Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials

Background Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases

in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of

robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of

facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality

outcomes, while also considering quality of care.

Methods Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based

cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality

of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality,

first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility

birth as the percentage of facility births in a woman’s village over the preceding 2 years, and we computed distances

from women’s regular residence to health facilities in a geospatial database. Associations between determinants of

facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models.

We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points,

when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility

birth and potentially reduced quality of care.

Findings Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality

outcomes. In women who were wealthier, facility births were much more common than in those who were poorer,

but mortality was not lower among them or their babies. Women with higher education had lower mortality risks

than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of

women living in areas closer to childbirth facilities had facility births and caesarean sections than women living

further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among

women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency

newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we

found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per

1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06–1·21) and of composite mortality outcomes than among

women living in areas where these services were further away. Protective effects of facility birth were restricted to

the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal

mortality with increasing wealth (OR 1·09, 1·03–1·14) and lower perinatal mortality with increasing distance from

childbirth facilities (OR 0·93, 0·89–0·98) after free health insurance was introduced in July 1, 2008.

Interpretation Facility birth does not necessarily convey a survival benefit for women or babies and should only

be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding

uncomplicated births.