Measuring Effective Coverage for Facility Delivery using Health Facility and Household Surveys in Bangladesh, 2014 to 2022

Technical Summary: Measuring Effective Coverage for Facility Delivery in Bangladesh (2014–2022)

Problem Statement
Despite significant progress in reducing maternal mortality and increasing facility-based delivery rates in Bangladesh, the translation of service utilization into health gains has slowed. While facility delivery coverage rose from 37% in 2014 to 65% in 2022, maternal mortality remains a concern, with a substantial proportion of deaths occurring within health facilities. This discrepancy suggests that high "crude coverage" (service contact) masks significant deficits in the quality of care and facility readiness. Traditional metrics fail to capture whether women receive care of sufficient quality to achieve intended health benefits. Consequently, there is a need to estimate "effective coverage"—a metric integrating service utilization with the quality of care provided—to identify readiness gaps and missed opportunities that hinder progress toward Sustainable Development Goal 3.1.

Methodology
This study employed a cross-sectional analysis using linked data from the Bangladesh Demographic and Health Surveys (BDHS) conducted in 2014, 2017–18, and 2022, and the corresponding Bangladesh Health Facility Surveys (BHFS).

• Data Sources: The analysis focused on women aged 15–49 who had a live birth within the two years preceding each survey. Household data on delivery location were merged with facility-level data on service readiness.
• Readiness Assessment: Facility readiness was evaluated using tracer indicators aligned with the WHO health system building blocks framework. These indicators covered human resources, clinical guidelines, equipment, diagnostics, and medicines.
  • BEmOC (Basic Emergency Obstetric Care): Assessed using 15 tracer items.
  • CEmOC (Comprehensive Emergency Obstetric Care): Assessed using 22 tracer items (the 15 BEmOC items plus 7 additional items for advanced interventions like C-sections and blood transfusion).
  • Readiness scores were calculated as the proportion of available and functional items out of the total tracer items for each facility type.
• Ecological Linking: Since household surveys do not identify specific facilities, an ecological linking approach was used. Individual service utilization data were linked to facility readiness estimates based on the type of facility (public hospital, public primary facility, private facility, NGO facility) and administrative division.
• Effective Coverage Calculation: Effective coverage was derived by multiplying crude facility delivery coverage by the corresponding facility readiness score. This allowed for the quantification of the "readiness gap" (difference between crude and readiness-adjusted coverage) and "missed opportunities."
• Equity Analysis: Inequalities were examined across wealth quintiles, maternal education, place of residence (urban/rural), and administrative divisions.

Key Results

• Divergence of Crude and Effective Coverage: While crude facility delivery coverage increased by 28 percentage points (from 37% in 2014 to 65% in 2022), effective coverage increased by only 11 percentage points (from 22% to 33%). The gap between crude and effective coverage widened from 15 to 32 percentage points over the study period.
• Facility Readiness Trends: Overall readiness scores remained low and showed mixed trends.
  • BEmOC Readiness: Increased slightly from 39% (2014) to 42% (2022).
  • CEmOC Readiness: Increased marginally from 33% to 34%.
  • Declines: Significant declines were observed in the availability of trained staff (33% to 18% for BEmOC), clinical guidelines (37% to 10% for BEmOC), and specific CEmOC components like blood typing capacity (41% to 7%) and anesthetic equipment.
  • Improvements: Some equipment availability improved, such as examination lights, neonatal bag and masks, and gloves.
• Role of Private Facilities: Private facilities accounted for 45% of all live births in 2022, nearly doubling their share from 2014. However, private facilities generally demonstrated lower readiness scores compared to public hospitals, particularly regarding trained staff and guidelines.
• Inequities: Significant disparities persisted across socioeconomic groups. In 2022, effective coverage ranged from 22% among the poorest women to 44% among the wealthiest. While the rural-urban gap narrowed, a substantial disparity remained. Notably, the gap between crude and effective coverage was often larger among wealthier and more educated women, largely due to their higher utilization of private facilities with lower readiness scores.
• Regional Variations: Khulna had the highest crude coverage (82%) but the largest gap between crude and effective coverage (49 percentage points). Sylhet was the only division where the coverage gap narrowed between 2017 and 2022.

Key Contributions

• Methodological Advancement: This study addresses limitations of previous assessments by using consistent, nationally representative datasets (2014, 2017, 2022) and applying the WHO health system building blocks framework to select readiness items available across all survey years.
• Comprehensive Equity Analysis: Unlike prior studies that focused primarily on regional differences, this analysis provides a granular disaggregation of effective coverage across wealth, education, residence, and administrative divisions.
• Identification of Quality Bottlenecks: The study quantifies the specific "readiness gaps" (e.g., lack of trained staff, guidelines, and essential medicines) that prevent increased utilization from translating into health gains.
• Private Sector Focus: It highlights the critical role of the private sector in Bangladesh's maternal health landscape and identifies it as a major area of quality deficit despite high utilization.

Significance and Claims
The paper claims that high facility delivery utilization in Bangladesh is currently insufficient to drive proportional reductions in maternal mortality due to systemic quality deficits. The authors assert that:

1. Quality Over Quantity: Continued gains in maternal outcomes cannot be achieved solely by expanding service contact; there is an urgent need to shift focus toward strengthening the content and quality of care.
2. Private Sector Regulation: The growing reliance on private facilities, which currently exhibit lower readiness, necessitates stronger regulation, accreditation, and quality assurance mechanisms.
3. Policy Implications: Policymakers must prioritize the availability of trained staff, clinical guidelines, essential medicines, and emergency transport systems.
4. Monitoring Framework: Embedding effective coverage indicators into routine monitoring systems is essential to distinguish between high utilization and high-quality care, enabling targeted interventions to address quality bottlenecks in high-contact, low-quality settings.

The study concludes that addressing the gaps in facility readiness and the "missed opportunities" in care delivery is crucial for transforming contact points into effective care and accelerating progress toward national and global maternal health goals.