Measuring readiness-adjusted coverage for facility delivery using health facility and household surveys in Bangladesh, 2014, 2017, and 2022

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.