Background and rationale: Good-quality obstetric and newborn care in health facilities is central to reducing maternal and neonatal deaths and stillbirths, as well as improving the future health of women and children. Institutional births have increased dramatically across the globe, but the places where births occur vary enormously and are poorly understood. Simply increasing institutional delivery coverage is very unlikely to reduce mortality if facilities lack basic requirements for emergency obstetric & neonatal care, have inadequate staffing, or cannot refer in emergencies.

In many parts of sub-Saharan Africa, births have mostly increased in facilities with lower capacity to handle obstetric emergency, low birth volume, or both. Lower quality of obstetric care and lack of emergency capabilities in such facilities has led some to recommend a policy of hospital births for all, though there is no global consensus. More evidence is needed to determine the best balance of childbirth care services across primary to tertiary levels to adequately provide life-saving and respectful childbirth care. A study involving 22 countries in sub-Saharan Africa is being conducted as part of the Countdown to 2030 phase III to generate evidence that will inform national and global decisions on future MNH strategies.

Research questions and study design:

  1. Where do women give birth, by what mode (vaginal or caesarean section), who attends them, by facility sector/volume/level, nationally, regionally, and by socio-economic group (DHS/MICS and HMIS data)?
  2. What are the health outcomes (neonatal mortality, stillbirths) by facility sector/volume/level, nationally, regionally, by socio-economic groups (DHS/MICS & HMIS)?
  3. What are facilities’ levels of readiness and accessibility to conduct routine deliveries and basic and comprehensive emergency obstetric and newborn care (health facility assessments and linked census or geospatial data)?
  4. What are the intended and actual health policy and system characteristics (e.g. organization of services, resources, quality service delivery, financing and information) in place for the provision of routine and emergency childbirth care (documents and health systems data)?
  5. To what extent do countries with higher levels of safe, effective, equitable, ready and accessible childbirth care have favourable MNH-related policy and systems characteristics, and where are adjustments or additions needed in future strategies to improve maternal and newborn outcomes?

Participating countries: Burkina Faso, Cameroon, Chad, Democratic Republic of Congo, Côte d’Ivoire, Ethiopia, Ghana, Guinea, Kenya, Liberia, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia, Zimbabwe

Core analyses will be conducted in Phase 1 in all 22 countries using DHS/MICS, HMIS and policy/health systems documents/data. Expanded analyses will be undertaken in Phase 2 in select countries that have SARA/SPA/health facility assessment, GIS, and other health systems data.

Planned outputs: Reports on MNH delivery strategies (each country), tools for MNH data analysis using multiple data sources, joint scientific paper (cross-country), additional country papers on select results, disseminations to inform reviews.