# Location of births by health facility type: a time trend analysis from 1995 to 2023 in 130 low- and middle-income countries

## TL;DR

From 1995 to 2023, public hospitals became the main location for births in low- and middle-income countries, while private hospitals and lower-level facilities played smaller roles.

## Contribution

This study provides the first comprehensive global analysis of trends in delivery locations by facility type and sector across 130 low- and middle-income countries.

## Key findings

- In 2023, 47.5% of deliveries in LMICs occurred in public hospitals, with public hospitals accounting for most of the increase in facility births since 1995.
- Delivery in lower-level facilities was more common in countries with higher neonatal mortality rates and lower development levels.
- Private hospitals provided more than half of births in only two countries, while public lower-level facilities served as the main delivery location in 12 countries.

## Abstract

With major increases in facility births in low- and middle-income countries (LMICs) since 1995, a key question is what types of facilities met the increased demand. Understanding the evolving delivery landscape is crucial to informing debates about optimal models for balancing access, quality, and equity. We studied the distribution of delivery location by health facility level and sector (private versus public) in 130 LMICs from 1995 to 2023.

We used 745 data sources with delivery location information in our analysis. We first categorised births as in-facility or not, then further classified facility births by level (hospital or lower-level) and sector (public or private). We used spatiotemporal Gaussian process regression to model the share of births by facility type from 1995 to 2023 and compared delivery patterns to development and health indicators.

In 2023, 47.5% (95% uncertainty interval [UI] 46.4–48.6) of deliveries in LMICs were in public hospitals, 19.2% (18.3–20.2) were in private hospitals, 13.0% (12.3–13.8) were in lower-level public facilities, 2.0% (1.9–2.2) were in private lower-level facilities, and the remaining 18.2% (17.3–19.2) were outside health facilities. In 106 countries, more than half of deliveries were in public hospitals, while in 12 countries, public lower-level facilities provided care for more than half of births. In only two countries were private hospitals used for more than half of births, while in the remaining ten countries no facility type provided the majority of care. Between 1995 and 2023, nearly two-thirds (62.1%) of the 41.0 percentage-point increase in facility births was borne by public hospitals. Delivery in lower-level facilities was more common in countries with lower levels of development and higher neonatal mortality rates.

The mix of delivery locations represents the diversity of health systems worldwide. Our analysis highlights the pivotal and growing role of public hospitals in delivery care, though public lower-level delivery care is common in high-mortality contexts. Policy makers should account for the facility mix and the complex roles of public and private sectors when designing strategies to improve maternal and perinatal outcomes.

The Gates Foundation.