Effective coverage of childbirths in health facilities in Nepal: cross-sectional study combining Demographic and Health Survey 2022 and Health Facility Survey 2021

Background Crude intervention coverage, such as percentage of facility-based childbirths, does not reflect care quality. Effective coverage provides a more accurate measure by accounting for the quality of maternal health services. This study aimed to estimate effective coverage of facility-based childbirth in enabling environments in Nepal. Methods We used data from Nepal’s Demographic and Health Survey 2022 including 1,977 women and the Health Facility Survey 2021 with a sample of 804 facilities. We calculated the percentages of births by facility type and the percentage of facility types with enabling environments for childbirth services. We combined the results from two surveys to estimate effective coverage of births for routine childbirth, basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC). Results Around 80 % of all births occurred in health facilities nationwide. This reduced to 18.5% nationwide when only births in facilities equipped for routine childbirth were considered, and further to 12.9% and 12.2%, respectively for BEmONC and CEmONC. The reduction between crude and effective coverage across facility types varied from 36.8% to 13.5% in government hospitals, from 16.1% to 4.7% in private hospitals for routine childbirth. While, 20.1% of births were in health posts, no health posts had enabling environments for routine childbirth. Conclusions Fewer than one in five births occur in health facilities with enabling environments for acceptable quality care. This emphasizes the need for policymakers to prioritize the quality of childbirth services in well-equipped and well-staffed facility environments to improve maternal and neonatal outcomes.