Abstract / Summary
Bangladesh has achieved major reductions in maternal mortality, yet progress has slowed despite high increasing use of facility-based delivery. In 2022, 65% of women delivered in a health facility, suggesting that increased utilization alone may not be sufficient to achieve further reductions in maternal mortality unless facilities are adequately prepared to provide delivery care. We estimated readiness-adjusted coverage of facility delivery by linking household and health facility data and examined socioeconomic and geographic differences in coverage. We conducted a cross-sectional analysis using the Bangladesh Demographic and Health Surveys from 2014, 2017-18, and 2022 and Bangladesh Health Facility Surveys in the corresponding years. Facility readiness was assessed using tracer indicators across human resources; guidelines; equipment; diagnostics; and medicines, and commodities. Weighted mean readiness scores were calculated by division, facility type, and mode of delivery and ecologically linked to individual women. Readiness-adjusted coverage was estimated by multiplying each woman’s facility-delivery indicator by the corresponding readiness score and calculating the survey-weighted population mean. Differences were examined by wealth, education, residence, and division. Facility-delivery coverage increased from 37% in 2014 to 65% in 2022, while readiness-adjusted coverage increased from 23% to 33%. Thus, the absolute gap between facility use and readiness-adjusted coverage increased from 14 to 32% points. In 2022, lower facility readiness was influenced by limited trained staff, clinical guidelines, logistics, and essential medicines. Additionally, notable socioeconomic disparities were evident, with readiness-adjusted coverage from 22% among the poorest women to 44% among the wealthiest in 2022. Private facilities accounted for 45% of all live births in 2022; however, their readiness was generally lower than that of public facilities. Overall, although facility-delivery coverage increased by 28% points between 2014 and 2022, readiness-adjusted coverage increased by only 11% points, from 22% to 33%, highlighting a persistent gap between facility use and structural readiness for delivery care. The increase in facility-based delivery in Bangladesh has outpaced improvement in readiness-adjusted coverage. Strengthening essential facility inputs, particularly in the private sector, and incorporating equity-focused readiness measures into routine monitoring could help ensure that increased service utilization is supported by adequate capacity to provide delivery care.