Providing quality care during pregnancy and childbirth is 

key for the health of the mother and baby. Skilled care provided at delivery, supported by well-equipped 

facilities, is critical to identifying and addressing complications in time for women to receive treatment and 

to save lives (Tura, Fantahun, and Worku 2013). Universal health coverage requires that the entire 

population have access to essential health care of sufficient quality (WHO 2010). Quality of care is also 

emphasized in the Third Sustainable Development Goal, which aims to reduce the maternal mortality ratio 

and end preventable deaths among newborns and children under age 5 (United Nations Development 

Program 2015).

The concept of effective coverage signifies the focus on quality of care in the international development 

community. Effective coverage measures performance of the health system in a given setting; it

incorporates the quality of an intervention with the conventional measurement of crude coverage—the 

proportion of people who use services among those in need (Colston 2011). Thus, the measure combines 

three aspects of health care service delivery into a single measure that encompasses need for service, use 

of services, and quality of care of those services. By incorporating both use and quality, effective coverage 

can be understood as the fraction of the maximum health gain actually delivered through the health system 

to the population in need (Ng et al. 2014; Shengelia et al. 2005). Specifically, it is calculated by dividing 

the number of people who received an intervention by the number of people in need of that intervention, 

adjusted by the quality of the intervention (Colston 2011; Shengelia et al. 2005). Typically, effective 

coverage is calculated in selected study areas or at the national level; however, it can be adapted to other 

administrative levels and for a variety of health needs (Ng et al. 2014). This study seeks to contribute to the 

knowledge about effective coverage, particularly for facility delivery, and presents a refined method for 

estimating effective coverage.

The concept of effective coverage first appeared several decades ago. The Tanahashi framework illustrated 

five stages for service provision, with effective coverage as the final stage after availability of health 

services, physical accessibility to services within reasonable distances, acceptability by those in need in 

terms of cost or religious or ethnic values, and contact, or actual use of the service (Tanahashi 1978). 

Shengelia et al. (2005) further constructed a framework for effective coverage that integrates need, use, and 
2

quality. More recent studies that have examined effective coverage of maternal and child health services 

have found substantial gaps in the quality of coverage (Hodgins and D’Agostino 2014; Kanyangarara et al. 

2018; Leslie et al. 2017; Nesbitt et al. 2013; Nguhiu, Barasa, and Chuma 2017; Willey et al. 2018). Studies

have identified considerable discrepancies between women’s reports of seeking or attending antenatal or 

intrapartum services and their receipt of the critical components of those services. For example, a study 

conducted in Zambia found that, while attending at least one visit for antenatal care (ANC) was nearly 

universal, only half of all women received at least eight of the core ANC interventions (Kyei, Chansa, and 

Gabrysch 2012). So, while crude coverage rates reflect women’s ability to receive health care, and may be 

informative, this indicator does not provide information about the actual quality of care received. Leslie et 

al. (2017) found that the poor quality of services multiplied by crude coverage rates led to poor effective 

coverage across eight low-income and middle-income countries. Further, the authors found significant 

differences in the average effective coverage between countries, likely due to economic differences. 

Within countries, effective coverage of maternal health care services has been found to be higher among 

wealthier households (Nguhiu, Barasa, and Chuma 2017) and lower in rural areas (Kanyangarara et al. 

2018). These results are consistent with studies showing that economically disadvantaged women not only 

have less access to and use of services, but also receive worse quality of care (Joshi et al. 2014; 

Kanyangarara et al.; Kruk et al. 2017; Kyei, Chansa, and Gabrysch 2012; Larson et al. 2017; Leslie et al.

2017).

While determining the level of crude coverage, which is a prerequisite for measuring effective coverage, is 

straightforward, measuring quality of care can be challenging because the calculation is prone to several 

limitations (Nguhiu, Barasa, and Chuma 2017). One approach to measuring quality of care is to incorporate 

the three dimensions of structure, process, and outcome (Donabedian 1988). Structure includes the physical 

attributes of a health facility including infrastructure, equipment, supplies, commodities, and the availability 

of trained personnel. Process describes how providers deliver the services to clients, while outcome refers 

to client satisfaction and health outcomes. Of concern for quality of delivery care is that there is no single

set of standard measures used to assess quality (Marchant et al. 2016; Nesbitt et al. 2013; Tripathi et al. 

2015; Van den Broek and Graham 2009; Willey et al. 2018), although research has presented a rationale for 

consolidating quality into key indicators (Gabrysch et al. 2012; Tripathi et al. 2015; WHO 2015). Across 

studies of quality of care in facility delivery, indicators have several common domains, including 

infrastructure, infection prevention, monitoring labor, essential medications, equipment, neonatal 

resuscitation, routine and emergency obstetric care, and clean cord care (Gabrysch et al. 2012; Larson et al. 

2017; Nesbitt et al. 2013; Tripathi et al. 2015; Willey et al. 2018; Winter et al. 2017).

Ideally, assessments of quality of facility-based delivery care should examine the facility’s readiness to 

provide delivery care as well as the practices that health providers should follow during delivery care. 

Tripathi et al. (2015) developed an index for quality of the process of intrapartum and immediate postpartum 

care (QOPIIPC), identifying 20 indicators to measure quality of care based on provider performance during 

delivery. However, assessments of the observation of delivery services are time-consuming and prone to 

measurement error. Moreover, routinely collected facility data are subject to their own quality limitations, 

particularly in resource-constrained and high-mortality settings (Lain et al. 2012; Tripathi et al. 2015). Thus, 

service readiness assessments such as the World Health Organization (WHO) Service Availability 

Readiness Assessment (SARA), the Demographic and Health Survey Program’s Service Provision 

Assessment (SPA), and similar health facility assessment tools have been used as substitutes (Willey et al. 
3

2018). These tools provide an overview of a facility’s capacity to provide services in terms of infrastructure, 

equipment, commodities, staffing, and management, but do not necessarily provide an observation of the 

services to capture actual service delivery. Using these data sources, quality measurements are limited to 

the readiness of facilities to provide quality services.

One way to assess effective coverage is to link data from assessments of health facilities that measure the 

quality of service delivery with data from household-based surveys that measure the use of services. 

Although it is desirable to directly link a woman to her nearest health facility, geographic displacement of 

GPS data to protect anonymity prohibits this approach. Further, this approach is problematic in areas where 

women have a choice of facilities to attend, given that household surveys do not confirm which facility a 

woman has used. Thus, a geographic linkage approach that summarizes facilities within administrative or 

geographic boundaries near clusters of households using GPS data collected in both types of surveys is 

commonly practiced.

Guided by the signal functions, or critical life-saving interventions for childbirth, proposed in Gabrysch et 

al. (2012), a study by Nesbitt et al. (2013) used proxy indicators for service delivery (health worker reports 

of how frequently an item was performed) with an assessment of the readiness to provide signal functions—

grouped into four domains of routine delivery care, emergency obstetric care, emergency newborn care, 

and non-medical care—among 86 facilities in 7 districts in Ghana. They found that most facilities 

demonstrated poor quality in the emergency obstetric care dimension and that the quality between the 

dimensions was inconsistent. Linking facility data to population data by districts, they found that although 

two-thirds of all births occurred in a health facility, only one in every four births occurred in a high-quality 

facility. Larson et al. (2017) also examined effective coverage of facility delivery by assessing crude 

coverage of delivery at health facilities through household-based surveys among women in the catchment 

areas of 24 government-managed health facilities in Tanzania, linking the women to the quality of delivery 

care in the health facilities. The authors examined different dimensions of quality of care, both 

independently and combined, and by two thresholds—high quality and minimum quality. The first

threshold, the high-quality standard, required that facilities must have nearly complete tracer indicators 

(90%), while the second threshold, a minimum standard, allowed for only 50% completion of indicators. 

The estimate of effective coverage reduced crude coverage from 80% to zero percent according to the high 

threshold, and to 25% according to the minimum threshold. Kanyangarara et al. (2018) examined the quality 

of care received by women who delivered in a health facility. The authors used a stringent cut-off of 20 or 

more out of 23 items essential to providing quality by linking women interviewed in either DHS surveys or 

Multiple Indicator Cluster Surveys (MICS) with SPA or SARA assessments of facilities in 17 countries. 

They found that the median coverage of delivery at an emergency obstetric and newborn care facility was 

42% among women who delivered in a facility with fewer than 20 of the essential items compared with 

28% among women who delivered in a facility with adequate quality of care.

Geographical linking has limitations, however, when linking individuals to a summary of nearby facilities 

(Do et al. 2016). Using this method, it is unknown whether the care a woman received reflects the average 

level of quality among the facilities near her. Willey et al. (2018) assessed the measurement of effective 

coverage using skilled attendance at delivery and facility readiness in Uganda to provide basic emergency 

obstetric and newborn care (BEmOC). This was done by comparing the more accessible geographicallinking method to the gold-standard but resource-intensive method of linking individuals to the facility they 

attended. This study found little difference between the two methods, suggesting that the ecological-linking 
4

method is a suitable proxy. More precise agreement was found with geographically linking when accounting 

for the variable levels of quality by facility type (Willey et al. 2018). While this finding is encouraging for 

using a geographical-linking method, this study was based on quality of care assessed in 35 health facilities 

in one district in Uganda, which were linked to reports from fewer than 700 women who delivered in these 

facilities.

This study contributes to the limited research on effective coverage of obstetric and newborn care in health 

facilities by linking data from nationally representative household surveys with data from surveys of health 

facilities in six countries with high prevalence of maternal and newborn mortality. We use a wide range of 

input-based quality-of-care indicators to provide a comprehensive assessment of the readiness of facilities 

to deliver obstetric and newborn care in these countries. In linking coverage and quality measurements, we 

use a refined ecological linkage approach stratifying the calculation by facility category, which has proven 

effective in producing similar estimates when the exact source of care is unknown.
5

2 DATA AND METHODS

2.1 Data

The analysis is based on data from the Demographic and Health Surveys and Service Provision Assessment 

surveys in six countries—Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. These countries were 

selected because they all have had a recent DHS survey and a recent SPA survey completed within two 

years of each other.

The DHS is a population-based household survey that provides representative data on population and health 

indicators at the national and regional levels for a specific country. The DHS usually employs a two-stage 

stratified cluster sampling design, with a predetermined number of clusters selected in the first stage and 

households selected in the second stage. All women age 15-49 in the selected households are interviewed 

to collect data on their sociodemographic characteristics and use of health services. Women with a birth in 

the five years before the survey are asked about delivery care, including place of delivery for all of her live 

births during this period. This study focuses on delivery care received for live births in the two years 

preceding the survey, to better synchronize the timing of the DHS data and the SPA data. Table 1 provides 

the number of births included in the analysis for each country, which ranges from 1,978 births in the 2016 

Nepal DHS to 6,596 births in the 2015-16 Malawi DHS.

The SPA is a health facility-based survey designed to provide information on the availability and quality of 

preventive and curative health services in a country. SPA surveys use four standard instruments for data 

collection. The Facility Inventory Questionnaire collects information on the availability of specific services 

and related infrastructure, supplies, medicines, staffing, procedures, and management practices. The 

Provider Interview Questionnaire collects information on the qualifications, training, and supervision 

experience among health workers who provide selected services. The SPA often includes observations of 

the process of delivering specific services (typically family planning, antenatal care, and sick child care) to 

assess the extent to which providers adhere to accepted service delivery standards. The Client Exit Interview 

focuses on the client’s recall or understanding of the consultation or examination and the client’s 

satisfaction with the service received during the visit. SPA data analyzed in this study primarily come from 

the facility inventory and the provider interviews. In each country except Haiti and Malawi, where the SPA 

was a facility census, a sample of formal health facilities was selected to represent the country and the 

administrative regions, as well as by type of facility and by managing authority. Hospitals are normally 

oversampled and sometimes included as a census because of their small number. The provider sample was 

selected among health service workers who provided the assessed services and were present at the selected 

facilities on the day of the SPA survey. For each facility, a target of eight providers was randomly selected 

with priority given to those whose service was observed. In facilities with fewer than eight providers, all of 

the providers present on the day of the assessment were interviewed. This study focuses on facilities that 

reported to provide delivery services.
6

Table 1 Description of SPA and DHS surveys included in the study

Country

DHS 

survey year

Number of 

births in the 

two years

preceding

the survey

SPA 

survey 

year

Number of facilities with delivery services

Non-CEmOC facilities CEmOC facilities All facilities

Unweighted Weighted Unweighted Weighted Unweighted Weighted

Bangladesh 2014 3,147 2014 520 267 66 13 586 280

Haiti 2012 2,747 2013 379 379 10 10 389 389

Malawi 2015-16 6,596 2013-14 529 517 11 11 540 528

Nepal 2016 1,978 2015 585 448 36 9 621 457

Senegal 2016 2,311 2015 358 361 4 2 364 363

Tanzania 2015-16 4,327 2014-15 905 896 46 8 951 905

Table 1 lists the SPA surveys in each country included in the analysis and presents weighted and unweighted 

numbers of facilities in each country that were included in the analysis. These facilities are classified into

comprehensive emergency obstetric care facilities and non-CEmOC facilities based on the availability of 

comprehensive emergency obstetric care signal functions. CEmOC facilities were not designated but were 

identified based on whether they provide all of the following services: parenteral administration of 

antibiotics, parenteral administration of oxytocic drugs, parenteral administration of anticonvulsants, 

manual removal of placenta, assisted vaginal delivery, removal of retained products, cesarean sections (Csections), and safe blood transfusion (WHO et al. 2009). The total number of facilities offering delivery 

care in a country ranges from 280 in the 2014 Bangladesh SPA to 905 in the 2015-16 Tanzania SPA. The 

great majority of them are non-CEmOC facilities.

2.2 Defining Components of Effective Coverage

As discussed in the introduction, effective coverage is coverage of a service adjusted for its quality. It is 

calculated among individuals in need of care as the mathematical product of the use of the service and the 

quality of care provided. To estimate effective coverage of facility delivery, we first calculated its two 

components—coverage of facility delivery, and the quality of facility delivery services—as described 

below.

2.2.1 Coverage of facility delivery

We estimated the coverage of facility delivery based on DHS data as the percentage of births in the two 

years preceding the survey that were delivered in a health facility. The coverage was disaggregated by type 

of facility where the delivery occurred. This is because women are expected to seek delivery care in a range 

of facilities with varied preparedness to provide delivery services. For each of the six countries studied, 

facility types were harmonized between the DHS and SPA. Facilities are generally categorized by managing 

authority (public or private) and level of facility (hospital, health center, dispensary or health post). In some 

cases, the DHS grouped facilities at different levels, for example private hospitals and private health centers, 

into one category because they were infrequently reported as a source of delivery care. In order to align 

DHS and SPA categories, we then combined these facility types into a single category in the SPA. Appendix 

Table 1 provides a summary of reported facility categories in both DHS and SPA by the harmonized 

classifications in each country.

2.2.2 Facility readiness to provide delivery care

As mentioned, quality of care is usually measured in three dimensions: structure, process, and outcome 

(Donabedian 1988). This study focused on structure, which refers to the physical attributes of a health 
7

facility including infrastructure, equipment, supplies, commodities, and the availability of trained 

personnel. In other words, it assesses whether a facility is ready to provide quality services.

We measured facility readiness to provide delivery care with a service readiness score based on a set of 

indicators for the structure component of providing obstetric and newborn care. The indicator selection was 

guided by three references: the World Health Organization (WHO) SARA Manual (WHO 2015), the 

indicators suggested by the Newborn Indicator Technical Working Group (Save the Children Federation, 

Inc. 2017), and the indicators suggested by Gabrysch et al. (2012) that are important to measure obstetric 

and newborn care at health facilities. The SARA manual includes a number of indicators that assess the 

readiness of health facilities to provide basic and comprehensive emergency obstetric care among many 

other health service areas. The Newborn Indicator Technical Working Group was initiated by the Children’s 

Saving Newborn Lives (SNL) program and consists of experts from several international research 

organizations who collaborate to propose and assess survey-based indicators to monitor and evaluate 

newborn health. Gabrysch and colleagues conducted a literature review and solicited opinions from over 

30 maternal and newborn health experts. The authors identified a shortlist of indicators for maternal and 

newborn emergency and routine care covering general health facility requirements, routine care for all 

mothers and babies, basic emergency care for mothers and babies with complications, and comprehensive 

emergency care functions (Gabrysch et al 2012). An indicator suggested by at least one of these three 

references was included in the analysis if data are available in the SPA. All indicators are dichotomous,

with Yes representing availability and No representing unavailability. In rare cases when data are missing 

for some facilities, the indicator was recoded as No for these facilities. In general, the selected indicators 

measure a facility’s readiness to provide delivery care in six domains: 1) comprehensive emergency 

obstetric care; 2) newborn signal functions and immediate care; 3) general requirements; 4) equipment;

5) medicine and commodities; and 6) guidelines, staff training, and supervision. Appendix Table 2 provides 

definitions of these indicators.

We calculated the readiness score using an equal-weight approach, in which a facility receives a total 

score—that is, the sum of all indicators standardized to have a maximum of 100. Equal weighting is the 

most intuitive approach to create a composite measurement compared with other commonly used weighting 

schemes (Shwartz, Restuccia, and Rosen 2015). Given this standardization, a facility’s score should be 

interpreted as the percentage of highest possible readiness that the facility could have. When computing the 

readiness score, equal weight was given to each domain and to each indicator within the same domain. This 

approach assumes that all domains and all indicators within the same domain are equally important in 

preventing maternal and newborn deaths. Since non-CEmOC facilities are not expected to provide Csections and safe blood transfusion, these two indicators were included in the calculation of readiness scores 

only for CEmOC facilities. This approach for creating an index, compared with other approaches—simple 

additive and principal components-based approach—has proven to be the most predictive of outcomes

(Mallick, Wang, and Temsah 2017).

The alternative to the equal-weight approach would be to weight domains and individual items differently. 

We explored a weighting procedure based on expert ratings of the importance of each item for preventing 

maternal and newborn deaths. Eight maternal and child health experts1at USAID provided independent 

 

1 The eight experts, including program managers and researchers who participated in this exercise, are from the Bureau 

of Global Health, Office of Maternal and Child Health and Nutrition at USAID.
8

ratings to each item on a scale of 1 (not important) to 5 (extremely important). Weights were calculated for 

items and domains based on the ratings. Appendix Table 3 provides average expert ratings on each item, as 

well as the item and domain weights calculated based on the ratings. The experts tended to give similar 

ratings to the items within the same domain. Most of the domains were weighted similarly except the 

guidelines, training, and supervision domain, which was weighted lower than the others.

The two approaches—equal weighting and expert ratings-based weighting—yielded similar readiness 

scores at the regional and national levels, with the equal-weight approach producing scores that were 

consistently a few percentage points higher (Appendix Table 4). Since expert ratings can vary by expert 

groups, the equal-weight approach was chosen in the final analysis because it is simple, replicable, and 

recommended by WHO (WHO 2015).

2.3 Effective Coverage Estimates

Effective coverage was estimated at both the regional and the national level, with the mathematical product 

of the coverage and readiness scored by accounting for types of facilities where delivery care was sought. 

In most countries, the regions are administrative regions or provinces for which both DHS data and SPA 

data are representative. In Tanzania, regions were further grouped into nine geographic zones to allow for 

a large sample size in each zone, therefore reduced sampling errors. While it may strengthen the validity of 

the estimates by further dividing each region into urban and rural areas, such division is not permitted due 

to potential inconsistencies in the classification of urban and rural between DHS and SPA. The number of 

regions varies across countries, from three regions in Malawi to ten regions in Haiti; the rest had six 

(Senegal), seven (Bangladesh and Nepal), and nine (Tanzania) regions or zones.

The formula for estimating effective coverage is described as follows.

At the regional level, the effective coverage is the summation of effective coverage of each type of facility 

that is constructed as the product of the coverage and readiness estimates:

where ECrrepresents effective coverage in region r,

Crj is the proportion of births delivered in facility type j in region r,

and

Qrj is the average readiness score of facility type j in region r.

We accounted for the DHS sampling weight when estimating facility delivery coverage and SPA sampling

weight when calculating readiness scores. The calculated readiness score for a specific facility category is

an average score of all facilities in the same category. Ideally, variations in client volume among facilities 

within the same category should be also adjusted for. However, we were not able to implement such 

adjustment in the calculation due to the unavailability of data.

The national effective coverage is the summation of regional effective coverage weighted by the proportion 

of births in each region:
9

where wrrepresents the proportion of births in region r.

Effective coverage of facility delivery can be considered essentially as facility delivery coverage after 

adjusting for facilities’ readiness to provide the service. Since the readiness score lies between 0 and 100%, 

the effective coverage should be equal to or below the crude coverage. In cases when all facilities reach 

100% of the maximum readiness, the effective coverage would be equivalent to the crude coverage. The 

national estimates are improved by taking regional variations into account because regions differ in the use 

of each type of facility and in readiness among facilities in the same category. 

The uncertainty of the estimates of effective coverage was assessed with an approximation procedure 

sometimes referred to as the “delta” method (Hogg and Craig 1965). We refer to the SPA and DHS estimates 

with the subscripts i=1 and i=2 respectively. The mean readiness score, noted as p1 for the facilities of a 

specified type and in a specified region, can be calculated with the coefficient of an OLS regression of 

readiness scores with no covariates. We call this coefficient b1 and the standard error of its mean is s1. The 

lower and upper ends of the 95% confidence interval for the readiness are L = b1 -1.96* s1 and 

U= b1+1.96* s1. We took into account the effect of survey design in the estimation of standard errors when 

the SPA was a sample survey. A finite population correction factor was adjusted for in the estimation, given 

the fact that the SPA sample was drawn from more than 5% of a finite population. 

The coverage of facility delivery, noted as p2, can be estimated using the coefficient b2 of a logit regression 

of facility delivery with no covariates. That is, logit(p2)=log[p2/(1- p2)]= b2. The sampling distribution of 

b2 is asymptotically normal with standard deviation s2. The lower and upper ends of the 95% confidence 

interval for logit(p2 ) are L = b2 -1.96* s2 and U = b2 +1.96* s2 . We can calculate the facility delivery 

coverage as p2 =[exp(b2 )]/[1+exp(b2 )]. If the same anti-logit transformation is applied to L and U , we 

obtain the lower and upper ends of the confidence interval for coverage. All estimates are adjusted for the 

survey design.

Effective coverage, p, is defined by p= p1* p2. A confidence interval for p is calculated by converting p to 

the logit scale with

F = logit(p) = log(

p

1 − p

) = log (

p1 ∗ p2

1 − p1p2

)

p1 and p2 are functions of the coefficients b1 and b2 respectively; the standard errors of b1 and b2 are s1

and s2 respectively; and the covariance of b1 and b2 is 0 because of the independence of the SPA and DHS. 

Therefore, the sampling variance of F is estimated with the delta method to be

s

2 = (

∂F

∂b1

)

2

s1

2 + (

∂F

∂b2

)

2

s2

2

and the standard error of F is the square root, s. The partial derivatives in this formula are calculated from 

the formula for F to be
10

∂F

∂b1

=

1

p1

(1−p1p2)

 and ∂F

∂b2

=

1−p1

1−p1p2

We calculate the lower and upper ends of a 95% confidence interval as L = F -1.96* s and U= F +1.96* s, 

and then apply the anti-logit transformation to L and U to get the lower and upper ends of the confidence 

interval for p= p1* p2 (effective coverage). Similar steps are used to obtain confidence intervals for the 

aggregated regional and national estimates.
11

3 RESULTS

We present results by individual country. Each country section starts with a description of types of facilities 

that reported providing delivery care services. We then give results on facility readiness to provide delivery 

care, including the availability of individual items and overall readiness scores. Facility delivery coverage 

is then described by facility type and region. Each country section ends with a presentation of estimates of 

effective coverage at the regional and national levels. Finally, a brief comparison across countries appears

at the end of the results chapter.

3.1 Bangladesh

3.1.1 Facility distribution by type

In Bangladesh, the health system is largely managed by 

the government at sub-national levels. Among 280 

facilities identified to provide delivery care, the 

majority (63%) are sub-upazila (union level) facilities, 

which are staffed with a medical assistant, a family 

welfare visitor, and a pharmacist (Figure 1a). These 

facilities provide mostly maternal and child health 

services with some curative care services. Among the 

rest, 2% are government hospitals and 14% are upazila 

(sub-district) facilities, which are managed at the subdistrict administrative level and have both inpatient and 

outpatient services with a number of staff including 

doctors, medical assistants, pharmacists, and 

technicians. One-fifth of facilities are private or nongovernmental facilities, at 12% and 9% respectively.

3.1.2 Facility readiness to provide delivery 

care

Appendix Table 5 shows, for non-CEmOC facilities at the national level as well as for seven divisions of 

the country, the availability of tracer items that are important for providing delivery care. For CEmOC 

facilities, availability is only reported at the national level because of the small number of CEmOC facilities

in the country. At the national level, among non-CEmOC facilities only a few readiness items were 

commonly available (that is, in over 90% of facilities), including wrapping the baby (94%) and encouraging

early breastfeeding (97%), and the facility has an improved water source (92%). Many items were poorly 

stocked or had limited availability at the national level. Less than a third of facilities had a skilled birth 

attendant 24 hours a day (29%) or emergency transportation (30%). Availability of medicines and 

commodities ranged from 17% for hydrocortisone to 32% with an injectable uterotonic and 33% with IV 

solution with an infusion set. The domain with the most limited availability was guidelines, training, and 

supervision. Nationally, 20% of facilities or fewer were staffed with at least one provider with recent 

training in all areas related to labor and delivery, and newborn care assessed. The availability of items 

increases among CEmOC facilities for all domains except the availability of guidelines and trained staff.

Figure 1a Distribution of facilities with 

delivery care by facility type, 

Bangladesh SPA 2014

Public hospital, 1.8

Public upazila, 

14.4

Public union, other, 

63.0

NGO, 8.9

Private hospital, 

clinic, 11.9
12

Even among CEmOC facilities, only 4 out of 13 facilities had at least one provider trained on CEmOC in 

the last 24 months.

We compared readiness scores between CEmOC facilities and non-CEmOC facilities at the national level. 

Overall CEmOC facilities received a significantly higher score than non-CEmOC facilities, even though a 

higher standard was applied to CEmOC facilities (availability of C-section and safe blood transfusion) 

(Appendix Table 6).

Figure 1b presents the readiness of facilities to provide delivery services in Bangladesh, by facility type and 

division. At the national level, facilities in Bangladesh have 47% of the maximum possible readiness to 

provide delivery care services. Readiness varies more by facility type than across divisions. The level of 

readiness is highest in public hospitals (77%), the least common type of facility, and lowest in public union 

or other public facilities (35%), the most common type of facility. Average readiness scores for the seven

divisions range from 39% in Rajshahi to 54% in Rangpur. These levels of readiness in hospitals or union 

health facilities are consistent across divisions; however, there is greater variation in the level of readiness 

among NGO facilities, from 43% in Barisal to 85% in Rangpur. Rangpur’s comparatively higher scores 

among NGOs as well as private hospitals/clinics (81%) and public union facilities (47%) help give it the 

highest total readiness score among the divisions.
13

Figure 1b Readiness score of delivery services by facility type and division, Bangladesh SPA 

2014

Figure 1c Percentage delivered in a health facility by facility type and division, among births in 

the two years preceding the survey, Bangladesh DHS 2014

80 79

76

72

80 77

80

77

58

69

66

70 70 72

65 68

33 31

35 36

28

47

35 35

43

64

60

84

45

85

63 64

74

70

62

67

64

81

62

65

43

46 47 49

39

54

47 47

0

10

20

30

40

50

60

70

80

90

100

Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet National

Public hospital Public upazila Public union, other NGO Private hospital, clinic Total

7 5 5

11 9

5 6 6

2 7 6

11

6

9 5 6

1

1 2

0

1 1

0

3 1

4

3

4

1 2

1

18 3

21

28

33

24

19

11

24

0

10

20

30

40

50

60

70

80

90

100

30 37 44 59 41 35 23 40

Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet National

Public hospital Public upazila Public union, other NGO Private hospital, clinic
14

3.1.3 Coverage of facility delivery

As determined in the 2014 Bangladesh DHS, and as Figure 1c shows, most births (60%) were not delivered 

in a health facility. Among those delivered in a health facility, most were in private hospitals and clinics, 

representing 24% of all births in the two years preceding the survey. Few births were delivered in NGO or 

union facilities. These trends are consistent across divisions. The highest level of facility delivery occurs in 

Khulna (59%) for all facility types combined, including 33% of births delivered in private facilities and 

11% in both public upazila facilities and public hospitals.

3.1.4 Effective coverage

The scatterplot in Figure 1d demonstrates the intersections between facility readiness and coverage of 

facility deliveries by division in Bangladesh. In this 

figure the intersections between readiness and 

coverage occur mostly in quadrant 3, where coverage 

(use of health facilities) is less than 50% and facility 

readiness also is less than 50%, indicating low levels of 

effective coverage (use of facility services adjusted for 

the level of quality). The Khulna division is in quadrant 

2, showing coverage higher than 50% and a readiness 

score close to 50%.

As the scatter plot in Figure 1d suggests and the map in 

Figure 1e depicts, effective coverage is low in Bangladesh, though with some variation across divisions. The 

national level of effective coverage is 27%, 13 

percentage points lower than the crude coverage level

of 40% (see Table 2). The level of effective coverage 

ranges from 16% in Sylhet to 41% in Khulna. Khulna 

appears to have significantly higher effective coverage 

compared with all other divisions. Effective coverage 

in Sylhet is significantly lower than in all other 

divisions except Barisal. Except for Khulna and Sylhet, 

the remaining division-level effective coverage lies 

within a narrow range of only a few percentage points, from 21% in Barisal to 28% in Dhaka, Rajshahi, 

and Rangpur. Overall, coverage of facility delivery itself remains a problem in Bangladesh, while low levels 

of service readiness among facilities further impede access to high-quality delivery care.

Figure 1d Readiness versus coverage by

division, Bangladesh

Figure 1e Effective coverage of facility 

delivery by division, Bangladesh

Barisal

Chittagong

Dhaka

Khulna

Rajshahi

Rangpur

Sylhet

Total

0

50

100

0 50 100

Coverage

Readiness

II I

III IV
15

Table 2 Coverage, readiness score, and estimated effective coverage by division, Bangladesh

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

Barisal 30.5 42.5 20.5 15.9 25.8

Chittagong 36.8 46.3 25.8 21.0 31.2

Dhaka 43.7 46.8 27.6 23.1 32.7

Khulna 58.8 49.3 40.9 35.0 47.0

Rajshahi 40.9 39.0 27.6 23.1 32.7

Rangpur 35.4 53.8 27.6 22.6 33.2

Sylhet 23.2 46.9 15.6 11.6 20.8

Total 39.7 46.5 26.8 24.5 29.1

Note: LB and UB represent the lower and upper bounds of the 95% confidence interval of the effective 

coverage. The same applies to other tables onwards. 

3.2 Haiti

3.2.1 Facility distribution by type

Several types of facilities in Haiti offer delivery 

services, including hospitals, health centers, and 

dispensaries. These facilities are managed by either the 

government, the private sector, or a mix of government 

and private. Health centers offer preventative and 

curative services, and are technical facilities that often 

possess the staff and medicines to offer a wide range of 

care. Dispensaries are a source for basic outpatient 

care, offering services for common and mild 

pathologies. In Haiti, hospitals and health centers with 

beds are mandated to provide delivery care services. 

Though facilities without beds and dispensaries have 

no such mandate, many reported providing labor and 

delivery care services.

A total of 389 facilities surveyed in the 2013 Haiti SPA 

reported offering delivery services. One-third of these 

facilities are dispensaries (includes all three possible 

managing authorities) (Figure 2a). The other facilities 

offering delivery services are hospitals and health centers. Government hospitals (11%) and government 

health centers (19%) contribute to nearly a third of all facilities with delivery care. The remaining third of 

facilities are split approximately between private hospitals, private health centers, and mixed hospitals and 

health centers. Only 10 of these facilities qualify as CEmOC facilities.

3.2.2 Facility readiness to provide delivery care

Each facility type in Haiti has been given a service readiness score based on the availability of structural 

tracer items (Appendix Table 7). CEmOC facilities reported having the most tracer items, though some 

items were rare—such as an exam light (30%), suction apparatus (10%), manual vacuum extractor (30%), 

guidelines for management of pre-term labor (20%), and training in newborn infection management (30%). 

Only half of CEmOC facilities had CEmOC guidelines available, and 60% had CEmOC training.

Figure 2a Distribution of facilities with 

delivery care by facility type, Haiti 

SPA 2013

Govt. 

hospital, 

10.5

Govt. 

health 

center, 

19.1

Private 

hospital, 

11.0

Private 

health 

center, 

12.8

Mix hospital, 

health center, 

13.6

Dispensary: govt., 

private, mix, 33.0
16

Among non-CEmOC facilities, availability of tracer items is shown for 10 regions (Appendix Table 6). 

Many items are available in each region, such as specific equipment, guidelines, and training items. Often,

if an item is uncommon among facilities in one region, it is also uncommon in every region. Equipment 

such as a manual vacuum extractor, vacuum aspirator kit, and partograph were seldom observed in more 

than 30% of facilities in any region. Additionally, guidelines for such practices as Integrated Management 

of Pregnancy and Childbirth (IMPAC), CEmOC, management of pre-term labor, and standard precaution 

were found in less than 30% of facilities in nearly every region.

Items that were regularly found (over 90% of facilities) were delivery beds and disposable latex gloves, and 

some immediate newborn care practices such as baby wrapping and early initiation of breastfeeding. 

Though nearly every item in the list of guidelines and trainings was not commonly found in any region, 

staff supervision was common in every region. Regional variation exists among specific items, and often 

the Sud, Ouest, and Nord regions have greater availability of tracer items than regions such as the Sud-Est 

and Nord-Ouest. Newborn signal functions and immediate care (excluding neonatal resuscitation) were 

more commonly available than any nearly other tracer items, though fewer than half of facilities had the 

basic necessity of improved sanitation (47%). Similar to Bangladesh, the overall readiness score was much 

higher among CEmOC facilities than non-CEmOC facilities in Haiti, at 78% and 52% respectively 

(Appendix Table 6).

As Figure 2b shows, overall, health facilities in Haiti have a readiness score of 53%. By region, the highest 

readiness scores are in the Sud (61%) and Centre (60%) regions, and the lowest in the Nord-Ouest region

(43%). By facility type, the range of readiness is wider. Overall, government hospitals have the highest 

readiness score, with 72% of the maximum capacity to provide delivery care services, followed closely by 

private hospitals, at 68%. Health centers score much the same among government, private, and mixed (58%, 

56%, and 54% respectively), but dispensaries are the least ready, with only 37% of the maximum capacity 

to provide delivery care services.

3.2.3 Coverage of facility delivery

Figure 2c shows facility delivery by type of facility in each of the regions. Nationally, only 39% of live 

births in the two years preceding the survey were delivered in a health facility. Regionally, this ranges from 

30% of births in Artibonite to 49% of births in the Ouest region. In nearly every region the majority of 

births that took place in a health facility occurred in government hospitals, though in the Nord and NordEst regions more births were delivered in mixed hospitals than any other type of facility. Private hospitals 

were also commonly used in the Ouest region. Health centers delivered a very small proportion of these 

births (1-6%).
17

Figure 2b Readiness score of delivery services by facility type and region, Haiti SPA 2013

Figure 2c Percentage delivered in a health facility by facility type and region, among births in the 

two years preceding the survey, Haiti DHS 2012

70 68

74

84

74

81

67

70

65

78

72

59 58 57

50

58 58 60 59

53

65

58

66

45

66

86 85 82

70 68

56

73

52

67

42

51

66

60

54 56

44

64

56

45

57 54 55

72

55 56

54

42 37 35 38 36

31

43

37 36 39 37

57

47

54

48 49

60 61

55

43

57

53

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

Ouest Sud-Est Nord NordEstArtibonite Centre Sud GrandAnse

NordOuestNippes National

Govt. hospital Govt. health center Private hospital

Private health center Mix hospital, health center Dispensaire govt., private, mix

Total

21

10 15

8

16 15

32

16 11

24 18

5

6

1

1

6 2

1

3

5

3

4

16

4

4

4

3

6

4

6

4

8

2

1

2

4

5 1

2

6

1

2

4

2

17

21

1

7

2

2

5

7 6

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

4 9 2 2 4 0 3 8 3 0 3 1 4 1 2 1 3 1 3 9 3 9

Ouest Sud-Est Nord Nord-EstArtibonite Centre Sud GrandAnseNordOuestNippes National

Govt. hospital Govt. health center Private hospital Private health center Mix hospital, health center
18

3.2.4 Effective coverage

Figure 2d illustrates the intersection between readiness 

scores and facility delivery coverage among births in 

the two years preceding the survey. Many regions in 

Haiti exhibit a readiness score higher than 50% but 

with facility delivery coverage less than 50%, as the 

data points in Figure 2d in quadrant 4 indicate. In 

Grand-Anse region, with a readiness score similar to all 

other regions in quadrant 4, only 21% of births were 

delivered in a health facility. The remaining four 

regions, the Sud-Est, Nord-Est, Nord-Ouest, and 

Artibonite, are in quadrant 3, with less than 50% 

coverage and a readiness score below 50%. Overall, 

Haiti’s regions have a large range of coverage of 

facility delivery, but slightly smaller differences in 

facility readiness scores.

Haiti has a total estimated effective coverage of 24%, 

reflecting the level of delivery coverage (40%) adjusted 

for facility readiness (see Table 3). As Figure 2e shows,

all regions have low effective coverage, from 11% in 

Sud-Est to 32% in the Ouest region, with most regions 

having an effective coverage below 25%. The Ouest 

region has a relatively high readiness level among its 

health facilities, combined with the highest level of 

coverage, at 50%. In contrast, the Sud-Est has low

facility delivery coverage, at 23%, and one of the 

lowest facility readiness scores (47%).

Table 3 Coverage, readiness score, and estimated effective coverage by region, Haiti

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

Ouest 50.0 57.4 31.5 26.7 36.7

Sud-Est 23.0 47.0 10.5 6.3 17.0

Nord 39.9 54.0 25.3 18.6 33.3

Nord-Est 38.0 48.0 19.2 12.6 28.1

Artibonite 30.2 49.3 20.0 14.2 27.4

Centre 31.2 59.8 17.5 11.3 26.1

Sud 40.7 60.9 27.4 19.2 37.4

Grand-Anse 21.4 55.0 14.4 9.1 22.1

Nord-Ouest 31.5 43.2 16.1 11.2 22.5

Nippes 38.7 57.0 24.8 16.3 35.8

Total 40.0 52.7 24.4 22.0 27.0

Figure 2d Readiness versus coverage by 

region, Haiti

Figure 2e Effective coverage of facility 

delivery by region, Haiti

Ouest

Sud-Est

Nord

Nord-Est

Artibonite Centre

Sud

Grand-Anse

Nord-Ouest Nippes

Total 

0

50

100

0 50 100

Coverage

Readiness

II I

III IV
19

3.3 Malawi

3.3.1 Facility distribution by type

Figure 3a shows the distribution of facilities with 

delivery services by type among the 528 facilities in 

Malawi that provide delivery services. Eleven are 

CEmOC facilities, over half are government health 

centers, and 22% are private not-for-profit health 

centers or maternity facilities, primarily Christian 

Health Association of Malawi (CHAM) facilities. The 

rest, including government hospitals, private not-forprofit (PNFP) hospitals, and private for-profit (PFP)

facilities (mainly health centers), make up a smaller 

proportion, at 9%, 8%, and 5% respectively. 

Government-managed facilities offer services free of 

charge, while CHAM facilities charge user fees, except 

for some preventative services and infectious disease 

treatment, and are located mainly in rural areas. 

Though hospitals provide a wide and comprehensive 

suite of services for inpatient and outpatient care, 

primary-level facilities (health centers, health clinics, 

and maternity facilities) typically offer mostly preventative and some curative care.

3.3.2 Facility readiness to provide delivery care

Appendix Table 8 shows the regional and national availability of tracer items that are important for 

providing high-quality delivery care in non-CEmOC facilities, as well as in CEmOC facilities. Overall,

CEmOC facilities were observed to have all or most of the essential items or services in the areas of 

newborn immediate care, general requirements, equipment, or medical commodities, which results in a 

higher readiness score among CEmOC facilities than those non-CEmOC facilities (Appendix Table 6).

CEmOC facilities appeared to have relatively lower availability of guidelines and trained staff. For example, 

only about a third of the CEmOC facilities reported having at least one provider trained in IMPAC and 

CEmOC in the past 24 months.

Among non-CEmOC facilities, the availability of the tracer items varies. For example, the most commonly 

observed items or services were parenteral administration of uterotonic drugs/oxytocin, skin-to-skin care, 

baby wrapping, early initiation of breastfeeding, improved water source, delivery bed, disposable latex 

gloves, infant scale, injectable uterotonic, and antibiotic eye ointment for newborn. These were available 

in over 90% of non-CEmOC facilities with delivery services in Malawi. Some other items or services, 

however, were available in less than 25% of facilities, including vacuum aspirator or D&C kit, 

hydrocortisone, staff training in IMPAC, and staff training in CEmOC. Regional variation is small for most 

items. More variation exists in the availability of electricity, 24/7 skilled birth attendance, examination light, 

skin disinfectant, and CEmOC guidelines, which show differences of more than 15 percentage points 

between the region with the highest availability and the region with the lowest availability.

Figure 3a Distribution of facilities with 

delivery by facility type, Malawi 

SPA 2013-14

Govt. hospital, 

9.0

Govt. health center, 56.8

PFP hospital, 

health center, 

clinic, 4.5

PNFP 

hospital, 

7.7

PNFP health center, 

maternity, 22.0
20

Overall, Malawi’s facilities have a readiness score of 59% (Figure 3b). All three regions have a score similar 

to the national level underscoring consistency in facility readiness across regions. Among the types of 

facilities, government hospitals and private not-for-profit hospitals have the highest readiness scores, at

nearly 80% of the full capacity to provide delivery care services. These two types of facilities also perform 

consistently well across regions, with a readiness score from 74% to 82%. The other three types of 

facilities—government health centers, private for-profit facilities, and private not-for-profit health 

centers/maternities—have a national score of about 55%. The regional variations for these three facility 

types are also small.
21

Figure 3b Readiness score of delivery services by facility type and region, Malawi SPA 2013-14

Figure 3c Percentage delivered in a health facility by facility type and region, among births in the 

two years preceding the survey, Malawi DHS 2012

74

79 81 79

53 54 54 55 54 56

51

54

79 77

82 79

57 55 55 55

58 59 59 59

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

North Central South National

Govt. hospital Govt. health center PFP hospital, health center, clinic

PNFP hospital PNFP health center, maternity Total

31 30 29 30

51 51 50 51

1 3

2

2

7 6

6

6

4 4 7 5

0

10

20

30

40

50

60

70

80

90

100

95 93 93 93

North Central South National

Govt. hospital Govt. health center PFP hospital, health center, clinic PNFP hospital PNFP health center, other
22

3.3.3 Coverage of facility delivery

Malawi has achieved a high level of facility delivery—

93% of births in the two years before the survey were 

delivered at a health facility (Figure 3c). A similar level 

is observed in all three regions. Delivery care is 

primarily provided by government health centers, at 

51%, followed by government hospitals, at 30% 

nationally. There is limited use of private for-profit 

facilities and private not-for-profit health centers and 

maternity facilities. In all three regions, the distribution 

of facility delivery among the different types of 

facilities is similar to the national average.

3.3.4 Effective coverage

Figure 3d plots coverage of facility delivery against 

facility service readiness for the country and for the 

three regions. The country average and all three regions 

are located in quadrant 1 and largely overlap each other. 

After taking into account the readiness of facilities to 

provide the service, the coverage of facility delivery in 

Malawi decreases by 30%, or 17 percentage points, 

from 93% for crude coverage to 66% for effective 

coverage. As Figure 3e illustrates, the effective coverage in all three regions is also estimated at 66% 

because of their similar levels of coverage and readiness. Table 4 summarizes findings on coverage, 

readiness, and effective coverage for Malawi nationally and by region.

Table 4 Coverage, readiness score, and estimated effective coverage by region, Malawi

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

North 94.7 67.5 66.2 58.2 73.4

Central 92.8 67.6 66.3 61.6 70.7

South 92.7 67.2 66.4 62.1 70.5

Total 92.9 67.4 66.4 63.4 69.2

Figure 3d Readiness versus coverage by 

region, Malawi

Figure 3e Effective coverage of facility 

delivery by region, Malawi

North

Central

South

Total

0

50

100

0 50 100

Coverage

Readiness

IV

I

III

II
23

3.4 Nepal

3.4.1 Facility distribution by type

A total of 457 facilities in Nepal, including 9 CEmOC 

facilities and 448 non-CEmOC facilities, reported that 

they provide delivery services. The majority (77%) are 

government health posts or sub-posts (Figure 4a). 

Other types of facilities with delivery care services are 

government hospital, government primary health care 

(PHCC) center, and private hospital, accounting for 

4%, 9% and 10%, respectively. Health posts provide 

basic curative and preventive outpatient services and 

are staffed by four or five health workers. Primary 

health centers often have a medical officer, more staff 

than a health post, and a few beds, enabling them to 

offer basic diagnosis and treatment of illnesses as well 

as other curative services. There is typically at least one 

small hospital in every district with several medical 

officers and around 15 health workers. However,

regional and central hospitals are much larger, with up 

to 200 staff members and 500 beds, and offering a wide 

and comprehensive range of services.

3.4.2 Facility readiness to provide delivery care

Appendix Table 9 shows the availability of tracer items that are important for providing delivery care in 

seven provinces among non-CEmOC facilities, and at the national level for CEmOC facilities. CEmOC 

facilities have most items available except a few medicines (chlorhexidine and antibiotic eye ointment for 

newborns), guidelines, and staff training. Only a few CEmOC facilities have guidelines on reproductive 

health services and standard precautions available. Their staff also reported limited staff training related to 

delivery and newborn care, and only one of the nine CEmOC facilities has training in CEmOC. Among 

non-CEmOC facilities, with some variability, the provinces often have similar items available at their health 

facilities. Some items are scarcely available in any region. For example, fewer than one in every four 

facilities has a 24/7 skilled birth attendant, manual vacuum extractor, vacuum aspirator, or hydrocortisone. 

Conversely, nine in every ten facilities routinely provide immediate newborn care (skin-to-skin care, 

wrapping baby, and early initiation of breastfeeding) and have sterilization equipment, a delivery bed, latex 

gloves, skin disinfectant, and IV diffusion supplies. Similar to CEmOC facilities, non-CEmOC facilities 

also reported limited availability of guidelines and staff training; these areas were rarely available in more 

than 25% of facilities. As in other countries, CEmOC facilities had a much higher readiness score than nonCEmOC facilities in Nepal (Appendix Table 6).

Figure 4b shows readiness scores by facility type and region in Nepal. Overall, Nepal’s facilities have a 

national service readiness score of 58%, which means that on average they have 58% of the maximum 

capacity to provide delivery services. Among the four types of facilities, government hospitals have the 

Figure 4a Distribution of facilities with 

delivery by facility type, Nepal 

SPA 2015-16

Govt. hospital, 

4.4

Govt. PHCC, 8.9

Govt. health post, 

sub-health post, 

76.9

Private hospital, 9.9
24

highest service readiness, at nearly 80%. Government health posts and sub-posts have the lowest readiness 

score, at a national average at 55%. Government primary health care centers and private hospitals have 

similar readiness scores, at 64% and 62% respectively.

Provinces show variations in readiness by type of facility that are similar to the national level. In all 

provinces, government hospitals have the highest readiness score, whereas government posts and sub-posts 

are the least ready, with just over 50% of the maximum capacity to provide delivery care services. Across 

provinces, government PHCCs vary in readiness, from a score of 55% in Province 1 to 72% in Province 7. 

Private hospitals also exhibit a wide range of readiness across provinces, from 50% in Province 1 to 75% 

in Province 5.
25

Figure 4b Readiness score of delivery services by facility type and province, Nepal SPA 2015-16

Figure 4c Percentage delivered in a health facility by facility type and province, among births in 

the two years preceding the survey, Nepal DHS 2015

81

78 80

73

82

75

84

79

62 61 62

65

69

62

72

64

56

61

54 52

60

51

56 55 54

65

60

69

75

59

66

62

58

63

57

55

63

52

58 58

0

10

20

30

40

50

60

70

80

90

100

Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7 National

Govt. hospital Govt. PHCC Govt. health post, sub-post, other Private hospital Total

31

23

46 44

31

16 22

30

2

3

1 4

2

1

6

3

7

4

9 10

11

15

32

10

15

8

14 10

10

2

2

10

0

10

20

30

40

50

60

70

80

90

100

56 37 70 67 54 34 62 53

Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7 National

Govt. hospital Govt. PHCC Govt. health post, sub-post, other Private hospital
26

3.4.3 Coverage of facility delivery

In Nepal, 53% of live births in the two years before the survey were delivered in a health facility (Figure 

4c).

2 The primary source of delivery care was government hospitals (30%), followed by private hospitals 

(10%), government health posts/sub-posts (10%), and government PHCCs (3%). In most of the provinces 

except Province 7, government hospitals are the leading source of delivery care. In Provinces 1, 2, and 3, 

private hospitals are more commonly used than government health posts/sub-posts and government PHCCs. 

Government health posts/sub-posts play a major role in Provinces 6 and 7 providing delivery care services,

given that the government health post is the most common facility type. In Province 7, 32% of births were 

delivered at government health posts/sub-posts, a share higher than that of government hospitals (22%).

3.4.4 Effective coverage

Figure 4d shows the level of service readiness and the 

coverage of facility delivery in Nepal nationally and in 

the provinces. The national average and five provinces 

(Provinces 1, 3, 4, 5, 7) are in quadrant 1, which 

indicates that both the average readiness score and 

coverage of facility delivery are higher than 50%. 

Among these provinces, Provinces 3 and 4 have the 

highest coverage but relatively poor readiness 

compared with other provinces. Provinces 2 and 6 are 

in quadrant 4, representing a readiness score higher 

than 50%, but facility delivery coverage lower than 

50%. Although facilities in Province 2 have the highest 

readiness score (63%) among all provinces, coverage 

is low, at only 37% of births delivered in a health 

facility. Province 6 has the lowest coverage of facility 

delivery and its facilities also are the least ready to 

provide delivery services. Overall, provincial differences are greater in coverage of facility delivery (from 

34% in Province 6 to 70% in Province 3) than in the 

readiness of facilities to provide the services (from 

52% in Province 6 to 63% in Province 2).

 

2 An additional 6% of births were reported delivered in such places as private clinics and NGO facilities in Nepal or 

India, or other unnamed places.

Figure 4d Readiness versus coverage by 

province, Nepal

Province 1

Province 2

Province 3

Province 4

Province 5

Province 6

Province 7

Total 

0

50

100

0 50 100

Coverage

Readiness

I

III IV

II
27

While 53% of births in Nepal were delivered in a health 

facility, effective coverage is estimated at only 42% at 

the national level (see Table 5). At the provincial level, 

effective coverage ranges from 27% in Province 6 to 

51% in Province 3. While Provinces 3, 4, and 7 have a 

higher effective coverage than other provinces, at about 

50%, Provinces 6 and 2 have the lowest effective 

coverage, at 27% and 34% respectively (Figure 4e).

Table 5 Coverage, readiness score, and estimated effective coverage by province, Nepal

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

Province 1 55.9 57.9 40.1 33.4 47.3

Province 2 37.4 63.0 33.7 28.4 39.5

Province 3 69.8 57.4 50.7 41.7 59.7

Province 4 67.1 54.6 50.3 41.7 58.8

Province 5 54.1 62.5 45.4 36.9 54.3

Province 6 34.1 52.4 27.1 21.4 33.6

Province 7 61.9 58.4 49.5 39.9 59.1

Total 52.7 57.7 41.9 38.9 45.1

Figure 4e Effective coverage of facility 

delivery by province, Nepal
28

3.5 Senegal

3.5.1 Facility distribution by type

The majority of health facilities in Senegal that provide 

delivery services are managed by the public sector 

(Figure 5a). Two-thirds of these facilities are government health posts, 21% are health huts, 5% are 

government health centers, and 1% are government 

hospitals. Health centers in Senegal are typically better

equipped and have more doctors and health workers 

than health posts, where typically no doctor is 

available, only nurses or midwives. Health huts are 

detachments of health posts, staffed with only health 

workers and providing only the most basic health 

services, including curative child care, growth 

monitoring, and vaccinations, as well as offering 

family planning services. Seven percent of all facilities 

in Senegal are privately managed (hospitals, clinics, or 

centers).

3.5.2 Facility readiness to provide delivery 

care

There is a broad range of availability of items for providing delivery care across and within both the types 

of facilities and regions (Appendix Table 10). At the national level, commonly available items (over 90%)

among non-CEmOC facilities include assisted vaginal delivery, skin to skin, wrapping the baby, and early 

breastfeeding, delivery bed, delivery pack, and an infant scale. A few items have only limited availability: 

parenteral administration of anticonvulsants for hypertensive disorders of pregnancy (24%), manual 

vacuum extractor (3%), guidelines for management of pre-term labor (14%), and at least one staff member 

with training in CEmOC (24%). Only 10% of non-CEmOC facilities were found to have a skilled birth 

attendant available at all times. Among CEmOC facilities, the majority of items are available in 100% of 

facilities, the key exceptions being at least one staff member with recent training in newborn care and a 

number of medicines and commodities. As expected, a much higher readiness score was found among 

CEmOC facilities than non-CEmOC facilities (Appendix Table 6).

Figure 5b shows that at the national level the average level of readiness among facilities was 60% of the 

maximum capacity to provide delivery services. Across all regions, government hospitals (the least 

prevalent facility type) have the highest readiness, at 85%, followed by government health centers (79%) 

and private hospitals, clinics, or health centers (72%). The lowest level of readiness was observed among 

health huts, with a score of 33% at the national level. These patterns are consistent across the regions. 

Facilities in Dakar are the best prepared to provide delivery services, with a readiness score of 73%, due to 

the absence of health huts in Dakar. The readiness in the North region is the lowest of all regions (54%), 

with government hospitals (80%), health centers (72%), and clinics (58%) having lower scores than their

respective facilities in all other regions.

Figure 5a Distribution of facilities with 

delivery by facility type, Senegal 

SPA 2015

Govt. hospital, 1.3

Govt. health 

center, 5.3

Govt. health post, 

65.2

Govt. health 

hut, 21.3

Private hospital, 

clinic, center, ...
29

3.5.3 Coverage of facility delivery

Figure 5c shows that, overall, 77% of births in the preceding two years were delivered in a health facility. 

Facility delivery coverage varies by region, from 63% in the North to 94% in Dakar. Nationally, among 

births delivered in a health facility, 44% were delivered in a government health post, the most common 

place of delivery, ranging from 25% in the East to 53% in Thiès. Nationally, very few babies were born in 

a health hut (3%) or a private facility (4%), although in Dakar, where private facilities are more accessible,

8% of births were delivered in a private facility (Agence Nationale de la Statistique et de la Démographie 

Sénégal and ICF International 2016).
30

Figure 5b Readiness score of delivery services by facility type and region, Senegal SPA 2015

Figure 5c Percentage delivered in a health facility by facility type and region, among births in the 

two years preceding the survey, Senegal DHS 2016

80

88 90

84

87 87 85

72

82 83

79

82 80 79

58

70 68 67 66 69

65

38

32

29

39

33 33

66

74 74

67 64

77

72

54

73

57

60

64 62 60

0

10

20

30

40

50

60

70

80

90

100

North Dakar Thiès Central East South National

Govt. hospital Govt. health center Govt. health post

Govt. health hut Private hospital, clinic, or center Total

6

9 6 5 6

9 7

11

39

27

14 13 12 19

41

38

53

53

25

37

44

3

0

2

4

2

7

3

2

8

4

4

2

1

4

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

6 3 9 4 9 2 8 0 4 9 6 7 7 7

North Dakar Thiès Central East South National

Govt. hospital Govt. health center Govt. health post Govt. health hut Private hospital, clinic, center
31

3.5.4 Effective coverage

Examining the intersection between readiness scores 

and facility delivery coverage for births in the two 

years preceding the survey reveals higher levels of 

coverage than readiness to provide delivery services in 

most regions, as Figure 5d depicts. All regions are in

quadrant 1, suggesting high levels of both coverage and 

readiness. There is considerable variation across the 

regions, however, marked more by differences in 

coverage than readiness. The highest levels of both 

coverage and readiness are in Dakar, while the North 

and East lag behind on both indicators.

Figure 5e presents the effective coverage of facility 

delivery by region and at the national level. After 

adjusting for service readiness by the type of facility, 

crude coverage is reduced from 77% to an effective 

coverage of 52%. There is considerable variation in 

effective coverage among regions, from 30% in the 

East to 64% in Dakar. Dakar’s surrounding area, the 

Thiès region, has the second highest effective 

coverage, at 62%. The level of effective coverage 

appears lowest in the East (30%) and North (38%) 

compared with other regions (see Table 6).

Table 6 Coverage, readiness score, and estimated effective coverage by region, Senegal

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

North 62.9 54.3 37.8 31.7 44.4

Dakar 93.9 72.6 63.9 46.9 78.0

Thiès 91.9 56.9 61.6 48.8 73.0

Central 80.1 59.8 54.6 48.4 60.6

East 48.9 63.8 29.7 23.3 36.9

South 67.0 61.7 46.7 38.5 55.1

Total 77.0 60.0 51.3 47.2 55.3

Figure 5d Readiness versus coverage by 

region, Senegal

Figure 5e Effective coverage of facility 

delivery by region, Senegal

North

Dakar Thies

Central

East

South

Total

0

50

100

0 50 100

Coverage

Readiness

III

I

IV

II
32

3.6 Tanzania

3.6.1 Facility distribution by type

Several types of facilities in Tanzania offer delivery 

services. Besides hospitals, there are health centers 

staffed by nurses and midwives that offer both 

preventative and curative care. Other facilities,

including clinics and dispensaries, mostly offer 

curative services. The 2014-15 Tanzania SPA surveyed

905 facilities that offered delivery services, the large 

majority managed by the government (Figure 6a). 

Seventy-two percent of these facilities are dispensaries, 

followed by a small proportion of government health 

centers, and very few hospitals. Religious facilities 

account for a little over 10%. Only eight of these 

facilities qualify as CEmOC facilities.

3.6.2 Facility readiness to provide delivery 

care

Service readiness scores were calculated based on the 

availability of structural tracer items (Appendix Table 

11). CEmOC facilities in Tanzania reported having the most tracer items, and nearly every item was

available in 9 out of 10 facilities in the country in all domains except guidelines, staff training, and supervision, though some equipment and medicines were found in less than one-third of facilities (suction 

apparatus, manual vacuum extractor, vacuum aspirator, chlorhexidine, and antibiotics). In most facilities, 

guidelines and training items were uncommon; only a third of CEmOC facilities had CEmOC guidelines

or CEmOC training.

For non-CEmOC facilities, there are some large regional differences in availability of tracer items, as 

Appendix Table 6 shows. Compared with other regions, more facilities in Zanzibar have general 

requirements, equipment, and medicines (excluding antibiotic items). However, Zanzibar has the fewest 

number of facilities that reported training in IMPAC, normal labor and delivery, CEmOC, and active 

management of the third stage of labor (AMTSL). Training and guidelines are uncommon in all regions 

except in the Western and Northern regions, where more than seven facilities in every ten reported training 

in neonatal resuscitation, newborn infection management, early and exclusive breastfeeding, thermal care, 

and cord care. Newborn signal functions are universally common across the regions. Some basic items have

large regional variation, such as handwashing necessities (46% in Western region versus 88% in Southern 

Highlands) and improved sanitation (19% in Central region versus 93% in Zanzibar). Given the greater 

availability of tracer items in CEmOC facilities than non-CEmOC facilities, the former had a higher 

readiness score, at 89% compared with 60% among non-CEmOC facilities.

Facilities in Tanzania have an overall readiness of 53% of the maximum capacity to provide delivery care 

services (Figure 6b). This varies only slightly by region, but varies greatly by facility type. Religious and 

government hospitals have the highest readiness scores (82% and 78% respectively), while government 

Figure 6a Distribution of facilities with 

delivery by facility type, Tanzania 

SPA 2014-15

Govt. hospital, 2.6

Govt. health 

center, 9.2

Govt. 

dispensary, 72.1

Private hosp., 

health center, 

other, 3.6

Religious 

hospital, 

1.6

Religious health 

center, other, 10.9
33

dispensaries have the lowest (49%). Other types of facilities perform similarly, at 65% for government 

health centers, 60% of private facilities, and 58% for religious health facilities. In every region, government 

and religious hospitals have high readiness scores, though readiness scores among health centers are 

consistently higher in Western, Northern, Central, and Southern Highlands regions than elsewhere. Zanzibar 

ranked lowest in readiness scores across government-managed hospitals and health centers.
34

Figure 6b Readiness score of delivery services by facility type and zone, Tanzania SPA 2014-15

Figure 6c Percentage delivered in a health facility by facility type and zone, among births in the 

two years preceding the survey, Tanzania DHS 2015-16

83

67

82

87

81 81 82 83

74

78

68 69 68 67 65 64

60

69

53

65

53 53 50 49 49 50

44 47 50 49

69 68

40

78

60

57

63 65

60

86

81

87 84 83 83 81

76

82

60

65 62 61

51

54

51 53

34

58 56 59

53 53

51

53

48 52

55 53

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

Western Northern Central Southern

highlands

Southern South

west

highlands

Lake Eastern Zanzibar National

Govt. hospital Govt. health center Govt. dispensary

Private hosp., health center, other Religious hospital Religious health center, other

Total

20 26 23

40 42

19 16

38

50

25

7

17

8

9

14

13

12

21

16

13

18

7

21

11

27

24

14

15 1

16

2 2

1

0

0

1

3

6

2

3

4

13 9

17

4

9

5

7

1

2 7

2

1

13 0

5

1

2

0

2

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

100

5 3 6 8 6 2 9 0 8 6 6 9 5 1 8 9 7 0 6 5

Western Northern Central Southern

highlands

Southern South

west

highlands

Lake Eastern Zanzibar National

Govt. hospital Govt. health center Govt. dispensary

Private hosp., health center, other Religious hospital Religious health center, other
35

3.6.3 Coverage of facility delivery

Among all births in the two years preceding the DHS survey, 65% were delivered in a health facility (Figure 

6c). In some regions (Western and Lake), only half of births were delivered in a facility compared with 

about 90% in the Eastern and Southern Highlands regions. In the regions with the highest facility delivery 

coverage, the majority of births were delivered in government hospitals, though government dispensaries

and health centers were also used. In the Western and Lake regions, births were delivered in a health facility 

almost as commonly in government dispensaries as in government hospitals. Other types of facilities 

generally delivered only a small proportion of births, except in the Northern, Central, Southern Highlands, 

and South West Highlands regions, where 9-17% of births were delivered in religious hospitals.

3.6.4 Effective coverage

Concerning the intersection between facility readiness 

scores and facility delivery coverage, all regions except 

Lake region are in quadrant 1 (Figure 6d), indicating 

that they have facility delivery coverage and facility 

readiness scores greater than 50%. The spread of data 

is only visible across regions along the y-axis, which 

shows the variation in coverage, while there is little 

variation in readiness scores, ranging from 52-58%. 

Coverage of facility delivery, ranging from 50-89%,

appears to occur in a few regions without evident 

correlation with readiness scores.

Figure 6e shows the level of effective coverage in 

Tanzania by facility type and region. Nationally, 

effective coverage is 44%, which is substantially lower 

than the conventional facility delivery coverage of 65%

(see Table 7). Every region’s effective coverage 

estimate is 16-27 percentage points lower than the level 

of crude coverage. Regionally, there is a large variation 

in effective coverage. The region with the highest 

effective coverage (Southern Highlands) is twice the 

level of the region with the lowest effective coverage 

(Lake region). The Southern Highlands, Eastern, and Southern regions have the highest effective coverage 

of all regions, at 68%, 63%, and 59% respectively. All other regions have an effective coverage below 50%, 

and lowest in the Western and Lake regions. The differences among regions are significant.

Figure 6d Readiness versus coverage by 

zone, Tanzania

Figure 6e Effective coverage of facility 

delivery by zone, Tanzania

Western

Northern

Central

Southern highlands

Southern 

South west highlands

Lake

Eastern

Zanzibar

Total

0

50

100

0 50 100

Coverage

Readiness

III IV

II I
36

Table 7 Coverage, readiness score, and estimated effective coverage by zone, Tanzania

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

Western 53.0 56.0 37.0 28.9 46.0

Northern 68.2 58.7 46.8 37.9 55.8

Central 61.7 52.8 42.9 35.1 51.0

Southern Highlands 89.5 53.4 67.7 55.7 77.8

Southern 85.8 51.2 58.5 48.0 68.3

South West Highlands 69.3 52.7 45.2 36.2 54.5

Lake 50.6 48.0 32.4 28.5 36.6

Eastern 89.0 52.3 63.1 55.6 70.0

Zanzibar 70.2 55.3 47.1 42.5 51.8

Total 65.0 52.7 44.2 41.6 46.8

3.7 Comparison of Countries

Table 8 and Figure 7 plot the countries’ national average of facility delivery against their facilities’ readiness 

score. In Figure 7 for each country, the width of the horizontal whisker indicates the range of the readiness 

score among the country’s regions, and the length of the vertical whisker represents the range of the facility 

delivery coverage among the regions. The longer the whisker, the greater the variability among the regions. 

Four countries—Malawi, Senegal, Tanzania, and Nepal—appear in quadrant 1, indicating a national 

coverage and readiness score both higher than 50%. Malawi has both the highest coverage of facility 

delivery and the greatest readiness to provide delivery services. Bangladesh has the lowest coverage and 

readiness, both lower than 50%. Haiti is in quadrant 4, with a readiness score above 50% but coverage 

below 50%. All countries demonstrate a larger regional variability in coverage than in readiness except 

Malawi, where the regions have similar levels of coverage and readiness. Senegal has the greatest range of 

crude coverage of both facility delivery and facility readiness by region.

Figure 7 National readiness score versus coverage and regional variations

Bangladesh

Haiti

Malawi

Nepal

Senegal

Tanzania

0

50

100

0 50 100 Coverage

Readiness

II

III IV

I
37

Table 8 Estimated effective coverage of facility delivery in all six countries

Coverage

Readiness 

score

Effective coverage

Estimate LB UB

Bangladesh

Barisal 30.5 42.5 20.5 15.9 25.8

Chittagong 36.8 46.3 25.8 21.0 31.2

Dhaka 43.7 46.8 27.6 23.1 32.7

Khulna 58.8 49.3 40.9 35.0 47.0

Rajshahi 40.9 39.0 27.6 23.1 32.7

Rangpur 35.4 53.8 27.6 22.6 33.2

Sylhet 23.2 46.9 15.6 11.6 20.8

Total 39.7 46.5 26.8 24.5 29.1

Haiti

Ouest 50.0 57.4 31.5 26.7 36.7

Sud-Est 23.0 47.0 10.5 6.3 17.0

Nord 39.9 54.0 25.3 18.6 33.3

Nord-Est 38.0 48.0 19.2 12.6 28.1

Artibonite 30.2 49.3 20.0 14.2 27.4

Centre 31.2 59.8 17.5 11.3 26.1

Sud 40.7 60.9 27.4 19.2 37.4

Grand-Anse 21.4 55.0 14.4 9.1 22.1

Nord-Ouest 31.5 43.2 16.1 11.2 22.5

Nippes 38.7 57.0 24.8 16.3 35.8

Total 40.0 52.7 24.4 22.0 27.0

Malawi

North 94.7 67.5 66.2 58.2 73.4

Central 92.8 67.6 66.3 61.6 70.7

South 92.7 67.2 66.4 62.1 70.5

Total 92.9 67.4 66.4 63.4 69.2

Nepal

Province 1 55.9 57.9 40.1 33.4 47.3

Province 2 37.4 63.0 33.7 28.4 39.5

Province 3 69.8 57.4 50.7 41.7 59.7

Province 4 67.1 54.6 50.3 41.7 58.8

Province 5 54.1 62.5 45.4 36.9 54.3

Province 6 34.1 52.4 27.1 21.4 33.6

Province 7 61.9 58.4 49.5 39.9 59.1

Total 52.7 57.7 41.9 38.9 45.1

Senegal

North 62.9 54.3 37.8 31.7 44.4

Dakar 93.9 72.6 63.9 46.9 78.0

Thiès 91.9 56.9 61.6 48.8 73.0

Central 80.1 59.8 54.6 48.4 60.6

East 48.9 63.8 29.7 23.3 36.9

South 67.0 61.7 46.7 38.5 55.1

Total 77.0 60.0 51.3 47.2 55.3

Tanzania

Western 53.0 56.0 37.0 28.9 46.0

Northern 68.2 58.7 46.8 37.9 55.8

Central 61.7 52.8 42.9 35.1 51.0

Southern Highlands 89.5 53.4 67.7 55.7 77.8

Southern 85.8 51.2 58.5 48.0 68.3

South West Highlands 69.3 52.7 45.2 36.2 54.5

Lake 50.6 48.0 32.4 28.5 36.6

Eastern 89.0 52.3 63.1 55.6 70.0

Zanzibar 70.2 55.3 47.1 42.5 51.8

Total 65.0 52.7 44.2 41.6 46.8

39

4 DISCUSSION AND CONCLUSION

Effective coverage—a measurement that adjusts the conventional measurement of facility use for the 

quality of care clients receive—is a useful tool for evaluating the impact of maternal and newborn health 

interventions, and monitoring a country’s progress toward achieving universal coverage of health care with 

sufficient quality (Colston 2011). This study estimated effective coverage of facility delivery in Bangladesh, 

Haiti, Malawi, Nepal, Senegal, and Tanzania by linking data from household surveys with data from health 

facility surveys. We focused on the structural dimension of quality of care, which we measured with a 

readiness score computed with a number of obstetric and newborn care indicators, using an equal-weight

approach. Other studies have used different methods to measure facility readiness, such as requiring a 

minimum number of items to deem a facility “ready” or not (Kanyangarara et al. 2018; Larson et al. 2017). 

The different measures of quality should be kept in mind in the interpretation and comparisons of effective 

coverage across studies.

Given the global efforts to improve maternal health, many developing countries have witnessed a 

remarkable increase in coverage of facility delivery in the last two decades. Among the six countries in our 

study, at least two-thirds of births in Senegal and Tanzania and more than 90% of births in Malawi were 

delivered in a health facility. While facility delivery coverage in Haiti and Bangladesh remains relatively 

low, their levels have doubled since 2000. Nevertheless, after taking into account facilities’ preparedness 

to provide delivery care services, the level of effective coverage in all countries studied becomes much 

lower. The reduction ranges from 20% in Nepal to 39% in Haiti, whose resulting national effective coverage 

is only 24%, the lowest among the six countries. Even though Malawi has achieved almost universal facility 

delivery, the effective coverage is much lower, at 66%, after adjusting for facility readiness to provide 

delivery services. Senegal is the only other country that has an effective coverage higher than 50%. These 

findings suggest that many women who delivered in a health facility did not necessarily receive the quality 

of care needed to avoiding preventable maternal and newborn mortality (Bhutta et al. 2014).

The substantial drop of coverage shown in this study when incorporating the quality-of-care component is 

also found in other health areas and other settings. Leslie et al. (2017) found that in eight high-mortality 

countries, after adjusting for the process aspect of quality of care, coverage was reduced by half or more 

when examining prevalence of four or more antenatal care visits, treatment for child illnesses (diarrhea, 

fever, or acute respiratory illness), and demand satisfied for modern contraception. In rural Burkina Faso, 

compared with the level of crude coverage of curative child care, at around 70%, the effective coverage 

was only an estimated 5% based on a high-quality standard and 45% based on a high or intermediate 

standard of quality (Koulidiati et al. 2018). A study in a rural region of Tanzania found that, while over 80% 

of women delivered their most recent birth in a health facility, few delivered at a facility that offered highquality routine or emergency obstetric care, and none delivered in a facility staffed by providers with a high

level of clinical knowledge and skills (Larson et al. 2017). The authors estimated that effective coverage of 

obstetric care was only 25%, even using a minimum threshold of quality. These studies, along with our own 

analysis, highlight the need for improving quality of care to achieve the health-related Sustainable 

Development Goals. To further reduce the prevalence of maternal and newborn deaths, global efforts should 

go beyond increasing the use of health services to also promoting higher-quality services, because health 

care can only achieve its full potential when it offers sufficient quality.
40

In examining readiness to provide delivery service, our analysis found that facilities are often poorly 

equipped and/or have a shortage of essential supplies or medicines for care of mothers and newborns, even 

among such high-level facilities as comprehensive emergency obstetric care facilities. Staff training is 

important to ensuring that health providers possess the technical competence needed to provide services, 

yet in-service trainings in pregnancy, labor, and delivery care are universally inadequate. Across all 

countries studied, more than two-thirds of CEmOC facilities did not have a provider who received inservice training in CEmOC. Among non-CEmOC facilities, provision of basic emergency obstetric care 

and newborn resuscitation was limited in all six countries. Service guidelines were commonly missing 

among all facilities. While it is expected that lower-level facilities might not be equipped with all of the 

tracer items examined, many lacked essential supplies or equipment or did not have an appropriate referral 

system. The majority of non-CEmOC facilities lacked an emergency transportation system, even though it 

is critically important for these facilities to be able to transfer medical emergencies or complications that 

they are not able to treat themselves.

We found that in all six countries a variety of facility types reported providing delivery care services, from 

peripheral facilities such as dispensaries, health posts, and union facilities to high-level facilities such as 

regional or national hospitals. In all countries, hospitals, private or public, are typically the type of facility

most prepared to provide adequate care, whereas lower-level facilities are much less prepared. Despite the 

poor readiness of these lower-level facilities, many were reported by women to be one of the major sources 

of delivery care. In fact, in several countries the type of facility least ready to provide delivery care was the 

most commonly reported source of delivery care. In Nepal, for example, despite having the lowest readiness

score, government health posts were widely used in Provinces 6 and 7. In Tanzania, delivery care was 

commonly sought in public dispensaries, the facility type with the lowest readiness score. A similar pattern 

was found in Senegal—the most commonly used type of facility, the government health post, had low 

service readiness scores compared with government hospitals and health centers. Measures can be taken to 

improve quality of care in these facilities, but another important strategy would be to increase the use of 

facilities with high readiness for delivery. Individuals may have limited access, perhaps physical or 

financial, to health facilities that are well prepared, usually government hospitals or private hospitals. 

Moreover, these high-level facilities may be already overburdened by serving a large population for a wide 

array of services. It was also common that the most prepared facilities were the fewest in number, as in 

Bangladesh, where the level of readiness was highest in public hospitals, the least common type of facility.

For facilities that are poorly prepared, it would be recommended to invest in emergency transportation as a 

first step.

CEmOC facilities were exceedingly rare. Entire regions of a country undoubtedly lack a CEmOC facility, 

as in Senegal, where only two CEmOC facilities were available among the six regions, indicating that lack 

of proximity may be a physical barrier for many women. It is expected that primary facilities will continue 

to play an important role in providing delivery services to women. Countries need to increasingly invest in 

these facilities, and ensure that they are properly equipped to deliver services and have a referral system in 

place. While investment in all domains of service readiness is needed, most urgent are expanding emergency 

obstetric care and newborn resuscitation, which are critical for saving mothers’ and newborns’ lives. More 

investment in human resources is also warranted, as demonstrated in our analysis and in other studies 

(Lanata 2007; Manzi et al. 2012).
41

While it is important to strengthen the ability of health facilities to provide quality delivery services, 

additional efforts should continue to improve the use of these services in countries or regions where a large 

proportion of women still deliver at home. Looking across countries and within countries, the wide variation 

in effective coverage appears to be a result of the differences in both facility delivery coverage and facility

readiness to provide good care. Malawi possesses the highest level of effective coverage because it has the

highest coverage and highest facility readiness, while Haiti, the country with the lowest use of facility 

delivery and a low facility readiness score, has the lowest level of effective coverage. However, national

levels of effective coverage align more with the level of coverage for facility births than with facility 

readiness. In fact, all countries except Malawi demonstrate a greater regional variability in the percentage 

of facility births than in facility readiness; hence, differences in effective coverage appear to be primarily 

driven by a country’s various levels of facility delivery coverage. In Senegal, for example, Dakar and Thiès, 

the two regions with the highest effective coverage, more than 90% of births were delivered in a health

facility, while the East region had less than 50% facility delivery and suffered from the lowest effective 

coverage. Haiti, Nepal, and Bangladesh, the regions with the highest percentages of facility deliveries, had 

double the level of effective coverage compared with countries with the lowest percentages of facility 

deliveries. In regions with very low readiness scores, levels of facility delivery are correspondingly low. 

The patterns observed between use of health facilities and their readiness to provide adequate services 

suggest that quality of care may be another factor that drives or deters facility use (Acharya and Cleland 

2000; Karim et al. 2015).

Haiti presents the lowest effective coverage among the six countries—just 24% at the national level. In five 

of its ten regions, effective coverage is below 20%. Though Haiti has readiness scores similar to Tanzania’s, 

its low effective coverage seems primarily a result of low levels of use of facility delivery. Due to the 

mountainous terrain in Haiti, women face a particular challenge in reaching health facilities (Alexandre et 

al. 2005). Further, half of all of the health facilities were destroyed in the earthquake in 2010 (Behrman and 

Weitzman 2016)—only three years before the Haiti SPA was conducted. Access to facilities with a better 

quality of services could be even more limited, and women in rural areas particularly likely to suffer, as 

those facilities are usually located in the metropolitan or urban areas (Gage and Guirlène Calixte 2006; 

Gage et al. 2017). Studies have found that physical proximity to a health facility is significantly associated 

with women’s use of maternal health services (Gage and Guirlène Calixte 2006; Wang, Winner, and 

Burgert-Brucker 2017). Many dispensaries in Haiti reported to provide delivery service, although they are 

not mandated to provide such services. Their readiness was also the lowest, but women rarely use 

dispensaries for delivery care. In addition to other factors that affect women’s access to facilities, quality 

of care provided by health facilities still plays an important role in the use of services, especially where 

access to services is less of an issue. A recent analysis showed that for Haitian women, the odds of facility 

delivery in a nonmetropolitan urban area doubled if they lived in an area with a high level of facility service 

readiness compared with women in an area with low readiness (Wang, Winner, and Burgert-Brucker 2017).

Second to Haiti, Bangladesh has the lowest effective coverage among the six countries, which is the result

of both limited use of health facilities for delivery and poor readiness among the facilities. About 60% of 

births in the country, and up to 70-80% in some regions, were delivered at home. Among the many factors

that could hinder women from using a health facility for delivery, the poor quality of services undoubtedly 

contributes to the low rate of use (Acharya and Cleland 2000; Karim et al. 2015). This is supported by our 

findings that the most commonly used sources, private hospital and clinics, have relatively better service 

readiness than other types of facilities. Union facilities, the most common type of facility, have the lowest
42

readiness and are the least used. It is believed that the poor quality of care in health facilities contributes to 

the stall of maternal mortality decline identified in the 2016 Bangladesh Maternal Mortality and Health 

Care Survey compared with the 2011 survey, despite an increase in facility delivery coverage between the 

two surveys (National Institute of Population Research and Training (NIPORT), International Centre for 

Diarrhoeal Disease Research Bangladesh (ICDDRB), and MEASURE Evaluation 2017). We found that 

only one-third of non-CEmOC facilities and less than two-thirds of CEmOC facilities had a 24/7 skilled 

birth attendant, and that the staff received little training on labor and delivery care; in addition, over half of 

the facilities did not have reliable electricity. The poor quality of obstetric care has also been reported in 

other studies (Anwar, Kalim, and Koblinsky 2009). While private facilities play a major role in providing 

facility delivery in Bangladesh, and they generally provide better quality of care, as indicated in this study 

and others (Alam et al. 2015; Siddiqui and Khandaker 2007; Sikder et al. 2015), they are usually less 

financially and geographically accessible compared with public facilities (Sikder et al. 2015). The 

Bangladesh SPA survey excluded private facilities with fewer than 20 beds. The exclusion of small private 

facilities could bias the effective coverage estimates if women also use these facilities for delivery care, but 

these facilities possess different levels of readiness from the facilities included in the survey.

Malawi has the highest effective coverage among the six countries—66% at the national level as well as 

67-68% in all three regions—and very high delivery coverage, at 93-95%. No other country in the study 

shows such consistency among regions, nor such universally high delivery coverage. Malawi’s high 

prevalence of facility delivery is due in part to a ban on informal birth attendants enacted in 2007—a policy 

aimed at transitioning births to the formal sector, where quality of care is higher (Godlonton and Okeke 

2016). Additionally, adoption of the Newborn Action Plan prioritized quality of care during labor, delivery, 

and the newborn period. This plan directed efforts to strengthening facility capacity including provision of 

medicines, commodities, equipment, staff training, and care guidelines (The Ministry of Health of Malawi 

2015).

Our study is subject to several limitations. First, the effective coverage estimated in this study is the facility 

delivery coverage adjusted for facility readiness, which is a score based on the availability of a range of 

structural inputs. Structure is only one aspect of the quality of care, according to the Donabedian (1988)

quality-of care-framework. We did not assess the process of the service delivery, that is, to what extent the 

providers adhere to acceptable standards of care. Possessing infrastructure, supplies, and equipment enables

a facility to provide good quality of care, but does not guarantee that it will do so. For example, even though 

they have functioning equipment, providers nevertheless might not measure a client’s blood pressure 

(Assaf, Wang, and Mallick 2016). The positive association between structure and process was found to be 

weak in 11 countries studied based on SPA data (Leslie, Sun, and Kruk 2017). The SPA typically observes

service delivery for three areas: antenatal care, family planning, and sick child care. It does not normally 

observe services for labor and delivery services. In the Malawi 2014-15 SPA, a special module was added 

to observe the labor, delivery, and newborn resuscitation services. We did not include these process 

indicators for Malawi because the interpretation of effective coverage could not be compared with the other 

study countries if process indicators were included as part of the quality measurement. A separate analysis 

focusing on Malawi would be more appropriate to estimate effective coverage incorporating a measure of 

the quality of actual service delivery rather than service readiness alone. Staff training, guidelines, and 

supervision tracer items can be used as a proxy for provider competence and standard adherence, though 

this domain was found to be the least common in every country in our study. This limitation suggests that 

our results might overestimate effective coverage in the absence of data on the process of service delivery.
43

It is obvious that indicators used to assess quality of care have an impact on effective coverage estimates. 

The readiness indicators in this study were chosen based on international guidance and empirical evidence. 

Together, these indicators provide a comprehensive picture of a facility’s preparedness to provide delivery 

services from multiple domains. Facilities were scored based on all of these indicators, except that two of 

them, C-sections and safe blood transfusion, were considered only for CEmOC facilities. Although not all 

facilities are expected to provide all tracer items examined, such a scoring approach is necessary to provide 

effective coverage estimates at the population level. That is, effective coverage aims to capture the expected 

level of coverage of services provided in a service delivery environment with the optimal readiness. 

However, the readiness score itself cannot identify where a service delivery problem lies. Facilities with a 

similar score could possess quite different specific tracer items. In other words, the readiness score measures 

an average facility readiness based on a range of indicators, from basic infrastructure (electricity and 

improved water source) to advanced service provision, but does not show which items are available and 

which are not. Information on the availability or lack of specific items should be assessed to identify specific 

areas that need improvement. Effective coverage must be interpreted with pragmatism, and the tracer items 

used to compute the measure should always be referenced.

Another limitation is associated with harmonizing facility categories between the SPA and DHS surveys. 

In the DHS recode data, some sources of care, especially those infrequently reported as place of delivery, 

were combined into one category. For example, private facilities, including hospital, health center, and 

others, could be recoded in one category. To adjust coverage by type of facility, we needed to match such 

categorization between the SPA and DHS surveys conducted in the same country. Therefore, an assumption 

was made such that any facilities grouped into one category had a similar level of readiness, which might

not be true. These facilities are usually not widely used for delivery, hence they have only a limited 

contribution to coverage. Invalidity of this assumption should not substantially affect the estimates of 

effective coverage.

Finally, we linked the DHS and SPA surveys at the regional level stratified by facility type. We used an 

average readiness score for all deliveries that occurred in the same type of facility. Variation in readiness 

may exist among the same types of facilities in the same region. However, matching deliveries with exact 

facilities is not possible because of limitations of the data. In fact, a study that compared exact-match and 

ecological-linking methods in Côte d’Ivoire found that both methods produced similar estimates of effective 

coverage for maternal and sick child health services, when a census of providers was available and provider 

category was taken into account (Munos et al 2018).

We found that adjusting for facility readiness reduces crude coverage of facility delivery everywhere, 

resulting in estimates of effective coverage that give a richer understanding of how need, use, and quality 

create a landscape of delivery care. Our findings reinforce the importance of prioritizing quality of obstetric 

and newborn care to achieve further reduction of maternal and neonatal mortality. Also highlighted in our 

results is the lack of specific items for service delivery, which should be kept in mind when interpreting 

estimates of effective coverage. Facilities too often lack the training and guidelines to properly offer their

services. Investing in equipment, medicines, and infrastructure without having competent health care 

providers may falsely characterize a facility as ready to provide quality care. Disaggregating by facility 

type added value to our analysis, since facility types have a wide range of readiness and use for delivery. 

Continued efforts are needed to increase the use of facility delivery services in countries where coverage 

remains low or varies substantially among different regions.

45

REFERENCES

Acharya, L. B., and J. Cleland. 2000. “Maternal and Child Health Services in Rural Nepal: Does Access 

or Quality Matter More?” Health Policy Plan 15(2):223-9.

Agence Nationale de la Statistique et de la Démographie (ANSD) Sénégal and ICF International. 2016. 

Senegal Enquête Continue sur la Prestation des Services de Soins de Santé (ECPSS) 2015. Rockville, 

Maryland, USA: ANSD/Sénégal and ICF International.

http://dhsprogram.com/pubs/pdf/SPA25/SPA25.pdf.

Alam, B., M. K. Mridha, T. K. Biswas, L. Roy, M. Rahman, and M. E. Chowdhury. 2015. “Coverage of 

Emergency Obstetric Care and Availability of Services in Public and Private Health Facilities in 

Bangladesh.” International Journal of Gynaecology & Obstetrics 131(1):63-9.

https://doi.org/10.1016/j.ijgo.2015.04.041.

Alexandre, P. K., G. Saint-Jean, L. Crandall, and E. Fevrin. 2005. “Prenatal Care Utilization in Rural 

Areas and Urban Areas of Haiti.” Revista Panamericana de Salud Pública 18(2):84-92.

Anwar, I., N. Kalim, and M. Koblinsky. 2009. “Quality of Obstetric Care in Public-Sector Facilities and 

Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and LowPerforming Districts of Bangladesh.” Journal of Health, Population and Nutrition 27(2):139-55.

Assaf, S., W. Wang, and L. Mallick. 2016. Provider Counseling and Knowledge Transfer in Health 

Facilities of Haiti, Malawi, and Senegal. DHS Analytical Studies No. 60. Rockville, Maryland, USA: ICF 

International. http://dhsprogram.com/pubs/pdf/AS60/AS60.pdf.

Behrman, J. A., and A. Weitzman. 2016. “Effects of the 2010 Haiti Earthquake on Women’s 

Reproductive Health.” Studies in Family Planning 47(1):3-17. https://doi.org/10.1111/j.1728-

4465.2016.00045.x.

Bhutta, Z. A., J. K. Das, R. Bahl, J. E. Lawn, R. A. Salam, V. K. Paul, M. J. Sankar, H. Blencowe, A. 

Rizvi, V. B. Chou, and N. Walker. 2014. “Can Available Interventions End Preventable Deaths in 

Mothers, Newborn Babies, and Stillbirths, and at What Cost?” Lancet 384(9940):347-70.

https://doi.org/10.1016/S0140-6736(14)60792-3.

Colston, J. 2011. The Use of Effective Coverage in the Evaluation of Maternal and Child Health 

Programs: A Technical Note for the IDB’s Social Protection and Health Division. Washington, DC: 

Inter-American Development Bank.

Do, M., A. Micah, L. Brondi, H. Campbell, T. Marchant, T. Eisele, and M. Munos. 2016. “Linking 

Household and Facility Data for Better Coverage Measures in Reproductive, Maternal, Newborn, and 

Child Health Care: Systematic Review.” Journal of Global Health 6(2).

https://doi.org/10.7189/jogh.06.020501.

Donabedian, A. 1988. “The Quality of Care. How Can It Be Assessed?” JAMA 260(12):1743-8.
46

Gabrysch, S., G. Civitelli, K. M. Edmond, M. Mathai, M. Ali, Z. A. Bhutta, and O. M. R. Campbell. 

2012. “New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and 

Emergency Newborn Care.” PLoS Medicine 9(11). https://doi.org/10.1371/journal.pmed.1001340.

Gage, A. D., H. H. Leslie, A. Bitton, J. G. Jerome, R. Thermidor, J. P. Joseph, and M. E. Kruk. 2017. 

“Assessing the Quality of Primary Care in Haiti.” Bulletin of the World Health Organization 95(3):182-

190. https://dx.doi.org/10.2471%2FBLT.16.179846.

Gage, A. J., and M. Guirlène Calixte. 2006. “Effects of the Physical Accessibility of Maternal Health

Services on Their Use in Rural Haiti.” Population Studies 60(3):271-288.

https://doi.org/10.1080/00324720600895934.

Godlonton, S., and E. N. Okeke. 2016. “Does a Ban on Informal Health Providers Save Lives? Evidence 

from Malawi.” Journal of Development Economics 118:112-132.

https://doi.org/10.1016/j.jdeveco.2015.09.001.

Graham, W. J., A. McCaw-Binns, and S. Munjanja. 2013. “Translating Coverage Gains into Health Gains 

for All Women and Children: The Quality Care Opportunity.” PLoS Medicine 10(1).

https://doi.org/10.1371/journal.pmed.1001368.

Hodgins, S., and A. D’Agostino. 2014. “The Quality–Coverage Gap in Antenatal Care: Toward Better 

Measurement of Effective Coverage.” Global Health: Science and Practice 2(2):173-181. 

https://dx.doi.org/10.9745%2FGHSP-D-13-00176.

Hogg, R. V., and A. T. Craig. 1965. Introduction to Mathematical Statistics. 2nd ed. New York: Macmillan 

Publishing Co., Inc.

Joshi, C., S. Torvaldsen, R. Hodgson, and A. Hayen. 2014. “Factors Associated with the Use and Quality 

of Antenatal Care in Nepal: A Population-Based Study Using the Demographic and Health Survey Data.”

BMC Pregnancy and Childbirth 14(1):94. https://doi.org/10.1186/1471-2393-14-94.

Kanyangarara, M., V. B. Chou, A. A. Creanga, and N. Walker. 2018. “Linking Household and Health 

Facility Surveys to Assess Obstetric Service Availability, Readiness and Coverage: Evidence from 17 

Low- and Middle-Income Countries.” Journal of Global Health 8(1).

https://dx.doi.org/10.7189%2Fjogh.08.010603.

Karim, R. M., M. S. Abdullah, A. M. Rahman, and A. M. Alam. 2015. “Identifying Influence of 

Perceived Quality and Satisfaction on the Utilization Status of the Community Clinic Services; 

Bangladesh Context.” Bangladesh Medical Research Council Bulletin 41(1):1-12.

https://doi.org/10.1186/s12913-016-1461-z.

Koulidiati, J. L., R. C. Nesbitt, N. Ouedraogo, H. Hien, P. J. Robyn, P. Compaore, A. Souares, and S. 

Brenner. 2018. “Measuring Effective Coverage of Curative Child Health Services in Rural Burkina Faso: 

A Cross-Sectional Study.” BMJ Open 8(5). doi:10.1136/bmjopen-2017-020423.
47

Kruk, M. E., A. Chukwuma, G. Mbaruku, and H. H. Leslie. 2017. “Variation in Quality of Primary-Care 

Services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania.”

Bulletin of the World Health Organization 95(6):408. http://dx.doi.org/10.2471/BLT.16.175869.

Kyei, N. N., C. Chansa, and S. Gabrysch. 2012. “Quality of Antenatal Care in Zambia: A National 

Assessment.” BMC Pregnancy and Childbirth 12(1):151. https://doi.org/10.1186/1471-2393-12-151.

Lain, S. J., R. M. Hadfield, C. H. Raynes-Greenow, J. B. Ford, N. M. Mealing, C. S. Algert, and C. L.

Roberts. 2012. “Quality of Data in Perinatal Population Health Databases: A Systematic Review.”

Medical Care 50(4):e7-20. https://doi.org/10.1097/MLR.0b013e31821d2b1d.

Lanata, C. F. 2007. “Human Resources in Developing Countries.” Lancet 369(9569):1238-9.

https://doi.org/10.1016/S0140-6736(07)60573-X.

Larson, E., D. Vail, G. M. Mbaruku, R. Mbatia, and M. E. Kruk. 2017. “Beyond Utilization: Measuring 

Effective Coverage of Obstetric Care Along the Quality Cascade.” International Journal for Quality

Health Care 29(1):104-110. https://doi.org/10.1093/intqhc/mzw141.

Lawn, J. E., H. Blencowe, S. Oza, D. You, A. C. Lee, P. Waiswa, M. Lalli, Z. Bhutta, A. J. Barros, P. 

Christian, C. Mathers, and S. N. Cousens. 2014. “Every Newborn: Progress, Priorities, and Potential 

Beyond Survival.” Lancet 384(9938):189-205. https://doi.org/10.1016/S0140-6736(14)60496-7.

Leslie, H. H., A. Malata, Y. Ndiaye, and M. E. Kruk. 2017. “Effective Coverage of Primary Care Services 

in Eight High-Mortality Countries.” BMJ Global Health 2(3). doi:10.1136/bmjgh-2017-000424.

Leslie, H. H., Z. Sun, and M. E. Kruk. 2017. “Association between Infrastructure and Observed Quality 

of Care in 4 Healthcare Services: A Cross-Sectional Study of 4,300 Facilities in 8 Countries.” PLoS 

Medicine 14(12). https://doi.org/10.1371/journal.pmed.1002464.

Mallick, L., W. Wang, and G. Temsah. 2017. A Comparison of Summary Measures of Quality of Service 

and Quality of Care for Family Planning in Haiti, Malawi, and Tanzania. DHS Methodological Report 

No. 20. Rockville, Maryland, USA: ICF. http://dhsprogram.com/pubs/pdf/MR20/MR20.pdf.

Manzi, F., J. A. Schellenberg, G. Hutton, K. Wyss, C. Mbuya, K. Shirima, H. Mshinda, M. Tanner, and 

D. Schellenberg. 2012. “Human Resources for Health Care Delivery in Tanzania: A Multifaceted 

Problem.” Human Resources for Health 10:3. https://dx.doi.org/10.1186%2F1478-4491-10-3.

Marchant, T., J. Bryce, C. Victora, A. C. Moran, M. Claeson, J. Requejo, A. Amouzou, N. Walker, T. 

Boerma, and J. Grove. 2016. “Improved Measurement for Mothers, Newborns and Children in the Era of 

the Sustainable Development Goals.” The Journal of Global Health 6(1). 

https://dx.doi.org/10.7189%2Fjogh.06.010506.

National Institute of Population Research and Training (NIPORT), International Centre for Diarrhoeal 

Disease Research Bangladesh (ICDDRB), and MEASURE Evaluation. 2017. Bangladesh Maternal 

Mortality and Health Care Survey 2016: Preliminary Report. Dhaka, Bangladesh, and Chapel Hill, NC, 

USA: NIPORT, ICDDRB, and MEASURE Evaluation.
48

Nesbitt, R. C., T. J. Lohela, A. Manu, L. Vesel, E. Okyere, K. Edmond, S. Owusu-Agyei, B. R.

Kirkwood, and S. Gabrysch. 2013. “Quality Along the Continuum: A Health Facility Assessment of 

Intrapartum and Postnatal Care in Ghana.” PLoS One 8(11).

https://doi.org/10.1371/journal.pone.0081089.

Ng, M., N. Fullman, J. L. Dieleman, A. D. Flaxman, C. J. Murray, and S. S. Lim. 2014. “Effective 

Coverage: A Metric for Monitoring Universal Health Coverage.” PLoS Medicine 11(9). 

https://doi.org/10.1371/journal.pmed.1001730.

Nguhiu, P. K., E. W. Barasa, and J. Chuma. 2017. “Determining the Effective Coverage of Maternal and 

Child Health Services in Kenya, Using Demographic and Health Survey Data Sets: Tracking Progress 

Towards Universal Health Coverage.” Tropical Medicine & International Health 22(4):442-453.

https://doi.org/10.1111/tmi.12841.

Save the Children Federation, Incorporated. 2017. Newborn Indicators. 

http://www.healthynewbornnetwork.org/numbers/newborn-indicators/.

Shengelia, B., A. Tandon, O. B. Adams, and C. J. Murray. 2005. “Access, Utilization, Quality, and 

Effective Coverage: An Integrated Conceptual Framework and Measurement Strategy.” Social Science &

Medicine 61(1):97-109. https://doi.org/10.1016/j.socscimed.2004.11.055.

Shwartz, M., J. D. Restuccia, and A. K. Rosen. 2015. “Composite Measures of Health Care Provider 

Performance: A Description of Approaches.” The Milbank Quarterly 93(4):788-825.

https://dx.doi.org/10.1111%2F1468-0009.12165.

Siddiqui, N., and S. A. Khandaker. 2007. “Comparison of Services of Public, Private and Foreign 

Hospitals from the Perspective of Bangladeshi Patients.” Journal of Health, Population and Nutrition

25(2):221-30.

Sikder, S. S., A. B. Labrique, H. Ali, A. A. Hanif, R. D. Klemm, S. Mehra, K. P. West, Jr., and P. 

Christian. 2015. “Availability of Emergency Obstetric Care (EmOC) among Public and Private Health 

Facilities in Rural Northwest Bangladesh.” BMC Public Health 15:36.

Tanahashi, T. 1978. “Health Service Coverage and Its Evaluation.” Bulletin of the World Health 

Organization 56(2):295-303.

The Ministry of Health of Malawi. 2015. Every Newborn Action Plan: An Action Plan to End 

Preventable Neonatal Deaths in Malawi. Malawi: The Ministry of Health of Malawi.

Tripathi, V., C. Stanton, D. Strobino, and L. Bartlett. 2015. “Development and Validation of an Index to 

Measure the Quality of Facility-Based Labor and Delivery Care Processes in Sub-Saharan Africa.” PLoS 

One 10(6). https://doi.org/10.1371/journal.pone.0129491.

Tura, G., M. Fantahun, and A. Worku. 2013. “The Effect of Health Facility Delivery on Neonatal 

Mortality: Systematic Review and Meta-Analysis.” BMC Pregnancy and Childbirth 13(1):18.
49

UNICEF, WHO, World Bank Group, and United Nations. 2017. Levels & Trends in Child Mortality: 

Report 2017. New York: UNICEF.

United Nations Development Program. 2015. Sustainable Development Goals. Geneva: United Nations.

United Nations Economic and Social Council. 2017. Progress towards the Sustainable Development 

Goals: Report of the Secretary-General, 66. Geneva: United Nations.

Van den Broek, N., and W. Graham. 2009. “Quality of Care for Maternal and Newborn Health: The 

Neglected Agenda.” BJOG: An International Journal of Obstetrics & Gynaecology 116(s1):18-21.

https://doi.org/10.1111/j.1471-0528.2009.02333.x.

Wang, W., M. Winner, and C. R. Burgert-Brucker. 2017. “Limited Service Availability, Readiness, and 

Use of Facility-Based Delivery Care in Haiti: A Study Linking Health Facility Data and Population 

Data.” Global Health: Science and Practice 5(2):244-260. https://doi.org/10.9745/GHSP-D-16-00311.

WHO. 2010. World Health Report 2010: Health Systems Financing: Path to Universal Coverage.

Geneva: WHO.

WHO. 2015. Service Availability and Readiness Assessment (SARA): An Annual Monitoring System for 

Service Delivery Reference Manual.

http://www.who.int/healthinfo/systems/SARA_Reference_Manual_Chapter3.pdf?ua=1.

WHO, UNFPA, UNICEF, and AMDD. 2009. Monitoring Emergency Obstetric Care: A Handbook. 

Geneva: WHO.

Willey, B., P. Waiswa, D. Kajjo, M. Munos, J. Akuze, E. Allen, and T. Marchant. 2018. “Linking Data 

Sources for Measurement of Effective Coverage in Maternal and Newborn Health: What Do We Learn 

from Individual- vs Ecological-Linking Methods?” Journal of Global Health 8(1).

https://dx.doi.org/10.7189%2Fjogh.08.010601.

Winter, R., T. Pullum, L. Florey, and S. Hodgins. 2017. “Impact of Scale-up of Maternal and Delivery 

Care on Reductions in Neonatal Mortality in USAID MCH Priority Countries, 2000–2010.” Applied 

Demography and Public Health in the 21st Century 8:269-305.

51

APPENDICES

Appendix Table 1 Harmonized facility categories and reported categories in SPA and DHS

Harmonized facility category SPA facility category DHS facility category

Bangladesh

Government hospital Government district hospital Government hospital

Government district hospital

Government upazila facilities Upazila health complex Upazila health complex

Maternal and child welfare center Upazila health & family welfare center

Maternal and child welfare center 

Government union, other Government Union health and family welfare center Other Government sector 

Union health and family welfare center Community clinic 

Union subcenter (UNSC) / rural dispensary

Community clinic 

NGO NGO clinic NGO clinic

NGO hospital Other NGO sector

Private hospital, clinic Private hospital Private hospital/clinic

Haiti 

Government hospital Government university hospital Government hospital

Government departmental hospital Government maternity

Government community hospital

Other government hospital

Government health center Government health center with bed Government health center

Government health center without bed

Private hospital Private university hospital Private hospital/clinic

Private departmental hospital

private community hospital

Private hospital

Private health center Private health center with bed Private health center

Private health center without bed

Mix hospital, health center Mix hospital Mix hospital 

Mix health center Mix health center

Mix maternity center 

Dispensary Dispensary

Malawi

Government hospital Central hospital Government hospital

District hospital

Rural/community hospital

Other hospital

Government health center Government health center Government health center

Government maternity health Government health post

other Government sector

Private for-profit hospital, health center, 

clinic

Private hospital Private for-profit hospital/clinic

Private health center

Private clinic

Private maternity center

Private not-for-profit hospital private not-for-profit hospital CHAM/mission hospital

Private not-for-profit health center, 

maternity

Private not-for-profit health center CHAM/mission health center

Private not-for-profit maternity BLM

Private not-for-profit clinic

Nepal

Government Hospital Central government hospital Government hospital

Regional government hos 

Sub-regional government hospital

Zonal government hospital

District government hospital

Government primary health care center 

(PHCC) Government primary health care center (PHCC) Government primary health care center (PHCC)

Government health post, sub-post, other

Government health post Government health center

Government sub-health post Other government sector

Private hospital Private hospital Private hospital
52

Senegal

Government hospital Government hospital Government hospital

Government health center Government health center Government health center/maternity

Government health post Government health center Government health center

Government health hut Government health hut Government health hut

Private hospital, clinic, or center

Private hospital Private hospital/clinic

Private health center

Private health poster

Tanzania

Government hospital Government national referral hospital Government national referral hospital

Government regional hospital Government regional referral hospital 

Government district hospital Government regional hospital 

Government district-designated hospital Government district hospital 

Other government hospital

Government health center Government health center Government health center

Government dispensary Government dispensary Government dispensary

Private hospital, health center, other

Private hospital Private hospital

Private health center Private health center

private dispensary private dispensary

private clinic private clinic

Religious hospital Religious national referral hospital Religious national referral hospital

Religious regional hospital Religious district hospital

Religious district hospital Other religious hospital

Religious district-designated hospital

Other religious hospital

Religious health center, other Religious health center Religious health center

Religious other Religious other
53

Appendix Table 2 Obstetric and newborn care readiness indicators and definitions

Domain/ Indicator Name Definition

Domain A: Comprehensive emergency obstetric care

Parenteral administration of antibiotics Facility performed this signal function for emergency obstetric care at least once during the 

three months before the assessment

Parenteral administration of uterotonic drugs/oxytocin See above

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy See above

Manual removal of placenta See above

Assisted vaginal delivery See above

Removal of retained products See above

Caesarean section See above (incorporate the availability of equipment and materials for performing the 

service)

Blood transfusion See above (incorporate the availability of equipment and materials for performing the 

service)

Domain B: Newborn signal functions and immediate care

Neonatal resuscitation Facility performed neonatal resuscitation at least once during the three months before the 

assessment

Skin-to-skin Facility reported this intervention is routinely practiced

Breast feeding in 1st hour See above

Drying and wrapping newborns See above

Domain C: General requirements

Electricity Facility is connected to a central power grid and there has not been an interruption in 

power supply lasting for more than two hours at a time during normal working hours in the 

seven days before the assessment, or the facility had a functioning generator with fuel 

available on the day of the assessment, or else facility has a backup solar power.

Improved water source Facility has an improved water source available. For most countries, this means that water 

is piped into the facility or onto facility grounds, or else water comes from a public tap or 

standpipe, a tube well or borehole, a protected dug well, protected spring, rain water, or 

bottled water, and the outlet from this source is within 500 meters of the facility.

Improved sanitation Facility has a functioning flush or pour-flush toilet, a ventilated improved pit latrine, or 

composting toilet.

24/7 Skilled birth attendance Provider of delivery care available on-site or on-call 24 hours/day, with observed duty 

schedule.

Emergency transport The facility had a functioning ambulance or other vehicle for emergency transport that was 

stationed at the facility and had fuel available on the day of the assessment, or the facility 

has access to an ambulance or other vehicle for emergency transport that is stationed at 

another facility or that operates from another facility.

Domain D: Equipment

Sterilization equipment Facility reports that some instruments are processed in the facility and the facility has a 

functioning electric dry heat sterilizer, a functioning electric autoclave, or a non-electric 

autoclave with a functioning heat source available somewhere in the facility.

Delivery bed At least one delivery bed available and observed in delivery area.

Examination light Examination light (flashlight okay) available, observed, and functioning in delivery area.

Delivery pack Delivery pack OR cord clamp, episiotomy scissors, scissors/lade to cut cord, suture 

material with need, AND needle holder all available in delivery area.

Suction apparatus (mucus abstractor) Suction apparatus (mucus abstractor) available, observed, and functioning in the delivery 

area.

Manual vacuum extractor Manual vacuum extractor available, observed, and functioning in the delivery area.

Vacuum aspirator or D&C kit Vacuum aspirator or D&C kit available, observed, and functioning, in the delivery area.

Partograph Partograph available, observed, and functioning in delivery area.

Disposable latex gloves Disposable latex gloves observed in delivery area.

Newborn bag and mask Newborn bag and mask (AMBU bag and mask) available, observed, and functioning in the 

delivery area.

Infant scale Infant scale observed and functioning in delivery area.

Blood pressure apparatus (digital or manual) Manual or digital blood pressure apparatus observed and functioning in delivery area.

Hand-washing soap and running water or hand 

disinfectant

Hand-washing soap and running water or hand disinfectant available and observed in 

delivery area.

Domain E: Medicines and commodities

Injectable antibiotic Injectable antibiotics observed in delivery area (i.e., at “service site”) and at least one dose 

valid.

Hydrocortisone available at the facility Hydrocortisone observed at the facility and at least one dose valid.

Injectable uterotonic Oxytocin observed in delivery area with at least one dose valid.

Skin disinfectant Skin disinfectant available for newborns in delivery area.

Magnesium sulfate Magnesium sulphate available in delivery area with at least one dose valid.

IV solution with infusion set IV solution with infusion set available in delivery area with at least one set valid.

Chlorhexidine for cord cleaning Chlorhexidine solution (4%) for umbilical cord cleaning available in delivery area, with at 

least one dose valid.

Antibiotic eye ointment for newborn Tetracycline eye ointment for newborn available in delivery area and at least one dose 

valid.
54

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines

Guidelines available in delivery area

Guidelines: CEmOC Guidelines Guidelines available in delivery area

Guidelines: Guidelines for management of pre-term 

labor

Guidelines available in delivery area

Guidelines for standard precautions Guidelines available in delivery area

Training in neonatal resuscitation At least one provider of delivery/newborn care in facility received training in neonatal 

resuscitation in the past 24 months

Training in early and exclusive breastfeeding At least one provider of delivery/newborn care in facility received training in early and 

exclusive breastfeeding in the past 24 months

Training in newborn infection management 

(including injectable antibiotics)

At least one provider of delivery/newborn care in facility received training in newborn 

infection management (including injectable antibiotics) in the past 24 months

Training in thermal care At least one provider of delivery/newborn care in facility received training in thermal care in 

the past 24 months

Training in cord care At least one provider of delivery/newborn care in facility received training in cord care in the 

past 24 months

Training in IMPAC At least one provider of delivery/newborn care in facility received training in IMPAC in the 

past 24 months

Training in routine care during labor and delivery At least one provider of delivery/newborn care in facility received training in routine care 

during labor and normal vaginal delivery in the past 24 months

Training in CEmOC At least one provider of delivery/newborn care in facility received training in IMPAC in the 

past 24 months

Training in Active Management of Third Stage of 

Labor (AMTSL)

At least one provider of delivery/newborn care in facility received training in AMTSL in the 

past 24 months

Training in Kangaroo Mother Care (KMC) At least one provider of delivery/newborn care in facility received training in KMC in the 

past 24 months

Supervision At least half of interviewed providers reported being personally supervised at least once 

during the 6 months preceding the survey
55

Appendix Table 3 Weights based on expert ratings

Domain/ Indicator Name

Average rating 

(out of 5)

Local weight 

(item score 

/domain total)

Domain weight 

(domain 

average/total)

Global weight 

(local weight x 

domain weight)

Domain A: Comprehensive emergency obstetric care 4.859

Parenteral administration of antibiotics 4.875 0.125 0.206 0.026

Parenteral administration of uterotonic drugs/oxytocin 5.000 0.129 0.206 0.027

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 4.750 0.122 0.206 0.025

Manual removal of placenta 4.625 0.119 0.206 0.025

Assisted vaginal delivery 4.875 0.125 0.206 0.026

Removal of retained products 4.875 0.125 0.206 0.026

Caesarean section 5.000 0.129 0.206 0.027

Blood transfusion 4.875 0.125 0.206 0.026

Domain B: Newborn signal functions and immediate care 3.825

Neonatal resuscitation 5.000 0.261 0.163 0.042

Skin-to-skin 4.500 0.235 0.163 0.038

Breast feeding in 1st hour 4.250 0.222 0.163 0.036

Drying and wrapping newborns 4.500 0.235 0.163 0.038

Domain C: General requirements 4.425

Electricity 4.500 0.203 0.188 0.038

Improved water source 4.375 0.198 0.188 0.037

Improved sanitation 3.875 0.175 0.188 0.033

24/7 skilled birth attendance 5.000 0.226 0.188 0.042

Emergency transport 4.375 0.198 0.188 0.037

Domain D: Equipment 4.019

Sterilization equipment 5.000 0.096 0.171 0.016

Delivery bed 3.375 0.065 0.171 0.011

Examination light 4.250 0.081 0.171 0.014

Delivery pack 4.750 0.091 0.171 0.016

Suction apparatus (mucus abstractor) 3.875 0.074 0.171 0.013

Manual vacuum extractor 3.750 0.072 0.171 0.012

Vacuum aspirator or D&C kit 3.250 0.062 0.171 0.011

Partograph 1.750 0.033 0.171 0.006

Disposable latex gloves 4.625 0.089 0.171 0.015

Newborn bag and mask 5.000 0.096 0.171 0.016

Infant scale 2.875 0.055 0.171 0.009

Blood pressure apparatus (digital or manual) 4.875 0.093 0.171 0.016

Hand-washing soap and running water or hand disinfectant 4.875 0.093 0.171 0.016

Domain E: Medicines and commodities 3.813

Injectable antibiotic 4.750 0.156 0.162 0.025

Hydrocortisone available at the facility 1.750 0.057 0.162 0.009

Injectable uterotonic 4.875 0.160 0.162 0.026

Skin disinfectant 3.125 0.102 0.162 0.017

Magnesium sulfate 4.625 0.152 0.162 0.025

IV solution with infusion set 5.000 0.164 0.162 0.027

Chlorhexidine for cord cleaning 3.875 0.127 0.162 0.021

Antibiotic eye ointment for newborn 2.500 0.082 0.162 0.013

Domain F: Guidelines, staff training and supervision 2.592

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines 2.500 0.064 0.110 0.007

Guidelines: CEmOC Guidelines 2.625 0.068 0.110 0.007

Guidelines: Guidelines for management of pre-term labor 2.625 0.068 0.110 0.007

Guidelines for standard precautions 2.000 0.051 0.110 0.006

Training in neonatal resuscitation 2.750 0.071 0.110 0.008

Training in early and exclusive breastfeeding 2.375 0.061 0.110 0.007

Training in newborn infection management 

(including injectable antibiotics) 2.750 0.071 0.110 0.008

Training in thermal care 2.875 0.074 0.110 0.008

Training in cord care 2.750 0.071 0.110 0.008

Training in IMPAC 2.375 0.061 0.110 0.007

Training in routine care during labor and delivery 2.375 0.061 0.110 0.007

Training in CEmOC 2.375 0.061 0.110 0.007

Training in Active Management of Third Stage of Labor 

(AMTSL) 2.375 0.061 0.110 0.007

Training in KMC 2.250 0.058 0.110 0.006

Supervision 3.875 0.100 0.112 0.011
56

Appendix Table 4 Effective coverage of facility delivery: equal weight versus expert ratingsbased weight

Equal weight Expert ratings-based weight

Readiness 

score

Effective 

coverage 95% CI LB

95% CI 

UB

Readiness 

score

Effective 

coverage 95% CI LB

95% CI 

UB

Bangladesh

Barisal 42.5 20.5 15.9 25.8 40.9 19.9 15.5 25.1

Chittagong 46.3 25.8 21.0 31.2 44.9 25.0 20.4 30.3

Dhaka 46.8 27.6 23.1 32.7 45.4 26.9 22.4 31.8

Khulna 49.3 40.9 35.0 47.0 47.3 39.4 33.7 45.3

Rajshahi 39.0 27.6 23.1 32.7 37.6 26.7 22.2 31.8

Rangpur 53.8 27.6 22.6 33.2 51.5 26.1 21.3 31.5

Sylhet 46.9 15.6 11.6 20.8 44.9 15.3 11.4 20.2

Total 46.5 26.8 24.5 29.1 44.9 25.9 23.7 28.2

Haiti

Ouest 57.4 52.1 43.8 60.3 54.2 48.1 40.4 55.9

Sud-Est 47.0 38.4 31.8 45.5 42.6 33.7 27.7 40.3

Nord 54.0 46.1 37.7 54.8 50.4 41.7 34.0 49.7

Nord-Est 48.0 42.3 32.9 52.3 45.0 39.1 30.5 48.5

Artibonite 49.3 44.8 36.4 53.5 46.0 40.4 32.7 48.6

Centre 59.8 17.5 11.3 26.1 56.5 16.8 10.9 25.1

Sud 60.9 52.2 41.0 63.3 57.3 48.9 37.9 60.1

Grand-Anse 55.0 43.1 34.1 52.5 50.9 37.9 29.8 46.9

Nord-Ouest 43.2 40.6 33.8 47.9 40.4 37.8 31.3 44.7

Nippes 57.0 48.1 36.9 59.5 53.6 45.1 34.5 56.1

Total 52.7 45.6 41.9 49.3 49.4 41.8 38.3 45.3

Malawi

North 67.5 66.2 58.2 73.4 63.6 62.7 55.2 69.6

Central 67.6 66.3 61.6 70.7 64.8 63.5 59.0 67.8

South 67.2 66.4 62.1 70.5 63.7 62.9 58.8 66.8

Total 67.4 66.4 63.4 69.2 64.1 63.1 60.4 65.8

Nepal

Province 1 57.9 40.1 33.4 47.3 54.9 38.5 32.1 45.4

Province 2 63.0 33.7 28.4 39.5 61.3 32.2 27.1 37.7

Province 3 57.4 50.7 41.7 59.7 54.7 48.5 40.0 57.1

Province 4 54.6 50.3 41.7 58.8 51.0 47.2 39.2 55.4

Province 5 62.5 45.4 36.9 54.3 59.3 43.9 35.6 52.5

Province 6 52.4 27.1 21.4 33.6 49.4 25.6 20.2 31.8

Province 7 58.4 49.5 39.9 59.1 54.9 46.7 37.6 55.9

Total 57.7 41.9 38.9 45.1 54.7 40.1 37.1 43.0

Senegal

North 54.3 37.8 31.7 44.4 49.0 34.4 28.8 40.6

Dakar 72.6 63.9 46.9 78.0 69.5 60.2 44.6 74.0

Thiès 56.9 61.6 48.8 73.0 52.4 58.0 46.1 69.0

Central 59.8 54.6 48.4 60.6 54.5 50.3 44.6 56.0

East 63.8 29.7 23.3 36.9 57.7 27.2 21.4 33.9

South 61.7 46.7 38.5 55.1 55.7 43.3 35.8 51.2

Total 60.0 51.3 47.2 55.3 54.7 47.6 43.7 51.4

Tanzania

Western 56.0 37.0 28.9 46.0 50.3 34.8 27.1 43.4

Northern 58.7 46.8 37.9 55.8 52.8 43.8 35.4 52.5

Central 52.8 42.9 35.1 51.0 48.9 40.0 32.8 47.7

Southern 

Highlands 53.4 67.7 55.7 77.8 48.7 64.0 52.8 73.8

Southern 51.2 58.5 48.0 68.3 46.8 55.1 45.3 64.6

South West 

Highlands 52.7 45.2 36.2 54.5 49.5 42.7 34.3 51.6

Lake 48.0 32.4 28.5 36.6 44.4 30.4 26.7 34.4

Eastern 52.3 63.1 55.6 70.0 47.2 59.3 52.3 65.9

Zanzibar 55.3 47.1 42.5 51.8 50.8 43.8 39.5 48.1

Total 52.7 44.2 41.6 46.8 48.2 41.5 39.1 44.0
57

Appendix Table 5 Percentage of health facilities with structural tracer items, Bangladesh SPA 2014

Non-CEmOC facilities

Domain/Indicator Name Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet

Nati

Ave

Domain A: Comprehensive emergency obstetric care 

Parenteral administration of antibiotics 46.1 49.1 46.5 38.6 28.2 37.1 36.1 42

Parenteral administration of uterotonic drugs/oxytocin 44.9 48.0 48.3 55.5 27.5 68.7 41.3 48

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 17.2 21.0 23.6 31.1 17.6 53.1 28.4 26

Manual removal of placenta 43.8 41.9 35.7 34.4 39.7 45.4 43.3 39

Assisted vaginal delivery 40.1 43.0 46.1 39.8 46.1 43.9 63.0 45

Removal of retained products 27.8 27.3 25.8 25.5 29.7 43.5 28.3 29

Caesarean section na na na na na na na n

Blood transfusion na na na na na na na n

Domain B: Newborn signal functions and immediate care

Neonatal resuscitation 29.8 34.2 45.0 55.9 26.9 48.9 31.1 40

Skin-to-skin care 51.6 57.3 70.5 84.4 62.4 90.9 62.5 69

Wrap baby 90.1 90.8 98.7 98.4 96.4 87.8 89.5 94

Initiate breastfeeding within the first hour 91.8 97.5 100.0 98.8 100.0 91.2 87.9 97

Domain C: General requirements

Electricity 39.0 48.0 42.6 62.1 24.4 59.3 49.7 45

Improved water source 88.5 95.6 90.0 97.5 88.6 96.9 93.2 92

Improved sanitation 77.6 85.9 67.1 53.1 77.3 76.8 86.0 73

24/7 skilled birth attendance 37.8 25.7 27.6 30.7 17.4 44.0 30.1 28

Emergency transport 31.0 27.5 34.7 43.9 14.4 20.9 40.0 29

Domain D: Equipment

Sterilization equipment 61.4 58.5 65.5 57.3 30.5 94.7 59.6 61

Delivery bed 80.2 67.9 76.7 64.9 70.9 68.8 73.4 72

Examination light 42.1 51.4 66.2 72.7 44.7 93.3 72.4 63

Delivery pack 54.1 47.9 59.5 44.4 56.9 89.7 52.1 58

Suction apparatus (mucus abstractor) 40.5 45.1 53.3 54.0 25.6 49.0 31.8 45

Manual vacuum extractor 22.6 28.1 18.1 18.6 14.8 40.1 25.9 23

Vacuum aspirator or D&C kit 27.9 33.9 20.1 32.0 10.5 45.5 29.2 26

Partograph 25.7 16.2 28.5 27.3 12.7 35.2 21.9 24

Disposable latex gloves 82.7 63.7 57.7 81.2 62.8 98.2 96.1 70

Newborn bag and mask 48.6 39.8 45.6 48.9 26.9 62.3 43.7 44

Infant scale 50.1 53.7 48.7 57.2 76.5 89.5 51.1 59

Blood pressure apparatus (digital or manual) 87.0 82.3 88.9 82.0 99.8 100.0 92.8 89

Hand-washing soap and running water or hand 

disinfectant 69.6 69.0 75.3 73.4 68.9 94.7 83.1 75

Domain E: Medicines and commodities

Injectable antibiotic 20.1 30.4 39.8 18.8 27.6 23.2 30.0 30

Hydrocortisone available at the facility 11.2 20.7 21.7 13.5 8.8 11.7 20.5 17

Injectable uterotonic 19.9 26.9 33.6 30.2 28.1 46.2 33.4 32

Skin disinfectant 18.9 27.8 23.0 36.6 14.9 27.5 27.3 24

Magnesium sulfate 3.5 15.2 24.8 14.9 24.2 20.4 25.7 20

IV solution with infusion set 22.5 28.7 37.6 30.2 31.5 36.0 36.3 33

Chlorhexidine for cord cleaning 14.5 33.7 31.0 21.3 15.4 50.5 26.8 29

Antibiotic eye ointment for newborn 10.1 20.2 26.5 7.7 22.6 33.4 29.3 23
58

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines 30.8 17.3 23.8 18.8 4.1 56.4 20.2 23

Guidelines: CEmOC Guidelines 16.4 22.5 15.1 20.9 9.8 56.7 20.7 21

Guidelines: Guidelines for management of pre-term 

labor 19.1 15.8 18.8 12.6 11.4 41.4 34.1 20

Guidelines on standard precaution 29.6 19.1 31.7 19.9 9.9 59.1 19.8 27

Training in neonatal resuscitation 19.3 24.7 11.8 48.4 6.7 17.4 43.4 20

Training in early and exclusive breastfeeding 18.8 28.3 16.7 35.3 2.2 19.7 39.4 20

Training in newborn infection management 

(including injectable antibiotics) 11.4 13.0 6.9 18.2 1.2 9.5 17.0 9

Training in thermal care 21.8 15.7 7.9 33.7 1.2 7.4 33.0 13

Training in cord care 21.8 19.4 13.5 43.8 2.2 10.5 28.7 17

Training in IMPAC 11.4 12.5 6.2 11.0 1.9 7.4 10.6 8

Training in normal labor and delivery care 17.8 13.4 7.6 18.9 3.1 7.7 17.8 10

Training in CEmOC 12.2 6.9 5.4 14.7 1.0 4.3 3.9 6

Training in AMTSL 16.9 15.8 5.4 23.6 1.2 8.4 15.1 10

Training in KMC 11.8 17.2 14.3 33.7 2.2 9.6 19.1 14

Supervision 82.4 89.2 87.9 89.3 90.3 95.2 84.0 88

Number of facilities 15 53 92 24 34 32 17 26
59

Appendix Table 6 Service readiness scores for CEmOC facilities and non-CEmOC facilities

Bangladesh Haiti Malawi Nepal Senegal 

Readiness 

score 95% CI

Readiness 

score 95% CI

Readiness 

score 95% CI

Readiness 

score 95% CI

Readiness 

score 95% 

Non-CEmOC facilities 45.0 [43.0,47.0] 52.1 [50.6,53.6] 66.9 [65.9,68.0] 57.3 [56.0,58.5] 59.8 [58.3,6

CEmOC facilities 77.6 [73.6,81.7] 77.9 [71.1,84.7] 90.0 [86.5,93.5] 79.7 [76.7,82.7] 88.9 [86.7,9

National average 46.5 [44.6,48.4] 52.7 [51.3,54.2] 67.4 [66.3,68.4] 57.7 [56.5,59.0] 60.0 [58.4,6
60

Appendix Table 7 Percentage of health facilities with structural tracer items, Haiti SPA 2013

Non-CEmOC facilities

Domain/Indicator Name Ouest Sud-Est Nord Nord-Est Artibonite Centre Sud

GrandAnseNordOuest Nippe

Domain A: Comprehensive emergency obstetric care

Parenteral administration of antibiotics 70.3 40.0 61.1 42.3 45.1 47.6 73.9 40.0 46.1 50.

Parenteral administration of uterotonic drugs/oxytocin 72.3 45.7 66.7 65.4 60.8 76.2 100.0 75.0 58.1 75.

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 34.7 17.1 36.1 23.1 29.4 28.6 34.8 35.0 21.8 18.

Manual removal of placenta 55.4 34.3 47.2 42.3 52.9 42.9 56.5 65.0 42.2 50.

Assisted vaginal delivery 79.2 65.7 80.6 73.1 62.7 76.2 87.0 70.0 63.9 81.

Removal of retained products 53.5 48.6 50.0 42.3 41.2 52.4 47.8 65.0 32.0 37.

Caesarean section na na na na na na na na na n

Blood transfusion na na na na na na na na na n

Domain B: Newborn signal functions and immediate newborn care

Neonatal resuscitation 47.5 25.7 38.9 23.1 37.3 42.9 47.8 40.0 39.7 56.

Skin-to-skin care 78.2 97.1 86.1 69.2 76.5 85.7 91.3 95.0 84.0 93.

Wrap baby 97.0 97.1 94.4 84.6 88.2 95.2 100.0 95.0 96.0 100.

Initiate breastfeeding within the first hour 86.1 85.7 97.2 84.6 88.2 95.2 100.0 90.0 96.0 93.

Domain C: General requirements

Electricity 83.2 68.6 88.9 69.2 62.7 85.7 95.7 95.0 74.0 68.

Improved water source 72.3 85.7 77.8 69.2 68.6 71.4 87.0 85.0 70.1 93.

Improved sanitation 78.2 28.6 36.1 38.5 41.2 52.4 47.8 35.0 15.9 56.

24/7 skilled birth attendance 38.6 22.9 41.7 30.8 33.3 42.9 30.4 50.0 15.7 25.

Emergency transport 40.6 25.7 30.6 11.5 41.2 42.9 34.8 15.0 7.9 31.

Domain D: Equipment

Sterilization equipment 55.4 40.0 50.0 53.8 35.3 76.2 56.5 25.0 35.9 50.

Delivery bed 93.1 88.6 91.7 92.3 92.2 100.0 100.0 90.0 94.0 100.

Examination light 46.5 28.6 27.8 38.5 27.5 42.9 47.8 45.0 23.9 43.

Delivery pack 80.2 82.9 86.1 76.9 62.7 95.2 91.3 85.0 70.1 81.

Suction apparatus (mucus abstractor) 45.5 11.4 25.0 15.4 25.5 14.3 43.5 35.0 11.9 18.

Manual vacuum extractor 16.8 2.9 13.9 7.7 3.9 9.5 4.3 10.0 5.9 0.

Vacuum aspirator or D&C kit 28.7 20.0 25.0 15.4 11.8 4.8 26.1 15.0 9.9 18.

Partograph 22.8 25.7 19.4 23.1 23.5 28.6 26.1 40.0 7.9 31.

Disposable latex gloves 93.1 94.3 88.9 96.2 92.2 90.5 87.0 100.0 81.9 93.

Newborn bag and mask 49.5 25.7 38.9 15.4 27.5 47.6 56.5 25.0 11.8 43.

Infant scale 73.3 74.3 91.7 65.4 60.8 90.5 78.3 75.0 65.9 62.

Blood pressure apparatus (digital or manual) 87.1 88.6 91.7 73.1 84.3 100.0 82.6 75.0 92.1 93.

Hand-washing soap and running water or hand 

disinfectant 80.2 71.4 63.9 65.4 64.7 81.0 69.6 50.0 65.9 75.

Domain E: Medicines and commodities

Injectable antibiotic 40.6 20.0 33.3 30.8 19.6 47.6 34.8 25.0 17.8 37.

Hydrocortisone available at the facility 33.7 20.0 36.1 23.1 25.5 52.4 52.2 20.0 9.9 31.

Injectable uterotonic 52.5 51.4 55.6 50.0 41.2 52.4 60.9 60.0 45.8 50.

Skin disinfectant 66.3 51.4 61.1 65.4 64.7 76.2 73.9 65.0 53.7 68.

Magnesium sulfate 44.6 28.6 36.1 34.6 33.3 61.9 52.2 45.0 25.8 25.

IV solution with infusion set 40.6 40.0 50.0 50.0 41.2 52.4 34.8 40.0 31.8 43.

Chlorhexidine for cord cleaning 43.6 51.4 47.2 46.2 39.2 42.9 65.2 45.0 26.0 62.

Antibiotic eye ointment for newborn 45.5 40.0 63.9 42.3 58.8 57.1 52.2 40.0 41.9 37.
61

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines 15.8 31.4 19.4 26.9 23.5 19.0 21.7 15.0 26.0 25.

Guidelines: CEmOC Guidelines 15.8 14.3 19.4 15.4 15.7 19.0 21.7 30.0 14.0 18.

Guidelines: Guidelines for management of pre-term 

labor 12.9 5.7 16.7 3.8 11.8 23.8 13.0 20.0 9.9 18.

Guidelines on standard precaution 8.9 5.7 25.0 7.7 11.8 4.8 4.3 10.0 9.9 37.

Training in neonatal resuscitation 44.6 20.0 33.3 23.1 27.5 42.9 43.5 35.0 22.0 50.

Training in early and exclusive breastfeeding 51.5 28.6 30.6 34.6 31.4 42.9 34.8 30.0 19.8 50.

Training in newborn infection management 

(including injectable antibiotics) 39.6 22.9 25.0 23.1 31.4 42.9 26.1 25.0 18.0 37.

Training in thermal care 43.6 31.4 27.8 26.9 25.5 42.9 34.8 35.0 17.8 50.

Training in cord care 46.5 31.4 27.8 30.8 29.4 42.9 34.8 45.0 13.8 50.

Training in IMPAC 43.6 31.4 30.6 42.3 35.3 52.4 47.8 20.0 26.0 43.

Training in normal labor and delivery care 41.6 34.3 30.6 46.2 33.3 47.6 47.8 30.0 24.0 50.

Training in CEmOC 37.6 25.7 27.8 34.6 27.5 42.9 34.8 20.0 20.0 43.

Training in AMTSL 38.6 31.4 33.3 46.2 35.3 47.6 43.5 25.0 24.0 43.

Training in KMC 33.7 20.0 25.0 23.1 25.5 42.9 30.4 20.0 5.9 37.

Supervision 73.3 88.6 77.8 88.5 80.4 95.2 87.0 70.0 76.0 93.

Number of facilities 100 35 36 26 51 21 23 20 51 1
62

Appendix Table 8 Percentage of health facilities with structural tracer items, Malawi SPA 2013-14

Non-CEmOC facilities

CEmOC 

facilities

Domain/Indicator Name North Central South

National 

Average

National 

average

Domain A: Comprehensive emergency obstetric care

Parenteral administration of antibiotics 75.6 84.9 80.7 81.3 100.0

Parenteral administration of uterotonic drugs/oxytocin 98.1 97.0 98.7 97.9 100.0

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 46.4 49.2 48.6 48.4 100.0

Manual removal of placenta 35.8 44.7 42.4 42.0 100.0

Assisted vaginal delivery 57.1 52.7 45.2 50.3 100.0

Removal of retained products 42.4 38.1 35.0 37.6 100.0

Caesarean section na na na na 100.0

Blood transfusion na na na na 100.0

Domain B: Newborn signal functions and immediate newborn care

Neonatal resuscitation 93.2 90.5 82.8 87.7 100.0

Skin-to-skin care 100.0 96.5 98.7 98.1 100.0

Wrap baby 100.0 99.5 100.0 99.8 100.0

Initiate breastfeeding within the first hour 100.0 98.5 98.7 98.9 100.0

Domain C: General requirements

Electricity 69.9 75.8 58.8 67.4 91.0

Improved water source 88.3 95.5 97.4 94.9 100.0

Improved sanitation 24.1 28.1 21.2 24.3 54.6

24/7 skilled birth attendance 36.6 52.2 60.9 52.8 100.0

Emergency transport 89.3 88.4 90.0 89.3 100.0

Domain D: Equipment

Sterilization equipment 20.1 32.6 31.6 29.7 81.7

Delivery bed 98.0 99.0 98.3 98.5 100.0

Examination light 42.5 24.6 30.3 30.6 82.0

Delivery pack 86.4 90.4 96.0 92.0 100.0

Suction apparatus (mucus abstractor) 64.9 64.8 59.2 62.4 91.0

Manual vacuum extractor 34.7 43.1 38.5 39.5 100.0

Vacuum aspirator or D&C kit 18.2 23.1 24.5 22.7 91.0

Partograph 86.3 86.9 89.4 87.9 100.0

Disposable latex gloves 100.0 96.5 96.9 97.4 100.0

Newborn bag and mask 93.2 91.4 85.4 89.2 100.0

Infant scale 95.1 94.5 95.6 95.1 100.0

Blood pressure apparatus (digital or manual) 76.6 72.8 76.4 75.1 100.0

Hand-washing soap and running water or hand 

disinfectant 76.6 75.9 73.7 75.1 82.0

Domain E: Medicines and commodities

Injectable antibiotic 57.2 52.2 55.3 54.5 100.0

Hydrocortisone available at the facility 13.4 9.5 13.3 11.9 73.0

Injectable uterotonic 90.3 97.0 95.6 95.1 100.0

Skin disinfectant 63.0 46.7 57.4 54.5 91.0

Magnesium sulfate 83.5 82.9 85.7 84.2 100.0

IV solution with infusion set 69.0 65.4 67.6 67.1 64.0

Chlorhexidine for cord cleaning 34.8 30.7 39.4 35.2 64.0

Antibiotic eye ointment for newborn 98.1 90.5 93.9 93.4 91.0

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines 48.6 41.2 45.6 44.5 54.4

Guidelines: CEmOC Guidelines 40.8 21.6 25.0 26.8 54.7

Guidelines: Guidelines for management of pre-term 

labor 40.8 41.2 40.7 40.9 82.0

Guidelines on standard precaution 47.4 40.7 40.8 42.1 73.0

Training in neonatal resuscitation 70.7 58.2 60.4 61.6 91.0

Training in early and exclusive breastfeeding 56.2 45.2 45.6 47.5 72.9

Training in newborn infection management 

(including injectable antibiotics) 46.5 41.2 35.9 39.9 54.6

Training in thermal care 54.2 53.2 53.4 53.5 81.9

Training in cord care 55.2 55.7 53.4 54.6 72.9

Training in IMPAC 21.2 31.6 17.9 23.7 35.9

Training in normal labor and delivery care 37.7 44.7 32.8 38.2 54.3

Training in CEmOC 21.2 29.1 18.8 23.1 35.9

Training in AMTSL 35.7 47.7 34.5 39.7 54.3

Training in KMC 42.6 43.2 35.9 40.0 54.3

Supervision 76.7 86.4 82.9 83.0 91.0

Number of facilities 102 194 221 517 11
63

Appendix Table 9 Percentage of health facilities with structural tracer items, Nepal SPA 2015

Non-CEmOC facilities

Domain/Indicator Name Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7

Nat

Ave

Domain A: Comprehensive emergency obstetric care

Parenteral administration of antibiotics 35.6 64.6 40.2 35.5 57.8 28.6 33.5 3

Parenteral administration of uterotonic drugs/oxytocin 83.1 95.7 77.3 76.0 93.8 85.3 96.2 8

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 7.9 27.0 9.9 4.1 15.8 5.5 6.8 

Manual removal of placenta 51.3 54.3 31.6 32.4 57.1 34.4 44.7 4

Assisted vaginal delivery 11.4 35.0 12.9 8.7 22.4 16.5 15.3 1

Removal of retained products 40.5 44.3 25.6 15.5 46.0 23.9 39.8 3

Caesarean section na na na na na na na 

Blood transfusion na na na na na na na 

Domain B: Newborn signal functions and immediate newborn care

Neonatal resuscitation 42.3 54.0 27.9 19.1 46.1 43.5 33.5 3

Skin-to-skin care 96.4 84.9 89.0 98.1 93.3 75.5 93.5 9

Wrap baby 97.2 100.0 100.0 97.9 100.0 86.1 100.0 9

Initiate breastfeeding within the first hour 98.5 100.0 99.7 99.7 100.0 94.1 100.0 9

Domain C: General requirements

Electricity 80.5 69.0 72.4 54.0 77.1 94.2 76.3 7

Improved water source 91.8 100.0 91.9 87.6 85.2 61.9 77.7 8

Improved sanitation 97.1 90.6 95.3 92.0 89.8 79.4 83.3 8

24/7 skilled birth attendance 21.5 39.3 30.4 27.3 21.3 5.3 22.1 2

Emergency transport 55.1 81.7 81.1 67.4 64.1 37.7 51.7 6

Domain D: Equipment

Sterilization equipment 95.0 91.9 96.6 91.4 88.6 81.7 95.3 9

Delivery bed 94.9 96.2 95.0 95.8 99.7 93.3 100.0 9

Examination light 60.8 65.3 68.2 73.7 63.5 38.1 54.2 5

Delivery pack 91.4 95.2 91.1 87.5 100.0 91.5 95.1 9

Suction apparatus (mucus abstractor) 63.0 87.8 76.9 77.0 52.0 31.5 50.0 6

Manual vacuum extractor 28.2 28.8 22.0 13.4 16.9 14.1 22.6 1

Vacuum aspirator or D&C kit 18.4 35.0 25.1 10.4 17.7 10.8 21.3 1

Partograph 68.3 72.4 80.2 93.8 91.1 82.7 71.6 7

Disposable latex gloves 96.0 96.5 91.1 95.7 95.4 85.9 88.3 9

Newborn bag and mask 80.9 93.6 89.6 72.7 88.2 71.5 85.7 8

Infant scale 80.5 93.8 87.3 87.0 99.7 88.2 96.7 8

Blood pressure apparatus (digital or manual) 78.4 76.9 81.5 87.4 90.7 80.3 84.2 8

Hand-washing soap and running water or hand 

disinfectant 69.8 78.2 84.2 84.3 81.1 61.0 61.3 7

Domain E: Medicines and commodities

Injectable antibiotic 41.6 62.3 42.6 30.4 48.6 39.0 30.2 3

Hydrocortisone available at the facility 10.9 22.4 25.3 17.5 13.8 9.1 14.0 1

Injectable uterotonic 83.8 92.2 82.5 89.7 95.5 78.7 98.0 8

Skin disinfectant 87.5 96.2 94.7 91.4 93.9 83.7 93.4 9

Magnesium sulfate 62.9 59.8 63.1 84.0 81.9 65.3 86.7 7

IV solution with infusion set 88.0 89.8 86.8 93.6 92.9 83.2 98.6 9

Chlorhexidine for cord cleaning 61.9 52.6 60.4 41.0 75.7 37.6 72.3 5

Antibiotic eye ointment for newborn 25.1 24.5 40.0 53.4 48.2 45.2 37.0 4
64

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines na na na na na na na 

Guidelines: CEmOC Guidelines na na na na na na na 

Guidelines: Guidelines for management of pre-term 

labor na na na na na na na 

Medical Standards Volume III or reproductive health 

Guidelines 19.5 20.4 9.5 25.9 41.6 20.4 19.2 2

Guidelines on standard precaution 1.6 4.3 3.9 14.8 11.8 5.2 8.7 

Training in neonatal resuscitation 30.7 25.5 25.6 12.0 30.6 44.6 34.9 2

Training in early and exclusive breastfeeding 32.6 24.5 23.3 13.5 30.6 52.4 32.9 3

Training in newborn infection management 

(including injectable antibiotics) 23.5 8.5 11.6 6.5 23.3 38.9 19.0 1

Training in thermal care 30.7 21.4 21.4 11.4 26.2 42.4 27.7 2

Training in cord care 30.7 25.5 21.2 10.8 31.2 38.5 34.4 2

Training in IMPAC 2.0 3.8 0.0 0.3 0.0 0.7 0.6 

Training in normal labor and delivery care 30.6 24.6 28.6 13.5 25.3 23.9 30.2 2

Training in CEmOC 13.1 8.5 7.0 6.5 13.3 15.2 20.4 1

Training in AMTSL 31.9 33.7 29.1 12.9 24.1 26.2 32.4 2

Training in KMC 30.9 19.2 21.7 13.8 32.5 40.8 31.7 2

Supervision 76.0 81.6 59.3 84.2 91.7 72.5 88.6 7

Number of facilities 77 37 79 65 61 61 67 4
65

Appendix Table 10 Percentage of health facilities with structural tracer items, Senegal SPA 2015

Non-CEmOC facilities

Domain/Indicator Name North Dakar Thiès Central East South

National 

Average

Domain A: Comprehensive emergency obstetric care

Parenteral administration of antibiotics 47.5 85.3 55.5 68.3 41.2 57.5 58.9 

Parenteral administration of uterotonic drugs/oxytocin 83.3 98.4 64.3 80.5 87.3 74.3 79.6 

Parenteral administration of anticonvulsants for 

hypertensive disorders of pregnancy 21.2 44.3 15.1 25.8 34.4 17.1 23.9 

Manual removal of placenta 40.0 41.1 34.0 43.9 39.5 26.4 37.8 

Assisted vaginal delivery 98.3 100.0 93.6 94.3 94.4 99.3 96.4 

Removal of retained products 69.2 78.6 51.9 59.3 66.6 41.0 59.3 

Caesarean section na na na na na na na 

Blood transfusion na na na na na na na 

Domain B: Newborn signal functions and immediate newborn care

Neonatal resuscitation 41.3 85.2 55.5 53.9 43.2 43.0 51.2 

Skin-to-skin care 92.0 100.0 100.0 97.9 100.0 100.0 97.7 

Wrap baby 100.0 100.0 100.0 99.2 100.0 100.0 99.8 

Initiate breastfeeding within the first hour 99.3 100.0 100.0 99.2 100.0 99.2 99.5 

Domain C: General requirements

Electricity 42.4 67.1 34.5 41.9 68.7 52.1 47.2 

Improved water source 97.2 100.0 95.4 92.3 86.1 64.0 88.8 

Improved sanitation 93.6 100.0 86.0 84.9 89.6 84.7 88.6 

24/7 skilled birth attendance 2.5 40.0 8.5 10.5 8.4 6.4 10.0 

Emergency transport 45.2 57.1 31.3 49.9 75.1 65.4 51.6 

Domain D: Equipment

Sterilization equipment 35.1 100.0 41.7 37.3 28.3 40.7 42.6 

Delivery bed 98.3 100.0 100.0 96.8 97.9 99.2 98.4 

Examination light 57.1 95.3 60.9 53.2 54.0 66.8 61.3 

Delivery pack 98.4 100.0 100.0 97.2 96.9 100.0 98.6 

Suction apparatus (mucus abstractor) 29.7 73.5 35.3 22.9 9.0 20.4 28.9 

Manual vacuum extractor 3.5 7.9 2.1 2.3 2.3 2.6 3.1 

Vacuum aspirator or D&C kit 35.0 27.9 16.8 33.9 48.6 51.1 35.4 

Partograph 56.8 91.9 62.2 71.5 75.0 57.4 66.4 

Disposable latex gloves 86.9 100.0 84.3 82.0 95.7 91.9 87.9 

Newborn bag and mask 39.1 68.6 42.8 41.8 34.8 53.4 45.1 

Infant scale 87.0 100.0 97.4 88.9 83.8 90.1 90.5 

Blood pressure apparatus (digital or manual) 24.5 93.5 46.9 63.7 86.6 76.4 59.4 

Hand-washing soap and running water or hand 

disinfectant 88.9 100.0 84.3 87.8 92.7 87.0 88.8 

Domain E: Medicines and commodities

Injectable antibiotic 2.7 64.5 45.9 37.9 34.5 51.5 35.9 

Hydrocortisone available at the facility 41.2 41.8 37.2 44.5 45.5 50.1 43.5 

Injectable uterotonic 30.8 96.9 60.6 57.4 73.9 70.2 59.2 

Skin disinfectant 88.1 93.5 83.2 84.5 97.6 85.3 87.1 

Magnesium sulfate 19.6 54.4 39.1 30.6 35.0 46.4 34.8 

IV solution with infusion set 28.3 56.0 53.0 44.6 41.1 44.8 43.0 

Chlorhexidine for cord cleaning 25.9 59.3 41.8 43.8 85.6 78.7 50.9 

Antibiotic eye ointment for newborn 0.4 62.8 47.4 51.0 69.0 63.4 44.3 
66

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of Pregnancy 

and Childbirth (IMPAC) Guidelines 65.8 56.5 70.4 53.9 59.1 74.5 63.4 

Guidelines: CEmOC Guidelines 52.0 45.0 47.3 25.3 43.0 42.4 40.8 

Guidelines: Guidelines for management of pre-term 

labor 19.2 14.9 18.8 9.6 9.2 10.2 13.6 

Guidelines on standard precaution 23.5 52.2 38.3 30.4 65.3 54.8 39.4 

Training in neonatal resuscitation 44.6 34.9 35.5 58.3 75.5 65.0 52.5 

Training in early and exclusive breastfeeding 50.7 49.8 35.7 56.3 72.2 63.5 54.0 

Training in newborn infection management 

(including injectable antibiotics) 28.6 33.3 23.9 50.8 50.9 54.8 41.1 

Training in thermal care 47.8 49.8 33.7 56.8 74.0 66.8 54.0 

Training in cord care 47.8 49.8 33.7 57.0 74.0 65.0 53.7 

Training in IMPAC 18.4 52.9 25.6 34.5 27.0 45.1 32.4 

Training in normal labor and delivery care 42.6 52.9 35.4 48.0 42.4 50.0 45.2 

Training in CEmOC 17.9 26.5 18.6 24.5 17.0 37.0 23.9 

Training in AMTSL 30.9 42.9 26.5 40.8 31.3 45.1 36.6 

Training in KMC 49.0 39.8 30.0 54.8 56.0 61.2 49.7 

Supervision 56.1 37.6 49.1 51.8 35.9 45.7 48.6 

Number of facilities 78 31 56 100 31 65 361 
67

Appendix Table 11 Percentage of health facilities with structural tracer items, Tanzania SPA 2014-15

Non-CEmOC facilities

Domain/Indicator Name Western Northern Central

Southern 

Highlands Southern

South West 

Highlands Lake Eastern Zanzibar

Na

Ave

Domain A: Comprehensive emergency obstetric care 

Parenteral administration of antibiotics 43.0 31.9 50.5 20.9 25.2 43.6 28.1 30.4 22.5 3

Parenteral administration of uterotonic 

drugs/oxytocin 81.9 89.5 90.3 72.1 91.6 95 73.8 85.1 92.3 8

Parenteral administration of 

anticonvulsants for hypertensive 

disorders of pregnancy 24.6 18.1 13.0 7.2 3.8 6.8 7.2 22.8 17.5 1

Manual removal of placenta 37.8 31.3 36.5 30.5 59.1 27.4 31.3 27.0 21.0 3

Assisted vaginal delivery 81.6 78.1 78.5 57.2 75.5 55.9 74.0 58.6 29.1 6

Removal of retained products 38.7 21.7 63.8 32.0 33.7 26.3 37.3 25.1 29.3 3

Caesarean section na na na na na na na na na 

Blood transfusion na na na na na na na na na 

Domain B: Newborn signal functions and immediate newborn care

Neonatal resuscitation 50.1 56.2 59.0 74.4 57.9 61.3 35.4 36.4 35.5 5

Skin-to-skin care 89.7 99.8 91.3 99.4 100.0 95.4 92.4 84.3 81.3 9

Wrap baby 97.5 99.6 99.7 95.7 100.0 96.3 99.7 93.9 96.5 9

Initiate breastfeeding within the first hour 99.7 99.6 92.8 100.0 100.0 100.0 99.3 96.4 88.0 9

Domain C: General requirements

Electricity 87.9 54.2 66.7 63.9 68.4 56.1 72.8 56.6 86.8 6

Improved water source 74.2 69.7 66.2 65.6 61.2 41.8 56.0 65.6 90.3 6

Improved sanitation 25.6 28.1 18.7 25.7 31.7 19.5 45.3 45.7 92.6 3

24/7 skilled birth attendance 18.9 32.7 23.7 18.0 16.9 28.2 39.9 27.0 21.0 2

Emergency transport 57.7 67.5 78.2 42.5 35.8 68.4 74.5 48.4 43.6 6

Domain D: Equipment

Sterilization equipment 28.9 36.7 6.2 12.7 10.1 10.5 15.9 37.0 59.6 2

Delivery bed 100.0 100.0 100.0 98.0 89.0 96.0 99.4 100.0 100.0 9

Examination light 6.5 21.0 6.3 5.6 10.1 26.1 9.0 26.2 35.1 1

Delivery pack 87.9 86.3 89.5 92.2 85.0 95.2 78.8 88.2 52.5 8

Suction apparatus (mucus abstractor) 24.8 25.7 17.7 22.0 22.9 24.3 21.0 21.9 37.4 2

Manual vacuum extractor 2.5 7.0 3.5 1.2 1.0 1.4 7.3 8.3 11.6 

Vacuum aspirator or D&C kit 11.3 9.5 3.6 4.7 1.3 0.7 10.5 8.4 25.4 

Partograph 60.1 74.0 43.9 62.0 76.6 51.4 45.9 59.4 59.9 5

Disposable latex gloves 73.4 87.8 95.0 92.7 79.8 83.1 85.3 86.4 96.5 8

Newborn bag and mask 76.4 96.0 85.3 94.1 83.1 76.4 40.5 89.0 45.8 7

Infant scale 82.0 79.5 71.5 74.0 83.9 80.7 76.9 90.2 82.8 7

Blood pressure apparatus (digital or 

manual) 46.9 77.5 66.9 76.4 57.5 91.4 53.7 65.2 68.6 6

Hand-washing soap and running water 

or hand disinfectant 46.3 78.4 50.6 87.6 56.8 76.2 56.2 81.2 86.0 6

Domain E: Medicines and commodities

Injectable antibiotic 41.5 35.3 34.8 21.6 35.3 49.9 22.8 26.4 21.0 3

Hydrocortisone available at the facility 25.1 44.6 37.8 26.5 14.8 24.3 21.8 52.4 26.3 3

Injectable uterotonic 71.0 87.6 81.7 84.8 74.0 87.5 71.5 72.7 92.3 7

Skin disinfectant 63.3 70.2 55.6 42.3 71.9 64.9 62.7 60.1 64.0 6

Magnesium sulfate 40.3 41.8 21.1 35.7 50.4 57.0 34.0 48.8 71.2 4
68

IV solution with infusion set 40.6 55.3 47.4 49.5 28.5 62.5 44.1 45.7 85.5 4

Chlorhexidine for cord cleaning 6.3 19.6 5.0 11.0 9.0 25.4 9.3 9.9 8.2 1

Antibiotic eye ointment for newborn 8.8 34.2 29.3 46.9 9.9 46.3 16.5 30.1 7.0 2

Domain F: Guidelines, staff training and supervision

Guidelines: Integrated Management of 

Pregnancy and Childbirth (IMPAC) 

Guidelines 41.2 36.2 16.2 26.7 31.9 21.7 19.7 40.0 32.0 2

Guidelines: CEmOC Guidelines 14.4 5.6 7.5 9.1 3.8 1.5 5.9 22.7 8.2 

Guidelines: Guidelines for management 

of pre-term labor 7.7 7.7 8.1 30.4 12.9 4.8 4.4 18.0 7.0 1

Guidelines on standard precaution 12.1 47.2 16.0 38.9 21.9 31.6 19.6 31.0 33.9 2

Training in neonatal resuscitation 79.1 92.1 43.8 76.5 46.2 43.4 21.7 64.5 67.3 5

Training in early and exclusive 

breastfeeding 74.4 72.6 43.4 69.4 34.6 43.5 23.5 50.1 58.0 4

Training in newborn infection 

management (including injectable 

antibiotics) 66.3 54.3 34.8 45.3 30.7 34.6 20.7 34.7 46.3 3

Training in thermal care 76.7 87.4 41.3 61.5 43.0 38.4 22.6 41.3 53.3 4

Training in cord care 76.7 90.5 43.6 65.6 43.0 36.9 21.3 41.6 55.7 4

Training in IMPAC 26.0 24.7 13.2 21.0 10.9 20.0 11.6 13.9 4.7 1

Training in normal labor and delivery 

care 33.8 28.3 16.1 17.6 24.1 26.5 15.7 16.5 4.7 2

Training in CEmOC 28.6 20.6 9.1 13.7 12.6 15.8 14.1 13.7 2.3 1

Training in AMTSL 33.8 25.0 18.8 17.8 21.3 27.3 16.1 21.3 7.0 2

Training in KMC 59.3 57.8 38.8 55.5 33.8 36.7 19.6 39.8 52.2 4

Supervision 83.0 73.8 81.3 69.2 82.2 86.2 82.7 62.3 89.5 7

Number of facilities 84 109 103 114 65 103 198 113 7 8