Health facility readiness for maternal and newborn health care and its link with service utilisation: a geospatial analysis of four African countries, 2008–2023

Background Facility readiness, or the staff, supplies, equipment, and infrastructure available and operational in health facilities, is a pre-requisite for high-quality care. We examined facility readiness for maternal and newborn care alongside location of births by facility type in four African countries to track readiness-adjusted coverage and supply and demand dynamics for delivery services. Methods We used 42 health facility surveys in Burkina Faso, Ethiopia, Kenya, and Nigeria to construct maternal and newborn intrapartum care readiness scores. Geospatial small area models estimated readiness trends from 2008 to 2023 by facility type and region. We estimated location of births by facility type from population surveys and multiplied these by readiness scores to estimate readiness-adjusted coverage. Linear regression assessed the association between changes in facility delivery and readiness. Findings In 2023, readiness was highest in public hospitals (76.9%–93.5%) in all four countries. Readiness scores increased from 2008 to 2023 in Ethiopia, Kenya, and Nigeria but declined in Burkina Faso. Readiness-adjusted coverage varied widely across regions and was higher in more densely populated areas on average. Facility delivery was positively associated with readiness in Kenya and Ethiopia but negatively associated in Burkina Faso and Nigeria. Interpretation Facility readiness rose substantially in three of four countries since 2008, though improvement is still needed, particularly outside densely populated areas. The readiness-utilisation relationship is context-dependent. Policies that increase facility delivery should be paired with investments in facility capacity and strategies to ensure women deliver in adequately prepared facilities.