# Percent of births in health facilities

The proportion of births in all health facilities in the area, or ‘institutional births’ or ‘institutional deliveries’.

This indicator is calculated as:

(Number of births registered in health facilities / Expected number of live births) x 100

The denominator is calculated by multiplying the total population of the area by the crude birth rate of the same area. Other methods for calculating the expected number of live births can also be used.

The total expected number of births in an area is based on information about the population and the crude birth rate. National statistics offices tend to base population projections on the results of their most recent census. They may also have regional crude birth rates. If not, the crude birth rate is often available from national population-based surveys, such as the DHS. When possible, estimates for the specific geographical area should be used rather than applying the national crude birth rate to all regions. Regions are often selected for interventions or programs because of special needs and therefore tend to have poorer indicators than at national level. Usually, the birth rate in poorer areas is higher than the national average, so that use of the national average would result in an underestimate of the expected number of births, and the proportion delivered in facilities would therefore be overestimated.

Health facility records and national statistics for population and crude birth rate

To reduce maternal and infant mortality, the optimal long-term objective is that all births take place in (or very near to) health facilities in which obstetric complications can be treated when they arise. Many countries have made having 100% of deliveries in institutions their main strategy for reducing maternal mortality.  Previously, the minimum acceptable level was set at 15% of expected births. In the intervening years, many governments have committed themselves to increasing the proportion of women who give birth in health facilities, and some are aiming for 100%. Therefore, the minimum target for this indicator should be set by national or local governments.

Parallel analysis of the proportion of all births in all the facilities surveyed allows comparison of the proportion of births in emergency obstetric care facilities with the proportion of births in all facilities. This indicates the extent to which other facilities provide delivery services.  This indicator can also be analyzed by level of facility (hospital and non-hospital), by ownership or management (public and private) and by subnational area, in order to determine where women are delivering. Are women more likely to deliver in private or government facilities? Are there more institutional deliveries in certain subnational areas? Disaggregating data in this way can provide more specific information about which interventions are most needed, and where.

Giving birth in a health facility does not necessarily equate with high-quality care or fewer maternal deaths. Smaller health facilities may not have adequately trained staff, or staff may not have the equipment or the authority to treat life threatening complications. Many facilities do not function well because of poor management, which should be remedied before the number of births in the facility is increased greatly.  Furthermore, deliveries in institutions are not necessarily attended by skilled birth attendants. Therefore, additional information may be needed to see which cadres of workers are involved in deliveries and their level of competence.

access, safe motherhood (SM)

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