Background
Maternal mortality is one of the key health challenges in developing countries and sub-Saharan Africa in particular [
1]. According to estimates in 2015, there were 303,000 maternal deaths with most of them occurring due to complications related to pregnancy and childbirth. Almost all of the 303,000 deaths occurred in low-resource settings such as sub-Saharan Africa [
2]; and most of these deaths could be prevented. The good news is that between 1990 and 2015, maternal mortality worldwide dropped by about 44%, but this is low compared to the target set by the Millennium Development Goal (MDG) 5 to reduce maternal mortality worldwide by 75% by 2015. Therefore, as part of the Sustainable Development Goal (SDG) 3 on health, the target is to reduce the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births [
1].
There are complications that occur during and following pregnancy and childbirth that can contribute to maternal deaths. Most of these complications are preventable or treatable. More than half of maternal deaths take place within one day of birth [
3]. Malnutrition, including iodine deficiency, maternal anaemia, and poor-quality diet, also contribute to maternal mortality and the high incidence of stillbirths [
3]. Mothers who are HIV positive are also 10 times more likely to die than mothers who are HIV negative [
3]. According to the World Health Organization, most maternal deaths in sub-Saharan Africa are related to direct obstetric complications mainly haemorrhage, hypertension, sepsis, and obstructed labour, which combined account for 64% of all maternal deaths [
4]. Pneumonia and HIV/AIDS account for 23%, and unsafe abortion accounts for 4% of maternal deaths in Africa [
4].
The link between early and regular attendance of antenatal care and health facility delivery and improved maternal health outcomes has been documented for a considerable time. However, at least half of all births in developing countries occur in the absence of skilled birth attendants. This is largely influenced by socio-cultural factors, lack of understanding on the importance of skilled attendance at birth, financial hardship and physical accessibility [
5]. According to Gabrysch and Campbell [
5], socio-cultural factors often affect the decision to seek care compared to whether women actually reach the health facility. With respect to perceived benefit/need, the influence on delivery with skilled attendance is associated with factors related to women’s perception of the benefit of skilled attendance towards their health including that of their newborns. Economic accessibility refers to the ability of the family to meet the financial and transportation costs associated with the facility delivery. Physical accessibility indirectly affects decision-making to seek care and the ability to access health services after reaching a facility [
5]. These challenges have made it difficult to achieve the MDG of global reduction of maternal deaths. The role of health facility delivery in improving maternal and child health cannot be overemphasized; and it is one of the key stepping stones towards achieving the SDG 3.
Health is at the epicentre of the post-2015 development agenda. In particular, the 2030 Agenda for Sustainable Development seeks to achieve integrated goals and targets related to social, environmental, and economic factors. In order to address gaps in health care delivery, Universal Health Coverage (UHC) was included as target 3.8 as part of SDG 3. Specifically, SDG 3.8 aims at achieving UHC, including financial risk protection by improving access and quality of healthcare delivery including improved access to safe, effective, quality and affordable essential medicines and vaccines for all individuals. Therefore, under SDG 3, the global MMR is expected to reach under 70 deaths per 100,000 live births by 2030. Therefore, this study not only uses a rich source of data from sub-Saharan Africa but also builds on target 3.8 to assess changes in and determinants of health facility delivery from nationally representative surveys in sub-Saharan Africa. The study also seeks to present renewed evidence within the context of the SDG agenda to generate data for evidence-based decision making and enable deployment of targeted interventions to improve maternal health outcomes.
Discussion
Using data from 58 Demographic and Health Surveys from 29 sub-Saharan African countries, our study provides an opportunity to examine changes in health facility delivery as one of the components of health service delivery systems under the umbrella of Universal Health Coverage (UHC) [
10]. Examining changes since 1990 provides an opportunity to understand the existing gaps and possible interventions to implement in order to improve maternal and health outcomes in sub-Saharan Africa by 2030. We found an overall increase in more births being delivered in health facilities in later surveys (conducted since 2010) compared to earlier surveys (conducted since 1990s).While this increase is news noteworthy, almost 40% of births are not attended by skilled personnel in sub-Saharan Africa compared with 96% of births in developed countries which are attended by skilled personnel [
11]. Achieving the Sustainable Development Goal (SDG) 3 to reduce the MMR to less than 70 deaths per 100,000 live births by 2030 will require effective delivery and postpartum care to reduce preventable maternal and newborn deaths. This can be enhanced by health facility births under the care of skilled personnel.
Our study also found that the pattern of health facility deliveries varies within clusters or communities as well as within countries. While considering the fact that women from the same community will experience similar likelihood of delivering in a health facility, the results of this study highlight the importance of clustering effects in explaining differences in health facility delivery in sub-Saharan Africa. These effects are also observed at the country level. Building on the results from this study, available data shows that globally, births under the supervision of skilled personnel increased from 58% in 1990 to 78% in 2015 [
12]; and this increase was influenced by increases in facility births in urban areas. We also found similar results across the 29 countries in our study: the odds of urban women delivering in a health facility more than doubled the odds of rural women delivering in a health facility. Possible contributing factors for low health facility births in rural areas have often been linked to key factors such as limited access and proximity to health centres, cost of health care services, female autonomy, time available to access health care [
13] and myths about health facility delivery in some settings such as northern Nigeria [
14]. This disparity negatively affects under-5 mortality rates and neonatal mortality rates at the national, regional and international level. Interventions targeting the reduction in inequalities in access to health care are pivotal towards improving maternal outcomes in sub-Saharan Africa. The importance of the interplay between maternal health outcomes and rural/urban disparities is also reported in several studies in sub-Saharan Africa [
15,
16].
Our study also supports findings that maternal educational attainment and community women’s education are positively associated with health facility delivery. This finding further emphasizes the importance of interventions targeted at increasing women’s educational attainment. With increased maternal education, women are more likely to have more material resources and autonomy to access health care service [
17,
18].
Other studies from sub-Saharan Africa have also confirmed that wealth is also closely related to place of delivery. That is, poorest women are least likely to use facility delivery services [
16]. Our study provides further evidence towards this argument. Women from higher socio-economic status levels were more likely to deliver in health facilities than those from the lower socio-economic status levels.
With respect to children’s birth order, there is substantial evidence to suggest that facility delivery is more likely to decrease with the birth of the second or later children. However, insignificant differences are noted between second child and later births. A similar study in Nigeria suggests such trends may indicate that women of higher parity may stay away from health facilities due to increased maternal experiences or may be facing economic challenges due to increased family sizes, which may result to poor economic access to health facility [
18]. A systematic review of studies in sub-Saharan Africa also links higher parity to lower likelihood of health facility delivery [
16]. A systematic review of health financing policies in sub-Saharan Africa also documented varying degrees of policies that provide user fee exemption or reduction; national health insurance coverage; performance-based financing and user exemption; community insurance and other financing mechanisms that do not provide optimum health care services for families or women [
19]. When children have higher birth orders, they may not benefit from the range of available services due to economic challenges.
This study also contributes to a body of literature on the relationship between ANC and facility based delivery. The findings are consistent with evidence and confirm the study hypotheses that ANC attendance is predictive of facility based delivery. In particular, a very significant difference exists between women who never utilised ANC services and those who did. Similar results are reported in Tanzania and Ghana [
16] and Tanzania [
15]. Further, the study in Tanzania attributed significant differences between two or more ANC visits and health facility delivery, especially in rural areas. The Tanzania study also found that one visit did not usually lead to facility based delivery. In bivariate analyses, our analyses found that at the regional level, women in Middle Africa were more likely to deliver in health facilities than women in Western Africa. However, this effect was no longer significant in the adjusted regression models which implies that the effect of region is not pronounced when other factors are taken into consideration.
In general, later surveys were more associated with health facility delivery than earlier ones. The overall ratio of the observed to expected facility births showed that observed facility births were only 2% more than what would be expected. This is a very low ratio and underscores that the observed increases in facility births are still too low to show a significant impact in improving maternal and child health outcomes. While proximity to health centers and lack of access have been highlighted as key contributors to global maternal mortality and subsequently neonatal and under-5 mortality rates, least developed countries such as those in sub-Saharan Africa are faced with persistent challenges such as substandard quality of care, poor sanitation and dwindling economic opportunities which slow down progress in improving health outcomes [
14,
20]. Further cultural beliefs and norms such as gender inequity may be responsible for the observed low rates of health facility delivery in sub-Saharan Africa, in addition to challenges related to physical access. For example, women may be constrained from seeking health care services due to lack of permission from their spouses [
20].
Proven interventions to improve maternal and newborn health can be implemented during labour, delivery and postpartum period. Among other things, these interventions relate to diagnosis and monitoring progress of labour; maternal and child health; detection and management of complications; delivery and immediate care of the newborn baby; breastfeeding and postnatal care. Treatment and management of any complications can also be provided to women who deliver in health facilities [
21].
As the global community moves towards the deadline for achieving SDG 3 on health in 2030, countries are called upon to implement interventions aimed at achieving UHC. To achieve UHC, countries are called upon to strengthen health systems and implement robust health financing structures. In settings where out of pocket health expenditure is high, the poor are often disadvantaged and unable to access most of the health services. The rich may equally be disadvantaged particularly during severe or long-term illness. Recommended interventions also include pooling financial resources using compulsory mechanisms such as mandatory insurance schemes to defray the financial risks and promote good health among people. With reference to health facility delivery, UHC can be achieved by improving the capacity and availability of the healthcare workforce to deliver high quality services to people through integrated care [
10]. Investing in healthcare workforce is inevitable in order to address inequities in access to healthcare. Involving rural and disadvantaged communities in programming and delivery of interventions to improve health outcomes can lead to significant increases in health facility delivery [
20] and accelerate achievement of SDG 3 by 2030. Notwithstanding, addressing health challenges in sub-Saharan Africa requires not one or two interventions, but a package of interventions. The evidence for proven interventions is enormous. What remains is commitment and balancing investments to achieve optimum health outcomes for mothers and newborns.
Limitations
The study relies on data from Demographic Health Surveys. These household surveys are mainly conducted through verbal interviews with women and heads of households. Because DHS are conducted once in a few years, the interviews mean women have to reflect back on past decisions regarding delivery. While this may be feasible, it is also worth noting that the methodology is subject to recall bias. The definition of urban areas also tend to vary over time since in many countries, national statistical offices tend to define an urban area based on the size of the population and other key characteristics. The population size of towns and cities changes over time thereby affecting comparison of urban areas between surveys. Nevertheless, the strength of this study lies in the use of rich source of national representative Demographic and Health Surveys from 1990 to 2015 to assess changes in health facility delivery within the context of renewed calls at the international level to address existing maternal and child health challenges.