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BACKGROUND: Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa. METHODS: We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population. RESULTS: The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest. CONCLUSIONS: The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

BACKGROUND: Having hospitals located in urban areas where people, resources and wealth concentrate is efficient, but leaves long travel times for the rural and often poorer population and goes against the equity objective. We aimed to assess the current efficiency (mean travel time in the whole population) and equity (difference in travel time between the poorest and least poor deciles) of hospital care provision in four sub-Saharan African countries, and to compare them against their theoretical optima. METHODS: We overlaid the locations of 480, 115, 3787 and 256 hospitals in Kenya, Malawi, Nigeria and Tanzania, respectively, with high-resolution maps of travel time, population and wealth to estimate current efficiency and equity. To identify the potential optima, we simulated 7500 sets of hospitals locations based on various population and wealth weightings and percentage reallocations for each country. RESULTS: The average travel time ranged from 38 to 79 min across countries, and the respective optima were mildly shorter (

High-resolution poverty maps are important tools for promoting equitable and sustainable development. In settings without data at every location, we can use spatial interpolation (SI) to create such maps using sample-based surveys and additional covariates. In the model-based geostatistics (MBG) framework for SI, it is typically assumed that the similarity of two areas is inversely related to their distance between one another. Applications of spline interpolation take a contrasting approach that an area's absolute location and its characteristics are more important for prediction than distance to/characteristics of other locations. This study compares prediction accuracy of the MBG approach with spline interpolation as part of a generalized additive model (GAM) for four low- and middle-income countries. We also identify any potentially generalizable data characteristics influencing comparative accuracy. We found spatially scattered pockets of wealth in Malawi and Tanzania (corresponding to the major cities), and overarching spatial gradients in Kenya and Nigeria. Spline interpolation/GAM performed better than MBG for Malawi, Nigeria and Tanzania, but marginally worse in Kenya. We conclude that the spatial patterns of wealth and other covariates should be carefully accounted for when choosing the best SI approach. This is particularly pertinent as different methods capture geographical variation differently.

Studies on private sector family planning or childbirth care use by country & period. (PDF 257 kb)

Included study methods and results summary. (DOCX 121 kb)

Figure S1. Timing of Ugandaâ s health policies and major programmes, with focus on maternal/newborn heath. Overview of policies and programmes on a timeline (PDF document). (PDF 47 kb)

Key Words & MeSH Terms for Literature Review. (DOCX 104 kb)

PRISMA checklist. (DOC 62 kb)

Table S1. Sample sizes (unweighted) used in analyses, by survey. Table of sample sizes, by survey. Table S2. Comparison of estimates of deliveries from all births to most recent births, by survey. Table of estimates, by method. Table S3. Categorisation of ANC and delivery care locations into sector of provision, by survey. Table showing response options for ANC and delivery care locations by survey. Table S4. Change in coverage and co-coverage indicators over time. Table showing estimates and change over time. Table S5. Differences in the extent of socio-economic inequalities over time. Table showing extent of socio-economic inequalities. (PDF 320 kb)

Descriptive summary of studies included in review. (DOCX 46 kb)

Search strategy. (DOCX 12Â kb)

Contraceptive unmet need, use, sector of care, and provider type by country and period. (DOCX 15Â kb)

Missing information on sector of care among current users of modern contraception aged 15â 24Â years. (DOCX 14Â kb)

Detail of included studies. (DOCX 20Â kb)

DHS datasets & weighted sample sizes for populations included in analysis. (DOCX 16Â kb)