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Trends in health facility births in sub-Saharan Africa: an analysis of lessons learned under the millennium development goal framework.


Maternal mortality ratio (MMR) has been on the decline since 1990. However, most of the reduction took place since 2000 after the international community adopted the Millennium Development Goals (MDGs) (1). The adoption of the MGDs led to increased efforts by the United Nations Members States to improve the well-being of mothers and children by promoting, among other things, childbirth under the care and supervision of professionally trained birth personnel such as doctors, mid wives and nurses who are for the most part, accessible in health facilities. With the exception of Sub-Saharan Africa (SSA), the rates of births attended by skilled personnel in developing countries have shown impressive increases since the mid-1990s, with majority of the births occurring in health facilities (2). In 2014, 71% of births globally were attended by skilled personnel compared to 59% in 1990 (3,4). Several studies have and continue to examine factors associated with maternal mortality, especially in SSA, where the rates are extremely high. These studies have shown among other things, that increasing access to maternal health services including birth under the supervision of skilled personnel, is associated with better maternal outcomes (5,6,7). Given these, many programs and interventions have been put in place to increase access to and utilization of maternal health services. While these are invaluable measures to take, we must not lose sight of newborn health and survival. Neonatal mortality rate (NMR), although having declined impressively between 1990 and 2015, remains a global health problem and a major contributor to the high global infant mortality rate (IMR) (8). Globally, about 36% of neonatal deaths are due to infections whereas preterm birth complications and birth asphyxia account for 28% and 23%, respectively (9). Between 1990 and 2015, global NMR reduced from 33 deaths to 19 deaths per 1,000 live births. This decline is slower than that observed for under-5 mortality making neonatal mortality a large contributor to under-5 deaths globally (8).

In SSA, deaths of newborns during birth and in the first month of life are also largely caused by preventable infectious diseases (10,11). These causes of death have taken a toll on NMRs in SSA which currently lags behind many countries, and carries about half of the burden of the world's under-5 mortality (3 million in 2015). SSA has the highest risk of neonatal deaths and is also among the regions showing the least progress in reducing NMR (4,6). Many neonatal deaths can be averted by interventions that address the needs of women and infants, paying particular attention to care around the time of birth. Some studies have shown that the newborns delivered at home, whose deliveries are not supervised by skilled personnel, are more likely to develop infections--the leading cause of neonatal deaths in SSA (12-14), yet about 60% (18 million) of women in SSA give birth unattended at Home (15-17). These infections are mostly caused by the absence of sterilized birth conditions which are more feasible and attainable within the confines of a health facility.

Extant research has shown that infants whose mothers attend antenatal care and are delivered in health facilities have better outcomes. These studies also show that women who attend antenatal care are more likely to deliver in health facilities and to continue to utilize postnatal care services than women who do not attend antenatal care (18-20). Postnatal care services ensures that newborns get proper care in the period immediately following delivery which is when newborns are at highest risk of dying. Skilled care at birth and in the short time following birth is for the most part, accessible through delivery in health facilities, and has been proven to save the lives of many mothers and babies (21). Increasing the chances of delivering in health facilities among women in SSA is a plausible way to reduce child mortality, particularly the death of newborns.

Taken together, while remarkable progress has been made with MGD 5 regarding attaining two-thirds reduction in infant mortality, the target has not been reached globally. Although SSA, has shown tremendous progress in increasing child survival, it still lags behind many regions and countries continue to experience low skilled birth attendance due to low facility births as well as great disparity between the urban and the rural areas and among regions (8,22). Given the wealth of evidence on the beneficial effect of facility births on maternal and neonatal outcomes, it is imperative to examine how SSA has fared over the years with respect to facility births, how much change has occurred (regionally and between urban and rural areas), and the important lessons learned to guide future actions. It is also equally important to understand how facility births relate to neonatal mortality. These are important to understand as countries move on with action plans towards achieving the SDGs. The current study addresses this knowledge gap by i) Showing trends in health facility births in SSA by urban-rural areas and by region; and ii) Examining the correlation between health facility births and NMR in SSA.



Data come from the Demographic and Health Surveys (DHS) conducted between 1990 and 2014 which include various socio-demographic and health indicators including neonatal mortality, births attended by skilled health personnel and maternal mortality ratios (MMRs--for selected surveys). The data are publicly available online through the DHS STATCompiler (www.stat, which allows users to make custom tables based on hundreds of sociodemographic and health indicators spanning at least 80 countries. As of September 2015, the DHS database had 330 surveys of which 133 surveys were in SSA. Of the 133 SSA surveys, 10 had one single survey. Our study consist of data from 27 countries (10 in Western Africa; 5 in Middle Africa; 10 in Eastern Africa; 2 in Southern Africa) that had the earliest and most recent surveys (n=54) with births attended by skilled health personnel provided by region or country and type of residence (rural and urban). Using earliest and most recent surveys allows us to focus on a reasonable length of time in order to observe meaningful changes. Time intervals between the two surveys across the 27 countries ranged from 5 to 23 years, averaging 13.8 years of observation time. The interquartile range was between 7 and 21 years implying that half of the surveys were clustered within time interval of 14 years (Table 1).

DHS data, as with many other large-scale survey data, are problematic, however. They are associated with sampling variability of the estimates and non-sampling errors. For example, non-sampling errors are a function of the completeness with which women recall and report child deaths, the accuracy of the date of birth information reported by the mother for living children, and the accuracy of the age at death information given by the mother for the deceased children. Nevertheless, demographic techniques are available to overcome these challenges and lead to estimates or indicators which many countries in the less developed world and SSA in particular can use for health policy planning, implementation, and monitoring (16).


The main variable of interest was health facility births, defined as the percent of most recent births occurring within five years prior to the survey and that were delivered in a health facility. Our independent variable was residence of the women of reproductive age at the time of the interview (urban-rural) and neonatal mortality rate (NMR) defined as the probability of dying within the first month of life, and expressed per 1,000 live births.


Health facility births were identified by asking women "Where did you give birth to [Name]?" Possible options were "home", "other home", a list of different types of public, private or nongovernmental health facilities (e.g. Government Hospital, Government Health Centre, Private Clinic), and "Other places" that required specification. Analyzing inequity gaps in facility births between the initial and the latest surveys as well as urban-rural inequities is ideal as the Sub-Saharan African countries join the international community in implementing strategies to meet the Sustainable Development Goals focusing on health by 2030.


We used the percentage of women who had a recent health facility birth in the earliest and latest surveys and compared if the gap between the two surveys had narrowed or widened. We then examined the urban and rural differences as well as regional variations in the two sets of surveys to establish the direction and magnitude of the difference. Urban-rural disaggregation helps assess the context in which implementation of health policies varies by type of residence. Examining regional variations is ideal as it provides opportunities not only to understand the regional dynamics but also to learn from other countries. We also examined the correlation between NMR and percent of facility births. We related the results of this analysis to the various interventions that had taken place since the 1990s to encourage health facility births in SSA and to map out areas of successes and challenges.


Facility births at initial and latest surveys

For all the 27 countries included in the analysis, the median value for facility births increased from 44% at initial survey to 57% at the latest survey times representing a 13 percentage point increase (Figure 1). Corresponding average facility births for the 27 countries were almost equal to the median values, at 46% and 58%, respectively. The country with the highest percentage of facility births at the latest survey was Congo (Brazzaville) at 92% followed by Gabon at 90%. The lowest percentages of facility births were observed in Chad (13%) and Ethiopia (10%) (Figure 2).

Since the absolute changes can mask the real dynamics in that some countries already had highest percentage of facility births at the initial survey, we converted them into percentage changes between the two surveys. Results (Figure 2) show that Rwanda had the highest percentage change at 43% followed by Sierra Leona (29%) and Senegal (26%). Thus, the inequity gap between the leading country (Rwanda) and runner up (Sierra Leona) is 14 percentage points, much higher than the differences between the remaining countries (Figure 1). The lowest percentage changes were observed in Madagascar (-10%), Zimbabwe (-7%), Tanzania (-3%), Kenya (-1%), and Cameroon (-1%) (Figure 3).

Urban and rural health facility births at initial and latest surveys

In terms of urban--rural differences in facility births, rural areas on average had a higher percentage increase in facility births between initial and latest surveys (16%) than urban areas (6%). However, there were higher facility births in urban areas on average, compared to rural areas. Median urban-rural gap in health facility births at initial survey was 35% and at latest survey, median urban-rural gap reduced to 33% indicating a 2% overall gap reduction across the 27 countries. When gaps between urban and rural areas at initial and latest times are compared by regions, results show that Western Africa had the highest gap (42 % and 37%, respectively), Eastern Africa (38% and 36%, respectively), followed by Southern Africa (31% and 25%, respectively) with Middle Africa at the least (30% and 24%, respectively). Of all the regions, the smallest gap reduction was in Eastern Africa (2%) (Figure 4).

When the percentage increases in facility births are compared by regions, results show that Southern Africa had the highest increase at 19%, Western Africa at 18% followed by Middle Africa at 10% and the lowest in Eastern Africa at 8% (Figure 5).

Relationship between facility births and neonatal mortality rates at initial and latest surveys

The average and median NMRs during the initial survey for all the 27 countries were almost equal at 38.1 and 38.0 deaths per 1,000 live births, respectively. For the initial survey, the lowest and highest NMRs were 26 (Kenya) and 57 (Mali) deaths per 1,000 live births. Health facility births were inversely associated with NMR at initial survey times for all the 27 countries ([R.sup.2]=0.20, p=0.019) (Figure 6). In simple terms, an increase in facility births was associated with a decrease in NMRs. For the latest survey, the average and median NMRs for all the 27 Sub-Saharan African countries were almost equal at 29.4 and 28.0 deaths per 1,000 live births, respectively. For the latest surveys, the lowest and highest NMRs were 19 (Senegal) and 47 (Lesotho) deaths per 1,000 live births. Thus, the gap in NMRs between the initial and latest survey times for all the countries declined by 3 points from 31 deaths per 1,000 live births (Kenya and Mali) to 28 deaths per 1,000 live births (Senegal and Lesotho). Health facility births and NMRs were also inversely related at the latest survey times for all the 27 countries ([R.sup.2]=0.26, p=0.007) (Figure 7).


Our study provides a unique opportunity to critically examine facility births among Sub-Saharan African (SAA) countries and between urban and rural areas. We found an overall increase in health facility births from levels at initial surveys, although this was mainly driven by health facility births in urban areas. Despite this increase, more than 40% of births in SSA are not attended by skilled personnel compared to developed countries where 96% of births are attended by skilled personnel. Effective delivery and postpartum care can reduce preventable maternal and newborn deaths and is enhanced by facility birth, under the care of skilled personnel. With SSA accounting for 47% of child deaths in 2015, key interventions will reduce the rates of child mortality in SSA countries (7). Tremendous progress has been made in reducing global mortality, nonetheless, Millennium Development Goal (MDG 4) target of bringing down the rates of child mortality and by two thirds in 2015, from the 1990 levels was not met (22-23). In the wake of the new Sustainable Development Goals (SDGs), more ambitious goals have been set for 2030. SDG 3.2 seeks to end preventable deaths of newborns and children under-5 years, with all countries aiming to reduce rates to at least as low as 25 deaths per 1,000 live births including attaining neonatal mortality rates (NMR) of no more than 12 deaths per 1,000 live births. Realizing these targets may be compromised if the current child (and neonatal) mortality trends in SSA continue. Although births under the supervision of skilled personnel have increased globally from 58% in 1990 to 73% in 2013, this increase is mainly driven by increases in urban area (7). Rural areas continue to lag behind. We found the same trend among the 27 countries examined, with urban areas recording more facility births than rural areas. This disparity affects national, regional, and global facility births and skilled birth coverage rates and thus negatively impacts NMRs as well as under-5 mortality. Data from 2005-2013 show that poor people report lower number of births covered by skilled personnel than their wealthy counterparts. Given that rural areas are to a large extent, inhabited by people in the lowest wealth quintile, the issue of coverage by skilled birth personnel and access to health facility is more socially determined (7). The implication of disparities in skilled birth coverage is direr when we consider that SSA consists of low and middle income countries with lower overall socioeconomic status compared to high income countries, hence impacting coverage by skilled personnel. Our study found that despite the narrowing of the gap in facility births between urban and rural areas at both survey times, rural areas still recorded lower rates at both survey times.


At the regional level, Southern Africa registered the highest increase in facility births followed by Western Africa, Middle Africa, and Eastern Africa. The variations observed in health facility births may be indicative of the differences in cultural, economic, policy and programmatic factors that impact trends in facility births and NMRs. For example, despite having one of the lowest Gross National Income (GNI) per capita (US$1,290) among the 27 countries, Rwanda registered the highest increase (43%) in facility births compared to other countries such as Nigeria with GNI per capital that is more than four times higher than that of Rwanda. While cross-country variations in socio-cultural dynamics may compromise delivery of health services--for example, high illiteracy rates and myths about health facility delivery observed in some parts of northern Nigeria (24),--nonetheless, countries can leam from Rwanda's success story that is characterized by policies focusing on health workforce and infrastructure development, strong community involvement, a comprehensive community-based health insurance, among others (25). Countries can enact similar policies, while concurrently addressing socio-cultural factors that may impede effectiveness and progress.

Furthermore, we found that the gaps in facility births between urban and rural areas are strongly positively associated with NMR. As this gap widened, NMR increased. To improve NMR and to be on track for achieving the SGD targets for reducing under-5 mortality, the gap in facility births between urban and rural areas must be closed or at best narrowed. Urban and rural areas should enjoy equal access and utilization of skilled personnel during child birth. According to the World Health Organization, 34 out of the 47 countries projected to come short of the proposed SDG target for under-5 mortality (25 deaths per 1,000 live births by 2030) are in SSA. If the current trend continues, these countries may not meet the SDG target until 20508.

While proximity to health centers and lack of access may be an important contributor to global maternal mortality and subsequently neonatal and under-5 mortality rates, the least developed countries such as those in SSA are faced with several other challenges such as less standard quality of care, poor sanitation, limited economic opportunity, all of which slow down progress in reducing mortality rates. In addition, culture, beliefs and norms such as gender inequity may contribute to low facility births in SSA, besides proximity and /or lack of access. For example, women may be debarred from using health care services by their husbands and partners; they may also underutilize available maternal and child health services due to cultural beliefs that only weak women use those services (24,26).

Some limitations in our study are noteworthy. First, we did not examine the association between facility births and NMR in a multivariate model and as such we did not control for any extraneous variables. However, given the low p-values and the R-squared values (0.20-0.26) we obtained from our correlation (bivariate) analysis, it is highly unlikely that the strong association we observed can be completely attenuated by controlling for possible extraneous variables. Second, our study used facility birth as an indicator of skilled birth attendance at birth. While we know that there are occasions, when births occurring in health facilities (in SSA) are unattended due to absence of skilled personnel, these events are not typical and we do not think that they occur frequently enough to have any significant effect on our results.

To conclude, our study found an increase in facility births from initial survey to latest survey. However, these rates are still low and insufficient to meet the targets for the SDGs of reducing neonatal mortality rates (NMR) to 12 per 1,000 live births or lower. Aggressive efforts are needed to keep sub-Saharan African countries on track to achieve the SDGs. Given the strong inverse correlation we observed between facility births and NMR, policies focused on increasing access and utilization of maternal and health services is needed in SSA. An important lesson should be learned from Rwanda, where enactment of policies expanding maternal and health services have translated to increased facility births coupled with reduction in NMR over the years. It is also expedient for countries to pay close attention to urban-rural gaps in facility births and neonatal survival outcomes, as they implement these policies. Our trend analysis showed increases in facility births in urban and rural areas, but these did not eliminate the urban-rural gap in facility births. The better countries are able to close this gap, the more feasible it is to achieve the SDG target for infant and neonatal mortality. Furthermore, infections are one of the leading causes of neonatal deaths in SSA. It is important to ensure clean birth environment and sustained hygiene in the postnatal period particularly in rural areas where resources are more limited.

Maternal and child health services should be comprehensive enough to assure the health and wellness needs of women from preconception through pregnancy and postpartum. Furthermore, there is a need to continue to work on other areas such as reducing gender inequity, improving women's economic power and demystifying norms and cultural beliefs around use of health facilities. The MDG targets although not met, have led to impressive progress in maternal and child health indicators but sustained and persistent efforts are needed to maintain this progress. Interventions and services to increase facility births in rural areas need to be increased and strengthened.


We would like to thank the MEASURE DHS Program and the National Statistical Offices of the 27 Sub-Saharan African countries for making the data publicly available with financial support from USAID.

Conflict of Interest

The authors declare no conflict of interest. The views expressed in this article are those of the authors and should not be taken to represent those of their institutions.


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Ifeyinwa E. Udo [1] * and Henry V. Doctor [2]

Yale University School of Public Health, Center for Interdisciplinary Research on AIDS, 135 College Street, New Haven, CT 06520, USA [1]; World Health Organization, Regional Office for the Eastern Mediterranean, Informatcion, Evidence and Research, Health Information and Statistics, Nasr City, Cairo 11371, Egypt [2]

* For Correspondence: E-mail:; Phone: 443-831-1098
Table 1: Countries and Demographic and Health Surveys included in the
Analysis of Facility Births for sub-Saharan Africa.

Country            Initial     Latest        Observation
                   survey      survey        time *

Western Africa
  Benin            2001        2011-2012     11
  Burkina Faso     1993        2010          17
  Ghana            1998        2008          10
  Guinea           1999        2012          13
  Liberia          2007        2013          6
  Mali             2001        2012-13       12
  Niger            1992        2012          20
  Nigeria          1990        2013          23
  Senegal          1993        2014          21
  Sierra Leone     2008        2013          5
Middle Africa
  Cameroon         1991        2011          20
  Chad             1996-97     2004          7
  Congo            2005        2011-12
  Gabon            2000        2012          12
  Congo DRC        2007        2013-14       7
Eastern Africa
  Ethiopia         2000        2011          11
  Kenya            1993        2008          15
  Madagascar       1992        2008-09       17
  Malawi           1992        2010          18
  Mozambique       2003        2011          8
  Rwanda           1992        2010          18
  Tanzania         1992        2010          18
  Uganda           1995        2011          16
  Zambia           1992        2013-14       22
  Zimbabwe         1999        2010-2011     12
Southern Africa
  Lesotho          2004        2009          5
  Namibia          1992        2013          21
Mean (n=27)        --          --            13.8
Median (n=27)      --          --            13.0

Notes: *Observation time calculated based on the upper bound of the
year. For example, the 2010-2011 year uses 2011 as the end point.

Figure 2: Initial and Latest Percentage of Health Facility Births in
27 sub-Saharan African Countries for Surveys Conducted between 1990
and 2015

                             Initial      Latest

Congo Brazzaville             82           92
Gabon                         85           90
Benin                         76           87
Namibia                       67           87
DRC                           70           80
Malawi                        55           73
Senegal                       47           73
Rwanda                        26           69
Zambia                        51           67
Burkinafaso                   42           66
Zimbabwe                      72           65
Cameroon                      62           61
Lesotho                       40           49
Ghana                         43           57
Uganda                        37           57
Liberia                       37           56
Mali                          38           55
Sierra Leone                  25           54
Mozambique                    48           53
Tanzania                      53           50
Kenya                         44           43
Guinea                        29           40
Nigeria                       32           36
Madagascar                    45           35
Niger                         15           30
Chad                          12           13
Ethiopia                       5           10

Note: Table made from bar graph.

Figure 3: Percentage Increase in Health Facility Births Between
1990 and 2015 for 27 Countries in sub-Saharan Africa


Zimbabwe                         -7
Tanzania                         -3
Kenya                            -1
Cameroon                         -1
Chad                              1
Nigeria                           4
Mozambique                        5
Gabon                             5
Ethiopia                          5
DRC                              10
Congo Brazzaville                10
Guinea                           11
Benin                            11
Ghana                            14
Niger                            15
Zambia                           16
Mali                             17
Malawi                           18
Liberia                          19
Lesotho                          19
Uganda                           20
Namibia                          20
Burkinafaso                      24
Senegal                          26
Sierra Leone                     29
Rwanda                           43
Madagascar                      -10

Note: Table made from bar graph.

Figure 4: Initial and final Gaps and Gap Reductions in Facility
Births Between Urban and Rural Areas by sub-Saharan Africa Region

                           Gap reduction (Percent)

                 Western    Eastern    Southern     Middle
                 Africa     Africa     Africa       Africa
Initial Gap       42          38        31           30
Latest Gap        37          36        25           24
Gap reduction      5           2         6            6

Note: Table made from bar graph.

Figure 5: Percentage of Health Facility Births for the Initial and
Latest Surveys and Percentage Increase for sub-Saharan African


                    Initial    Latest    Increase
Southern Africa       54         73        19
Western Africa        38         56        18
Middle Africa         70         80        10
Eastern Africa        47         55         8

Note: Table made from bar graph.
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Author:Udo, Ifeyinwa E.; Doctor, Henry V.
Publication:African Journal of Reproductive Health
Article Type:Report
Geographic Code:60SUB
Date:Sep 1, 2016
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