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Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.

Original publication





Health affairs (Project Hope)

Publication Date





1576 - 1584


Anna D. Gage ( ) is a student in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts.


Humans, Obstetrics, Pregnancy, Health Policy, Health Facilities, Health Services Accessibility, Quality of Health Care, Kenya, Tanzania, Malawi, Namibia, Haiti, Nepal, Female, Quality Improvement