Availability and readiness of routine perinatal and emergency obstetric and newborn care services in health facilities in Burkina Faso: trend analysis from 2014 to 2020

Availability and readiness of routine perinatal and emergency obstetric and newborn care services in health facilities in Burkina Faso: trend analysis from 2014 to 2020 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Availability and readiness of routine perinatal and emergency obstetric and newborn care services in health facilities in Burkina Faso: trend analysis from 2014 to 2020 Aduragbemi Banke-Thomas, Marie-Jeanne Offosse, Kadari Cissé, Anna Gage, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7463045/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Despite significant reductions in recent decades, maternal mortality and stillbirth remain some of the leading causes of death in Burkina Faso. Routine perinatal and emergency obstetric and newborn care (EmONC) can reduce these deaths. This study analyses the trends in availability and health facility readiness to provide routine perinatal and EmONC in Burkina Faso between 2014 and 2020. Methods We conducted a trend analysis of repeated cross-sectional facility-based data using nationally representative 2014, 2016 and 2018 Service Availability and Readiness Assessment surveys and census-based 2020 Health Harmonised Facilities Assessment. Following descriptive analysis of included facilities, we used tracer elements in both surveys to estimate availability and readiness indices by survey year and health facility characteristics. Both indices were calculated using the equal-weighted approach, while the domain-weighted approach was used for readiness only. We assessed trends using a weighted multivariate linear regression, with trends adjusted for facility characteristics. Results Routine perinatal and basic EmONC availability index increased from 69.8% in 2014 to 74.9% in 2020 ( \(\:\beta\:=0.825;p<0.001)\) . After adjustment for facility characteristics, there was a statistically significant increment in routine perinatal and basic EmONC availability index from 2014 to 2020 in primary and public facilities, and in those in seven of 13 regions, but significant decline in urban-based facilities. There was also a significant reduction in readiness score for this service (65.0% in 2014 to 61.1% in 2020 ( \(\:\beta\:=-0.515;p<0.001)\) ), driven mostly by staff and guidelines. Adjusted trends showed statistically significant reduction in readiness index in secondary, tertiary, and private facilities. Availability index for comprehensive EmONC had a non-significant decline from 82.9% in 2014 to 79.6% by 2020, while its readiness score declined significantly, from 62.5% in 2014 to 46.5% in 2020 ( \(\:\beta\:=-1.981;p<0.001)\) , driven by all domains. Adjusted trends showed statistically significant reduction in secondary, tertiary, public, private, and urban-based facilities. Conclusion While availability of routine perinatal and EmONC services have mostly withstood effects of recent health system shocks, facilities’ readiness to provide these services declined. Staff capacity development and equipping of hospitals are needed to ensure that hard gains made in maternal mortality and stillbirth reductions in Burkina Faso are not reversed. Figures Figure 1 Figure 2 INTRODUCTION Globally, an estimated 260,000 women and over two million stillbirths died in 2023 due to complications related to pregnancy and childbirth, such as bleeding, hypertension, infection, and abortion [ 1 – 3 ]. Approximately 70% of the estimated maternal deaths occurred in sub-Saharan Africa (SSA), with Burkina Faso, a landlocked country in the region, being reported to have had an estimated 1,800 maternal deaths and over ໿14,000 stillbirths in 2023 [ 2 – 4 ]. Maternal mortality ratio (MMR) in Burkina Faso has improved from 524 to 334 deaths per 100,000 live births between 2000 and 2020 and by 2023, a further drop to 242 deaths per 100,000 live births was reported [ 2 ]. Stillbirth rate declined from 34·2 to 23.8 per 1,000 births between 2000 and 2020, further reducing to 18.9 by 2023 [ 1 ]. Despite these declining trends in MMR and stillbirth rate, maternal and perinatal mortality remain major public health challenges in the country, as both constitute some of its leading causes of death [ 5 ]. To date, the strategy to reduce deaths related to pregnancy and childbirth, re-emphasised by the Sustainable Development Goals (SDGs), has predominantly focused on increasing access to prompt emergency obstetric and newborn care (EmONC), provided by skilled health personnel [ 6 , 7 ]. Evidence from research indicates that prompt access to EmONC can prevent up to 50% of maternal deaths and 45–75% of stillbirths occurring after the onset of labour but before birth [ 8 ]. Within the healthcare system, EmONC is provided at two levels of care: basic and comprehensive. Facilities that provide care at the basic level are expected to be able to perform seven interventions otherwise referred to as ‘signal functions’: administer injectable antibiotics, oxytocics, anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery (AVD), and basic neonatal resuscitation [ 7 ]. There has been recognition that there are other key interventions needed for routine and emergency newborn care, in addition to the basic neonatal resuscitation in the WHO framework. This includes interventions such as thermal protection for newborns, hygienic cord care, kangaroo mother care (KMC), immediate and exclusive breastfeeding, corticosteroids for treating preterm babies, and injectable antibiotics for neonatal sepsis [ 9 ]. Facilities at the comprehensive level are expected to provide blood transfusion and caesarean section in addition to all seven basic interventions [ 7 ]. These services are all in addition to routine perinatal services needed by pregnant women who have not developed an emergency. A robust health system is the bedrock for availability and operational readiness of health facilities to be able to provide routine perinatal and EmONC services to pregnant women who need them. As per global guidance, routine perinatal and basic EmONC interventions in Burkina Faso are expected to be performed at all health facilities including those at the primary level and form a critical component of the referral system which ensures that pregnant women with less complex emergency needs can be managed at that level without overburdening the higher-level facilities such as hospitals [ 7 ]. On the other hand, hospitals which are typically comprehensive EmONC facilities are extremely important for complex care [ 10 ]. However, new policies, changes in management and leadership, fluctuation in health financing, conflict, and several other factors can affect service availability and readiness across levels of care [ 11 , 12 ]. Over the past decade, there have been several events in Burkina Faso that may have influenced EmONC service availability and readiness positively or negatively. For example, in 2014, the Burkinabé government implemented a performance-based financing scheme in six of the 13 administrative regions in the country (Boucle du Mouhoun, Centre Est, Centre Nord, Centre Ouest, Nord, and Sud Ouest) [ 13 ]. In 2016, a national policy known locally as Gratuité exempted user fees for maternity care and permitted health facilities to use funds generated through reimbursements to invest in service improvement in order to increase access and improve quality of care [ 14 ]. Other schemes, such as the Health Services Strengthening Programme 2018–2024 and the Strengthening Access to Primary Health Care Integrating Sexual and Reproductive Health Initiative which started in 2020, focused on improving quality of maternal, newborn, and child health services, including EmONC [ 15 , 16 ]. On the contrary, the popular insurrection in Burkina Faso in 2014 and terrorist attack in the capital, Ouagadougou that occurred in January 2016 [ 17 ], could have negatively affecting availability and readiness. Also, the country has had an active conflict since 2016 across the Boucle du Mouhoun, Centre-Nord, Est, Nord, and Sahel regions, with over two million people said to be internally displaced as of July 2024 [ 18 , 19 ]. More recently, there was the 2019 Coronavirus Disease (COVID-19) pandemic, which disrupted service provision globally [ 20 – 22 ]. There is minimal research assessing availability and health facility readiness of routine perinatal and EmONC services in Burkina Faso. A previously published study assessed readiness of hospitals in Burkina Faso to provide blood transfusion and caesarean section using data from a facility survey conducted in 2007 [ 23 ]. More recently, another study assessed availability and readiness of EmONC in Burkina Faso from 2014 to 2018 [ 24 ]. However, since 2018, Burkina Faso has been faced with numerous terrorist attacks predominantly in 2019 and 2020 which not only forced several Burkinabè to flee their places of residence, but it also massively crippled the health system [ 25 ]. As per available reports, majority of violent attacks that occurred in the Sahel area of West Africa between July 2019 to June 2020 were in Burkina Faso (516 versus 361 in Mali and 118 in Niger) [ 26 , 27 ]. Evidence capturing the wider timelines will be crucial to capture the impact of the conflict on health service provision and provide a comprehensive understanding of EmONC availability and readiness in the country, especially as the crisis continues to affect the health system [ 25 , 28 ]. The objective of this study was to analyze the trends in availability and health facility readiness to provide routine perinatal and EmONC services in Burkina Faso between 2014 and 2020. METHODS Study design and setting This study is a trend analysis of repeated cross-sectional surveys conducted between 2014 and 2020. It incorporates data from all 13 health regions of Burkina Faso, which had an estimated population in 2021 of 22 million, with women accounting for over half of this number [ 29 ]. The gross domestic product (GDP) per capita of Burkina Faso is US $ 857, lower than the average in SSA of US $ 1,501 and US $ 10,918 globally [ 30 ]. As of 2018, an estimated 41% of the population lives below the national poverty line of US $ 1.90 daily [ 29 ]. In Burkina Faso, the national health system is managed centrally by the Ministry of Health which sets out major strategic orientations and policies for health. At the regional level, there are 13 regional directorates which oversee implementation and coordination of health policies and provide support to the lowest administrative level, health districts. In all, there are 70 health districts, responsible for operational planning and implementing health policy directives. While the healthcare system in the country is administratively and geographically organized in three levels: district, regional, and national, service provision is structured across three levels of care: primary, secondary, and tertiary. Primary level care which includes routine perinatal and basic EmONC services is expected to be available at health centres locally known as the Health and Social Promotion Centre (CSPS) and medical centres, both at the district level. Secondary level care which includes routine perinatal and basic and comprehensive EmONC services should be available district hospitals, also referred to as medical centres with surgical units (CMA) and regional hospitals, both of which serve as referral hospitals for the primary level facilities. The tertiary level includes national and university teaching hospitals, which are expected to offer the most advanced health care including routine perinatal and basic and comprehensive EmONC services. Health facilities are spread across the public and private sectors though most births take place in public facilities. As of 2022, there were just over 3,700 health facilities [ 31 ]. Based on the 2021 Demographic and Health Survey, health facility delivery rates remain sub-optimal nationally with regional variations ranging from 43.9% in the Sahel region, where significant conflict is ongoing, to 98.2% in Cascades region [ 32 ]. Description of data source We used the Service Availability and Readiness Assessment (SARA) surveys and the Harmonized Health Facility Assessment (HHFA) survey for this analysis. SARA is a health facility-based survey used to assess availability (i.e. physical presence of services and the necessary resources to deliver them within a health facility) and readiness (operational capacity) of health facilities to provide health services based on the presence or absence of ‘tracer items’ needed for providing services including trained staff, guidelines, equipment, laboratory services, and medicine and supplies. The survey, which was developed by the World Health Organization (WHO) has been conducted in many low- and middle-income countries, including Burkina Faso. Specifically in Burkina Faso, the SARA survey, which has been used in published readiness assessment studies [ 24 , 33 – 36 ], four rounds of the survey were conducted biannually between 2012 and 2018. The survey sampled public and private health facilities and was conducted across all three levels of the Burkinabè healthcare system. All health facilities expected to provide secondary and tertiary levels of care in the country were included, while a random sample of health facilities expected to provide primary level care were included. The standard tool for the SARA survey as designed by the WHO was used for data collection in Burkina Faso [ 37 ], with the tool administered by trained data collectors to health facility leads or their designated alternatives who themselves were health personnel. Insights gathered from the interviewer-administered surveys were combined with direct observation to establish the availability and readiness of services. For this study, we used only the latest three rounds of the SARA survey (2014, 2016, and 2018) and excluded 2012 because some maternal health indicators were not included in the SARA survey that year [ 37 ]. The HHFA, also designed by the WHO, includes all the SARA indicators on service availability and readiness along with other indicators on quality and safety of care, management, and finance [ 38 ]. However, there are some distinctions between both surveys. For example, in SARA, any manoeuvre done during childbirth to reposition babies was counted as ‘assisted delivery’ in Burkina Faso and as such part of AVD availability, but the more precise definition involving use of forceps or ventouse was applied in HHFA [ 37 , 38 ]. The question on KMC availability queried if the service was “offered” in SARA compared to if it was “used” in HHFA, which also advised verification from a KMC unit, if this was available [ 37 , 38 ]. HHFA was conducted as a census of all 2,758 health facilities operational in the year 2020. The Ministry of Health in collaboration with the Research Institute of Health Sciences led data collection which was conducted across all 13 regions from November 2020 to January 2021. After an initial pilot survey to validate the tool, which was adapted to the context, health workers were deployed to lead data collection. The HHFA tool was administered using a face-to-face interview with the heads of health facilities or their designated alternatives. Study variables Outcome variables The two outcome variables of interest in this study were the availability and readiness of EmONC services. In the survey, availability and readiness of basic and comprehensive EmONC services are reported separately. Service availability refers to “the physical presence of the delivery of services, encompassing health infrastructure, core health personnel, and service utilization” [ 37 ]. This outcome focuses on whether a health facility offers a specific service. For routine perinatal and basic EmONC services, there are three domains (obstetric signal functions, newborn signal functions, and perinatal routine practices) with 16 tracer elements. For comprehensive EmONC, there is one domain with the two signal functions (blood transfusion and caesarean section). Service readiness is “ the availability of components required to provide services” . It assesses the operational capacity of a health facility to provide a specific service [ 37 ]. For service readiness, there are 27 indicators spread across three domains relating to staff and guidelines, equipment, and medicine and supplies for basic EmONC and 23 indicators across four domains relating to staff and guidelines, equipment, diagnostics, and medicine and supplies for comprehensive EmONC [ 37 ]. For both availability and readiness outcomes, each constituent indicator was defined as a binary variable, coded as ‘1’ if the indicator was confirmed as available in the health facility and ‘0’ if not. For our analysis, we selected only tracer elements that were common to SARA and HHFA, with three of 68 indicators reported in HHFA but not in SARA, excluded from our analysis. In addition, for indicators available in both surveys, we checked for alignment between their definition and the questions asked to elicit their availability and readiness status across both surveys. In instances of misalignment, for example, KMC availability, this was excluded from our analysis [ Additional file 1 ]. Independent variables The independent variables in this study were health facility location (urban or rural), level of health care (primary, secondary or tertiary), ownership (public or private), and health regions (Boucle du Mouhoun, Cascades, Centre, Centre Est, Centre-Nord, Centre-Ouest, Centre Sud, Est, Haut-Bassins, Nord, Plateau Central, Sahel, and Sud-Ouest). Statistical analysis The analytical approach prescribed by the WHO for analysis of the SARA data was used for this study [ 37 ]. For the descriptive analysis, the number of health facilities surveyed per year was estimated and summarised by health facility characteristics (healthcare level, facility ownership, rural or urban location, and region). All component tracer items for basic (henceforth combined with routine perinatal) and comprehensive EmONC service availability were assessed and availability index estimated based on the availability of each EmONC signal function amongst facilities offering birthing services for basic EmONC and secondary and tertiary facilities for comprehensive EmONC. Availability index was calculated using the equal weight approach, which consisted of an aggregate sum of all available items divided by the total number of expected items. This score was then expressed as a percentage by multiplying the score by 100, representing the proportion of elements available. Subsequently, the readiness index for the health facilities where required services were available at basic and comprehensive levels was calculated. For this, readiness score for each component tracer item was evaluated using the defined indicators for the respective three readiness domains for basic EmONC and four for comprehensive EmONC. Readiness score was expressed in percentage and interpreted as the percentage of tracer elements available for basic and comprehensive EmONC services on the date of the survey. The equal weight approach was used to calculate readiness index with n being the number of tracer elements available in a health facility and N the total number of tracers for the given domain [ 39 ]. The domain score was calculated using the formula: n/N*100. For a domain with seven items (like medicine and supplies), the domain score was equal to n/7*100. Overall readiness index was calculated as the mean of all items in the domains and presented by health facility characteristics [ 37 ]. This index expressed the percentage of necessary items for offering essential high quality EmONC available at the health facilities. The shortage of these items denotes the inability of health facilities to provide quality services. Temporal trend of availability and readiness score for both basic and comprehensive EmONC by domain and tracer elements was presented in tables and maps were used to highlight regional differences. Sampling weights were used for the 2014 to 2018 SARA surveys. The crude trend of availability of basic and comprehensive EmONC services was estimated using the Chi-square test for trend and measured the adjusted trend of the readiness index using weighted multivariate linear regression. The model was adjusted with the independent variables. The slope and p -value of the trend was assessed with 0.05 taken as the level of statistical significance. Multicollinearity between healthcare facility characteristics was checked before each regression analysis. Analysis was done using STATA 18.0 (StataCorp, College Station, Texas, US), while availability and readiness indices were mapped using QGIS (QGIS Development Team, London, UK). RESULTS Characteristics of the healthcare facilities surveyed by year The number of healthcare facilities surveyed was 766 in 2014, 677 in 2016, and 794 in 2018 and 2728 in 2020. Most included facilities operated at the primary level, ranging from 82.2% (2018) to 93.7% (2020) of health facilities surveyed. Similarly, between 68.6% (2018) and 79.5% (2014) of health facilities were publicly owned, and 57.2% (2018) to 66.8% (2020) of health facilities were in rural areas. Most surveyed facilities (18.7% in 2014 and 21.0% in 2016) were situated in Centre region, followed by Haut-Bassins (11.2% in 2016 and 11.9% in 2020) [Table 1 ]. Table 1 Characteristics of the surveyed healthcare facilities Health facilities 2014 n (%) 2016 n (%) 2018 n (%) 2020 n (%) All health facilities 766 (100.0) 677 (100.0) 794 (100.0) 2728 (100.0) Healthcare level Primary 659 (86.0) 567 (83.8) 653 (82.2) 2 557 (93.7) Secondary 89 (11.6) 93 (13.7) 119 (15.0) 144 (5.3) Tertiary 18 (2.4) 17 (2.5) 22 (2.8) 27 (1.0) Ownership Public 609 (79.5) 504 (74.5) 545 (68.6) 2 102 (77.1) Private 157 (20.5) 173 (25.6) 249 (31.4) 626 (22.9) Location Urban 265 (34.6) 256 (37.8) 340 (42.8) 905 (33.2) rural 501 (65.4) 421 (62.2) 454 (57.2) 1 823 (66.8) Health regions Boucle du Mouhoun 75 (9.8) 44 (6.5) 54 (6.8) 254 (9.3) Cascades 30 (3.9) 36 (5.3) 44 (5.5) 130 (4.8) Centre 143 (18.7) 142 (21.0) 145 (18.3) 432 (15.8) Centre Est 52 (6.8) 48 (7.1) 64 (8.1) 218 (8.0) Centre-Nord 50 (6.5) 39 (5.8) 49 (6.2) 168 (6.2) Centre-Ouest 69 (9.0) 55 (8.1) 59 (7.4) 277 (10.2) Centre Sud 34 (4.4) 38 (5.6) 41 (5.2) 147 (5.4) Est 50 (6.5) 42 (6.2) 53 (6.7) 133 (4.9) Haut-Bassins 84 (11.0) 76 (11.2) 89 (11.2) 324 (11.9) Nord 65 (8.5) 46 (6.8) 55 (6.9) 227 (8.3) Plateau central 44 (5.7) 40 (5.9) 51 (6.4) 191 (7.0) Sahel 44 (5.7) 40 (5.9) 44 (5.5) 69 (2.5) Sud Ouest 37 (4.8) 34 (5.0) 46 (5.8) 158 (5.8) Availability of basic EmONC services The proportion of health facilities offering birthing services was 88.1% in 2014 reducing to 78.4% by 2020 in a statistically significant decreasing trend ( \(\:\beta\:=-0.020;\text{p}<0.001)\) . For obstetric signal functions, AVD reduced from 99.8% in 2014 to 57.8% in 2020 ( \(\:\beta\:=-0.066;\text{p}<0.001)\) while all other obstetric signal functions showed statistically significant increasing trends, including, manual removal of placenta which increased from 80.6% in 2014 to 85.8% in 2020 ( \(\:\beta\:=0.055;\text{p}<0.001)\) , manual removal of retained products from 16.9% in 2014 to 47.2% in 2020 ( \(\:\beta\:=0.010;\text{p}<0.001)\) , parenteral administration of anticonvulsants from 21.9% in 2014 to 48.8% in 2020 ( \(\:\beta\:=0.045;\text{p}<0.001)\) , parenteral administration of antibiotics from 88.7% in 2014 to 92.1% in 2020, after a decline in 2018 ( \(\:\beta\:=0.023;p<0.001)\) , and parenteral administration of oxytocic from 90.2% in 2014 to 94.6% in 2020, after an initial decline in 2016 ( \(\:\beta\:=0.077;\text{p}<0.001)\) [Table 2 ]. Table 2 Percentage of availability of tracer indicators for basic EmONC and routine perinatal services Domain and tracer elements 2014 2016 2018 2020 slope p Facilities offering birthing services 88.1 86.8 75.4 78.4 -0.020 < 0.001 Obstetric signal functions Parenteral administration of antibiotics 88.7 91.8 85.7 92.1 0.023 < 0.001 Parenteral administration of oxytocic drug 90.2 87.5 88.8 94.6 0.077 < 0.001 Parenteral administration of anticonvulsants 21.9 29.3 38.9 48.8 0.045 < 0.001 Assisted vaginal delivery 99.8 99.1 96.1 57.8 -0.066 < 0.001 Manual removal of placenta 80.6 81.1 84.8 85.8 0.055 < 0.001 Manual removal of retained products 16.9 20.5 39.4 47.2 0.010 < 0.001 Newborn signal function Neonatal resuscitation 33.2 38.8 53.0 45.4 0.025 < 0.001 Antibiotics for preterm or prolonged premature rupture of membranes to prevent infection 66.3 83.4 74.5 85.6 0.024 < 0.001 Corticosteroids in preterm labour 16.0 21.0 23.1 21.1 0.008 < 0.001 Injectable antibiotics for neonatal sepsis 46.9 47.9 51.0 87.8 0.065 < 0.001 Routine perinatal services Administration of oxytocin for the prevention of postpartum haemorrhage 98.7 99.3 97.6 94.6 -0.007 < 0.001 Monitoring and management of labour using partograph 96.4 96.1 93.5 95.1 -0.003 0.005 Immediate and exclusive breastfeeding 99.7 99.9 99.1 99.7 -0.001 0.120 Hygienic cord care 99.8 99.7 98.9 94.3 -0.009 < 0.001 Drying and wrapping the newborn and immediate skin to skin contact 99.3 98.6 99.3 98.0 -0.002 0.004 For newborn signal functions, though generally low showed statistically significant increasing trends in availability. For example, neonatal resuscitation increased from 33.2% in 2014 to 45.4% in 2020 after a decline in 2018 ( \(\:\beta\:=0.025;\text{p}<0.001)\) , antibiotics for preterm or prolonged premature rupture of membranes increased from 66.3% in 2014 to 85.6% in 2020 after a decline in 2016 ( \(\:\beta\:=0.024;\text{p}<0.001)\) , corticosteroids in preterm labour increased from 16.0% in 2014 to 21.1% in 2020 after a slight decline in 2018 ( \(\:\beta\:=0.008;\text{p}<0.001)\) , and injectable antibiotics for neonatal sepsis from 46.9% in 2014 to 87.8% in 2020 ( \(\:\beta\:=0.065;\text{p} 94% available across years, there were slight statistically significant reductions in administration of oxytocin for postpartum haemorrhage (PPH) prevention ( \(\:\beta\:=-0.007;\text{p}<0.001)\) , monitoring and management of labour using partograph ( \(\:\beta\:=-0.003;\text{p}<0.005)\) , hygienic cord care ( \(\:\beta\:=-0.009;\text{p}<0.001)\) , and drying and wrapping the newborn and immediate skin to skin contact ( \(\:\beta\:=-0.002;\text{p}=0.004)\) [Table 3 ]. Table 3 Routine perinatal and basic EmONC service availability index by health facility characteristics Health facility characteristics 2014 2016 2018 2020 Adjusted trend p for trend All health facilities providing birthing services 69.8 73.1 74.9 74.9 0.825 < 0.001 Healthcare level Primary 68.7 72.2 72.5 74.3 0.761 < 0.001 Secondary 91.9 87.9 86.1 85.2 -0.603 0.099 Tertiary 93.1 93.0 88.8 89.8 -0.579 0.454 Health facility type Public 69.7 73.4 75.7 75.1 0.676 < 0.001 Private 71.2 68.1 70.9 72.5 -0.039 0.924 Residence Urban 76.3 79.4 81.7 79.4 -0.474 0.042 Rural 68.5 71.9 72.3 73.8 0.725 < 0.001 Health regions Boucle du Mouhoun 65.3 72.3 81.7 79.3 2.142 < 0.001 Cascades 66.5 73.4 71.8 75.8 1.149 0.005 Centre 72.8 75.5 75.3 74.4 -0.177 0.596 Centre Est 76.3 69.6 76.5 75.1 0.025 0.942 Centre-Nord 74.2 74.1 75.7 75.8 0.139 0.627 Centre-Ouest 65.0 67.9 69.0 72.6 1.073 < 0.001 Centre Sud 72.5 67.9 69.2 71.3 0.277 0.457 Est 70.0 78.6 84.1 80.0 1.138 < 0.001 Haut-Bassins 65.2 69.7 76.6 73.5 1.090 < 0.001 Nord 71.9 79.2 77.9 75.4 0.171 0.512 Plateau central 65.4 63.1 67.9 70.2 1.021 0.002 Sahel 78.0 89.2 88.6 89.9 1.568 < 0.001 Sud Ouest 71.5 71.4 65.0 70.8 -0.146 0.682 Basic EmONC availability index increased from 69.8% in 2014 to 74.9% in 2020 ( \(\:\beta\:=0.825;p<0.001)\) . After adjustment for facility characteristics, there was a statistically significant increment of basic EmONC availability index in primary facilities ( \(\:68.7\%\:to\:74.3\%;p<0.001)\) , however, secondary and tertiary facilities showed a general declining trend, but neither was statistically significant [Table 3 ]. For public facilities, there was a slight statistically significant improvement in basic EmONC availability index, initially increasing from 69.7% in 2014 to 75.7% in 2018 but subsequently reduced to 75.1% by 2020 ( \(\:\beta\:=0.676;p<0.001)\) . For health facilities in urban settings, the basic EmONC availability index initially increased from 76.3% in 2014 to 81.7% in 2018 but then reduced to 79.4% in 2020 in an overall decreasing trend that was statistically significant ( \(\:\beta\:=-0.474;p<0.042)\) [Table 3 ]. There was a general trend of improvement in basic EmONC across almost all regions, including seven which showed statistically significant increments, including Boucle du Mouhoun ( \(\:\beta\:=2.142;p<0.001)\) , Cascades ( \(\:\beta\:=1.149;p=0.005)\) , Centre-Ouest ( \(\:\beta\:=1.073;p<0.001)\) , Est ( \(\:\beta\:=1.138;p<0.001)\) , Haut-Bassins ( \(\:\beta\:=1.090;p<0.001)\) , Plateau central ( \(\:\beta\:=1.021;p<0.001)\) and Sahel ( \(\:\beta\:=1.568;p<0.001)\) . The one exception was in Centre, but this trend was not statistically significant [Table 3 ]. Service readiness of routine perinatal and basic EmONC services, tracers, and domain Among health facilities that provide birthing services, there was a declining trend in overall readiness, but this was non-significant. Staff and guidelines reduced from 72.1% in 2014 to 52.0% in 2020 ( \(\:\beta\:=-3.214;p<0.001)\) . Medicines and products reduced from 55.4% in 2014 to 53.0% in 2018 before increasing to 64.0% by 2020 ( \(\:\beta\:=1.743;p<0.001)\) . Equipment remained largely unchanged over the period [Table 4 ]. Reviewing specific tracer indicators for each domain, three of the four indicators for staff and guidelines, 10 of 17 indicators for equipment, and two of seven indicators for medicine and product showed a significant downward trend [ Additional file 2 ]. Table 4 Overall readiness score and readiness score for routine perinatal and basic EmONC services Domain 2014 2016 2018 2020 Adjusted trend p for trend Staff and guideline 72.1 62.4 53.7 52.0 -3.214 < 0.001 Equipment 67.7 65.8 69.3 67.5 -0.073 0.397 Medicine and products 55.4 53.3 53.0 64.0 1.743 < 0.001 Overall score 65.1 62.0 62.8 64.3 -0.068 0.432 The adjusted trend showed statistically significant reduction in readiness index over time in secondary ( \(\:\beta\:=-1.004;p=0.005)\) and tertiary ( \(\:\beta\:=-1.709;p<0.001)\) health facilities while primary health facilities showed a non-significant increment over time. The adjusted trend also showed that the readiness index significantly decreased in private facilities ( \(\:\beta\:=-1.076;p=0.004)\) but no significant change was observed in public facilities. Further, a statistically significant decline was observed in health facilities located in urban areas ( \(\:\beta\:=-0.716;p=0.001)\) . Analysis by health region shows a statistically significant increase in Boucle du Mouhoun ( \(\:\beta\:=1.012;p<0.001)\) and Cascades ( \(\:\beta\:=1.029;p=0.005)\) and a converse statistically significant decrease in Centre ( \(\:\beta\:=-0.615;p=0.045)\) and Centre Nord ( \(\:\beta\:=-0.947;p=0.003)\) [Table 5 ]. Centre Nord and Sahel consistently had some of the highest service readiness across the survey years [Figure 1 ]. Table 5 Readiness for routine perinatal and basic EmONC by healthcare facilities characteristics Health facility characteristics Service readiness scores over the survey years 2014 2016 2018 2020 Adjusted slope p All health facilities 65.1 62.0 62.8 64.3 -0.068 0.432 Healthcare level Primary 64.3 61.4 60.2 63.8 0.062 0.487 Secondary 80.7 72.1 73.7 71.2 -1.004 0.005 Tertiary 87.1 79.2 84.2 74.7 -1.709 0.040 Health facility type Public 65.1 62.0 62.3 64.6 0.036 0.676 Private 65.6 62.0 65.2 60.9 -1.076 0.004 Residence Urban 69.2 64.2 69.5 64.9 -0.716 0.001 Rural 64.3 61.6 60.3 64.1 0.114 0.223 Health regions Boucle du Mouhoun 62.5 64.0 66.2 68.6 1.012 < 0.001 Cascades 60.5 56.3 59.4 64.5 1.029 0.005 Centre 61.9 59.4 64.3 59.8 -0.615 0.045 Centre Est 63.4 59.2 60.2 62.0 -0.094 0.751 Centre-Nord 74.1 65.6 69.7 66.6 -0.947 0.003 Centre-Ouest 64.9 61.1 63.5 64.8 0.072 0.790 Centre Sud 63.0 59.1 53.2 60.7 -0.022 0.948 Est 64.2 62.0 66.8 64.4 -0.054 0.874 Haut-Bassins 62.5 61.1 60.4 60.6 -0.421 0.134 Nord 68.4 68.1 62.3 68.0 -0.072 0.749 Plateau central 66.1 53.6 57.6 62.9 0.115 0.710 Sahel 70.8 71.6 68.7 72.3 0.114 0.738 Sud Ouest 64.2 67.2 59.5 64.3 -0.182 0.564 Availability of comprehensive EmONC services by year Overall, availability of caesarean section and blood transfusion in secondary and tertiary health facilities has not significantly changed over time. In 2014, 84.1% of secondary and tertiary health facilities offered caesarean sections reducing slightly to 83.2% by 2020. For blood transfusion, 89.0% of these facilities offered the service in 2014 reducing to 77.4% in 2018 and increasing to 82.3% by 2020. Availability index for comprehensive EmONC decreased from 82.9% in 2014 to 75.7% in 2018, then increased to 79.6% by 2020, depicting an overall non-statistically significant decreasing trend ( \(\:\beta\:=-0.009;p=0.310)\) . After adjustment for facility characteristics, there was a statistically significant increment in comprehensive EmONC availability index in public facilities ( \(\:\beta\:=0.012;p=0.048)\) and those located in Boucle du Mouhoun ( \(\:71.4\%\:to\:87.5\%;p=0.049)\) , while facilities in most of the health regions mostly showed a general declining or increasing trend, which was not statistically significant [Table 6 ]. Table 6 Availability index of comprehensive EmONC by healthcare facilities characteristics Health facility characteristics Availability index scores over the survey years 2014 2016 2018 2020 slope p All secondary and tertiary facilities 82.9 81.5 75.7 79.6 -0.009 0.310 Healthcare level Secondary 80.0 77.0 70.8 77.5 -0.009 0.429 Tertiary 94.1 100.0 94.6 87.5 -0.012 0.267 Health facility type Public 89.7 88.9 97.9 93.3 0.012 0.048 Private 66.7 68.4 50.5 64.2 -0.014 0.447 Residence Urban 84.7 86.4 75.1 80.6 -0.015 0.127 Rural 70.0 45.4 83.6 60.0 0.027 0.449 Health regions Boucle du Mouhoun 71.4 100.0 100.0 87.5 0.032 0.049 Cascades 50.0 30.9 61.8 33.3 0.007 0.916 Centre 81.0 84.1 59.2 75.0 -0.029 0.157 Centre Est 71.4 73.9 86.9 77.8 0.018 0.555 Centre-Nord 100.0 100.0 100.0 100.0 - - Centre-Ouest 83.3 55.3 82.5 100.0 0.044 0.166 Centre Sud 100.0 75.0 100.0 80.0 -0.007 0.742 Est 100.0 100.0 100.0 83.3 -0.021 0.112 Haut-Bassins 77.8 83.5 81.8 81.3 -0.002 0.935 Nord 100.0 100.0 100.0 100.0 - - Plateau central 75.0 70.8 57.4 60.0 -0.033 0.508 Sahel 80.0 100.0 82.8 80.0 -0.007 0.842 Sud Ouest 100.0 100.0 100.0 71.4 -0.046 0.091 Service readiness of comprehensive EmONC services by year There was an overall significant reduction in readiness score for comprehensive EmONC across the years, with scores reducing from 62.5% in 2014 to 46.5% in 2020 ( \(\:\beta\:=-1.981;p<0.001)\) . Staff and guidelines reduced from 75.6% in 2014 to 52.6% in 2018 before increasing to 59.5% by 2020 ( \(\:\beta\:=-1.961;p=0.008)\) . Diagnosis reduced from 62.8% in 2014 to 47.3% in 2020 ( \(\:\beta\:=-2.643;p=0.001)\) . Medicines and products reduced from 62.5% in 2014 to 24.4% in 2020 ( \(\:\beta\:=-1.981;p<0.001)\) [Table 7 ]. Reviewing specific tracer indicators for each domain, one of the three indicators for staff and guidelines, two of five indicators for equipment, both indicators for diagnosis, and five of nine indicators for medicine and product showed significant downward trends [ Additional file 2 ]. Table 7 Overall readiness score and readiness score for comprehensive EmONC Domain 2014 2016 2018 2020 Adjusted trend p for trend Staff and guideline 75.6 61.4 52.6 59.5 -1.961 0.008 Equipment 44.4 35.8 43.5 35.0 -0.978 0.089 Diagnosis 62.8 66.3 56.7 47.3 -2.643 0.001 Medicine and products 66.7 52.4 53.5 46.8 -2.399 < 0.001 Overall readiness score 62.5 51.4 51.2 46.5 -1.981 < 0.001 The adjusted trend showed statistically significant reduction in comprehensive EmONC readiness index over time across all facilities expected to provide the service ( \(\:\beta\:=-1.981;p<0.001)\) . Specifically, adjusted trend showed that the readiness index significantly decreased in secondary ( \(\:\beta\:=-1.927;p=0.001)\) and tertiary ( \(\:\beta\:=-2.112;p=0.007)\) health facilities over time. The adjusted trend also showed that the readiness index significantly decreased in public ( \(\:\beta\:=-1.715;p<0.001)\) and private ( \(\:\beta\:=-2.316;p=0.031)\) facilities. Further, a statistically significant decline was observed in health facilities located in urban areas ( \(\:\beta\:=-1.939;p<0.001)\) . Analysis by health region shows a statistically significant reduction in Centre ( \(\:\beta\:=-3.336;p=0.005)\) , Centre Est ( \(\:\beta\:=-2.155;p=0.046)\) , Centre Nord ( \(\:\beta\:=-4.536;p=0.026)\) and Centre Sud ( \(\:\beta\:=-3.041;p=0.003)\) [Table 8 ]. Plateau Central had one of the lowest service readiness indices across the survey years [Figure 2 ]. Table 8 Readiness of comprehensive EmONC by healthcare facilities characteristics Health facility characteristics Service readiness scores over the survey years 2014 2016 2018 2020 Adjusted slope p All health facilities 62.5 51.4 51.2 46.5 -1.981 < 0.001 Healthcare level Secondary 58.8 48.1 45.9 42.6 -1.927 0.001 Tertiary 76.8 65.1 71.5 60.8 -2.112 0.007 Health facility type Public 67.2 54.1 62.7 54.3 -1.715 < 0.001 Private 51.3 46.8 38.2 37.5 -2.316 0.031 Residence Urban 63.9 54.3 51.6 47.3 -1.939 < 0.001 Rural 52.5 30.0 44.7 28.0 -2.116 0.292 Health regions Boucle du Mouhoun 52.1 53.3 64.5 56.9 2.044 0.218 Cascades 77.5 35.9 40.4 55.0 -0.208 0.939 Centre 63.1 60.1 44.9 44.5 -3.336 0.005 Centre Est 60.7 37.7 50.1 43.3 -2.155 0.046 Centre-Nord 77.5 66.3 68.6 47.5 -4.536 0.026 Centre-Ouest 60.8 40.3 55.3 62.5 0.461 0.761 Centre Sud 70.0 58.8 57.2 43.0 -3.041 0.003 Est 68.0 51.0 66.6 47.5 -0.900 0.461 Haut-Bassins 60.6 50.5 57.3 41.3 -1.884 0.240 Nord 67.5 59.0 58.6 58.0 -1.494 0.103 Plateau central 46.3 35.4 34.2 35.0 -1.335 0.440 Sahel 57.0 53.8 56.5 52.0 1.158 0.319 Sud Ouest 68.8 63.3 61.2 34.3 -3.018 0.058 DISCUSSION We conducted a trend analysis of the availability and readiness of health facilities to provide childbirth and EmONC services in Burkina Faso between 2014 and 2020. Our results showed a statistically significant reduction in availability of birthing services, despite the increasing number of CSPS in Burkina Faso during the period reviewed, increasing from 1760 in year 2014 to 2041 in 2020, according to the Annuaire Statistique [ 40 ]. Almost all basic EmONC services, excluding AVD, showed statistically significant slightly increasing trends in availability. For newborn signal functions, though generally low, all included services, showed statistically significant increasing trends in availability. For perinatal services, there were slight statistically significant reductions in administration of oxytocin for PPH prevention, monitoring and management of labor using, hygienic cord care, and drying and wrapping the newborn and immediate skin to skin contact. The trends in availability of routine perinatal and basic EmONC services that we observed mostly mirror findings from the previous study in Ilboudo et al. which ended their analysis with data from the 2018 SARA survey [ 24 ]. However, with our study extending beyond 2018, we were able to observe declining, incremental, and stabilizing trends in availability which are reflective of events between 2018 and 2020. After adjustment, though routine perinatal and basic EmONC availability index significantly increased over the survey years in primary facilities, there were non-significant declining trends in secondary and tertiary facilities. In addition, increasing trends were observed in public facilities and in six of 13 regions but decline in urban facilities. The generally increasing trends in service availability observed especially in primary facilities and those in conflict-affected regions such as Boucle du Mouhoun and Sahel have been reported during most of the same period (2014 to 2018) for other maternal health services in Burkina Faso including ante-natal care [ 41 ]. It is possible that some of these observed temporal improvements might be linked to the government and donor-funded interventions such as the Strengthening Access to Primary Health Care Integrating Sexual and Reproductive Health Initiative which focused on strengthening health systems in regions most affected by humanitarian crisis [ 16 ]. One of the key deliverables of the initiative was training of over 350 health workers to provide care to women and adolescents [ 16 ]. Considering that routine perinatal and basic EmONC availability had significantly reduced from 2010 to 2014 [ 42 ], it is notable that efforts to improve services have made a difference, though parenteral administration of anticonvulsants, manual removal of retained products, neonatal resuscitation, and corticosteroids in preterm labour were only available in less than half of the surveyed facilities. One surprising finding was from our study the massive drop in AVD from 96.1% in 2018 to 57.8% in 2020. The high figures from 2014 up to 2018 had been reported in the study by Ilboudo et al. [ 24 ], however, these do not seem to tally with earlier trends from the country or across similar African countries. AVD is well-established as being the least-available EmONC signal function in many low- and middle-income countries [ 43 ]. As such, it appears the estimated high proportions for AVD has more to do with the ascribed operational definition of AVD in Burkina Faso during the years of the SARA survey as opposed to a real problem with service availability. For comprehensive EmONC availability, after adjustment, this was about 80% for both caesarean section and blood transfusion across all years. This estimate is not so dissimilar from that reported for the country in 2012 prior to our survey years [ 44 ]. In that same study, Burkina Faso was ranked as having one of the least number of facilities per 100,000 population for caesarean section and blood transfusion, with a rate of 0.3 [ 44 ]. In our study, there was a slightly significant increasing trend in public facilities and those in Boucle du Mouhoun after adjustments. This might have more to do with the decentralization of health service delivery. including for comprehensive EmONC, across the country [ 45 ]. The increase in comprehensive EmONC availability within the public sector is a notable finding, as services are usually less costly to use in public facilities compared to private ones [ 46 ], and women in similar settings have tended to associate technical capacity for comprehensive EmONC with public facilities [ 47 – 49 ]. This means if the service is available in the public sector, they will most likely seek care there. On the other hand, there was an overall non-significant decline in facility readiness for basic and a significant decline for comprehensive EmONC from 2014 to 2020. This is similar to the overall trend reported in an earlier study showing trends until 2018 [ 24 ]. Within the public sector where the vast investments in health system strengthening have been made, only a marginal improvement in readiness, which was not statistically significant, was observed. For basic EmONC, there was a notable slight increment by 2020, which appears to be primarily driven by the medicine and products domain. This suggests that any improvements observed relate to actions or interventions between 2018 and 2020. At a time when the country was faced with conflict and the COVID-19 pandemic, both of which have been reported to have disrupted services globally [ 20 , 25 , 50 ], it appears these had minimal negative impact, if at all any, on readiness for childbirth and basic EmONC services. Indeed, a study by Maïga et al. reported that the pandemic did not cause major service disruptions in routine perinatal and basic EmONC services in Burkina Faso [ 51 ]. We postulate that support from programmes being implemented at the time shielded any negative effect on service readiness. For example, across four regions of Boucle du Mouhoun, Centre-North, North, and Sahel, seven health centers and 24 laboratories were equipped with essential medicines, medical-technical materials, and laboratory supplies [ 16 ]. Another project, the Health Services Strengthening Project which started in 2018 [ 15 ], might explain some the improvements in readiness for basic EmONC that we observed in our study, since we found that their target interventions and sites showed improvements. Contrarily, urban poles in the country like the Centre region, and, secondary and tertiary as well as private facilities, which are expected to have high readiness for providing EmONC generally [ 10 , 52 ], were the ones driving the decline we observed in our study, after adjusting for facility characteristics. This might be because these facilities were not the focus of the 2018 health system strengthening intervention [ 15 , 53 ]. In any case, despite the investment, readiness for basic EmONC was consistently higher among secondary and tertiary facilities than in primary facilities in our study. Researchers have reported a similar pattern in the Democratic Republic of Congo and Tanzania [ 54 , 55 ]. For readiness for comprehensive EmONC service provision, our analysis showed a significant and sustained decline on overall readiness reducing from 62.5% in 2014 to 46.5% in 2020 ( \(\:p<0.001)\) , based on the equal-weighted approach. It appears the trends are heading to a pre-2010 period when less a third of hospitals in Burkina Faso were assessed to be able to continuously provide caesarean and blood transfusion [ 23 ]. Assessing the domains, the decline was more so notable for staff and guidelines, medicine and products, and diagnosis. Unlike basic EmONC services, comprehensive EmONC services including caesarean and blood transfusion do not seem to have been avoided disruptions caused by the pandemic. As was widely reported at the time, the COVID-19 pandemic exposed weaknesses of health systems [ 21 ] and in Burkina Faso, there was a reduction in caesarean section coverage [ 51 ]. Regarding study strengths, we used the two largest datasets that are representative of the country. In doing this, we were also able to use the most recent available dataset, the HHFA, to ensure recency of our analysis. Second, our analysis considered sampling weights for the 2014 to 2018 SARA surveys, allowing comparability of our estimates from the SARA and HHFA surveys. Third, we included tracer elements that had not been considered in previous analysis, including adult bag and mask, thermometer, and Betamethasone or dexamethasone injectable [ 24 ], thereby ensuring that the full range of readiness elements are incorporated in our analysis. Fourth, we prioritized accurate and complete definition of outcome measures in line with WHO guidance and alignment between SARA and HHFA surveys used for our analysis in terms of tracer elements included [ 37 , 38 ]. However, there are limitations to bear in mind in interpreting our results. First, we used secondary data from a cross-sectional survey conducted at health facilities in Burkina Faso for which we were not responsible for its quality or completeness. Irrespective, the standardised SARA approach, which was also used to collect the data in Burkina Faso [ 37 ], would have limited the risk of poor-quality data being collected, though it does not preclude issues with imprecise service definition such as was the case with the definition used for AVD in Burkina Faso before 2020. In any case, the dataset has been used for several similar analyses in Burkina Faso [ 23 , 24 , 36 , 56 , 57 ]. Second, we could not use the 2012 data because some maternal health indicators were not included in the SARA survey that year [ 37 ]. The previously published study by Ilboudo et al. could also not report 2012 data [ 24 ]. Third, the survey questionnaire was completed by the head of health facilities or their appointed representative. This might cause a desirability bias, especially for availability indicators. Fourth, we could not accurately assess the trend in KMC availability as the question to establish its status was posed differently across both surveys; from a supply side lens (asking if service was “offered”) in SARA and a demand side lens (asking if service was “used”) in HHFA, with the latter also requiring verification from KMC units [ 37 , 38 ]. This might have led to some heads of health facilities interpreting the question differently across both surveys. When KMC availability was assessed previously, it was assessed as increasing from 58.6% in 2014 to 71.9% in 2018 [ 24 ]. Despite these limitations, our results point to some key implications for policy. First, despite the decreasing trend in proportion of health facilities offering birthing services, efforts to enhance the availability and readiness of health facilities to manage pregnant women including those with obstetric emergencies have had a more significant impact on routine perinatal and basic EmONC service provision. Indeed, these initiatives, which have been implemented since 2018, targeted improvements in facility readiness at the primary level[ 15 , 16 , 53 ] and it appears they have either stabilised or improved readiness for routine perinatal and basic EmONC services. This development will facilitate the early detection of obstetric emergencies, especially in the context of the user fee exemption policy, Gratuité, being implemented in the country since 2016, which has led to increased service utilisation, even in conflict-affected parts of the country [ 58 , 59 ]. However, the stagnation in availability, which pre-dates our study needs to be addressed. To optimise location of facilities, government need to consider access to care, as evidence shows that journeys of over 30 minutes increased odds of maternal deaths [ 60 ]. Also, the non-significant increase in readiness across the public sector and the decline in readiness for comprehensive EmONC are concerning. The public sector is the more widely sought for care while comprehensive EmONC facilities are designated to handle the most complex cases, which often lead to poor pregnancy outcomes including maternal and perinatal mortality. Furthermore, within the existing facilities, several components for comprehensive EmONC still require improvement, including lifesaving oxygen, anaesthesia equipment, specific anaesthesia medications and diagnostic resources. There are also notable gaps in the proportion of trained staff for comprehensive EmONC. Going forward, it is essential to develop a targeted capacity development programme to strengthen the ability of skilled health personnel to manage complicated obstetric emergencies in referral health facilities. The programme should also include provision of practical management guidelines. Direct investment in service readiness of EmONC is one of the main approaches to reducing maternal mortality and though cost of its provision could be high [ 61 , 62 ], several strategies for cost savings and ensuring value for money have been highlighted in the literature including task shifting of comprehensive EmONC services like caesarean to lower cadre health personnel [ 63 , 64 ], building capacity using local consultants [ 65 , 66 ], and adaptation of generic global guidance on provision of low-cost effective EmONC interventions [ 67 ]. Future research should consider understanding the ‘why’ underpinning the observed trends. This might be better served by qualitative research conducted in purposively selected health facilities across the country. Future analysis should be used to continue monitoring trends in routine perinatal and EmONC service availability and readiness, and impact of interventions. CONCLUSION This is an update of the trend in availability and readiness of routine perinatal and EmONC services in Burkina Faso, within a dynamic context marked by plurality of health system strengthening efforts and health system disruptions including institutional instability, insecurity and the COVID-19 pandemic. Our results show that, despite the difficult context, there has been an improvement in availability and readiness for routine perinatal and basic EmONC services, mostly attributable to targeted health system strengthening efforts starting from 2018 that focused on the primary level of care, rural areas, and in many of the most conflict-affected regions of the country. However, with the observed declining trend in availability and readiness for comprehensive EmONC in referral health facilities, the government must prioritize strengthening the operational capacity of health facilities to match its efforts to provide fee-exempt EmONC to all women through the Gratuité program. Government intervention must focus on ensuring the availability of medicines, diagnostic resources, and qualified staff to deal with complicated obstetric emergencies. This will ensure that the hard gains in maternal mortality and stillbirth reductions that have been reported in Burkina Faso are not reversed. Declarations Ethics and consent to participate We obtained ethical approval from the Burkina Faso Ethics Committee for Research in Health (Comité d’Ethique pour la Recherche en Santé - CERS) under protocol 2024-01-02. As our study utilises only aggregated secondary data, informed consent to participate was not applicable. Consent for publication Since our study uses aggregated secondary data, in which individual information is not identifiable, informed consent for publication was not required. Competing Interest declaration The authors declare that they have no competing interests. Author contributions AB-T and M-JO conceptualized the study. All authors contributed to the study design. Material preparation, data collection and analysis were performed by M-JO, KC and AB-T. The first draft of the manuscript was written by KC and AB-T. All authors, including DS, AG and AH reviewed the manuscript, contributed to the drafting of the final manuscript and agreed for it to be submitted for publication. Funding statements The authors received no external funding for this article's research, authorship, and/or publication. Data availability The data supporting this study's conclusions are accessible via the Ministry of Health of Burkina Faso. However, restrictions apply to the availability of these data, which are accessed by the authors for the current study, rendering them unavailable to the public. The data are accessible upon request and with the authorisation of the Ministry of Health of Burkina Faso. References Comfort H, McHugh TA, Schumacher AE, Harris A, May EA, Paulson KR, et al. Global, regional, and national stillbirths at 20 weeks’ gestation or longer in 204 countries and territories, 1990–2021: findings from the Global Burden of Disease Study 2021. The Lancet. 2024;404(10466):1955–88. WHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. Trends in maternal mortality 2000 to 2023: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]. New York; 2025. Available from: https://data.unicef.org/wp-content/uploads/2025/04/Trends-in-maternal-mortality-2020-2023.pdf IGME, UNICEF, WHO, World Bank Group, United Nations. Standing up for stillbirth: Current estimates and key interventions - Report of the United Nations Inter-agency Group for Child Mortality Estimation 2024 [Internet]. New York; 2025. Available from: https://childmortality.org/wp-content/uploads/2025/03/UNIGME-Stillbirth-Report-2024.pdf WHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva, Switzerland: World Health Organization; 2023. 1–108 p. World Health Organization. Health data overview for Burkina Faso [Internet]. Data. 2024 [cited 2024 Oct 19]. Available from: https://data.who.int/countries/854 United Nations. Sustainable Development Goals: 17 goals to transform our world [Internet]. Sustainable Development Goals. 2016 [cited 2020 Oct 12]. Available from: http://www.un.org/sustainabledevelopment/sustainable-development-goals/ WHO, UNFPA, UNICEF, Averting Maternal Deaths and Disabilities. Monitoring emergency obstetric care: a handbook. Geneva, Switzerland: WHO Press; 2009. Paxton A, Maine D, Freedman L. The evidence for emergency obstetric care. International journal of gynaecology and obstetrics. 2005;88:181–93. Gabrysch S, Civitelli G, Edmond KM, Mathai M, Ali M, Bhutta ZA, et al. New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Care. 2012;9(11). Banke-Thomas A, Wright K, Sonoiki O, Banke-Thomas O, Ajayi B, Ilozumba O, et al. Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines. Glob Health Action. 2016;9:31880. van den Hoed MW, Backhaus R, de Vries E, Hamers JPH, Daniëls R. Factors contributing to innovation readiness in health care organizations: a scoping review. BMC Health Serv Res [Internet]. 2022 [cited 2024 Oct 21];22:997. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08185-x Mohammadpour M, Zarifinezhad E, Ghanbarzadegan A, Naderimanesh K, Shaarbafchizadeh N, Bastani P. Main Factors Affecting the Readiness and Responsiveness of Healthcare Systems during Epidemic Crises: A Scoping Review on Cases of SARS, MERS, and COVID-19. Iran J Med Sci [Internet]. 2021 [cited 2024 Oct 21];46(2):81. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7966936/ Seppey M, Ridde V, Somé PA. Scaling-Up Performance-Based Financing in Burkina Faso: From PBF to User Fees Exemption Strategic Purchasing. Int J Health Policy Manag [Internet]. 2020 May 1 [cited 2024 Oct 21];11(5):670. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9309920/ Boxshall M, Kiendrébéogo JA, Kafando Y, Tapsoba C, Straubinger S, Metangmo PM. An Overview of the User Fee Exemption Policy (Gratuité) in Burkina Faso [Internet]. Ouagadougou; 2020 [cited 2024 Jan 24]. p. 1–69. Available from: https://thinkwell.global/wp-content/uploads/2020/09/Gratuite-in-Burkina-Faso_18-September-2020.pdf Sanou AC. Projet de renforcement des services de santé (PRSS) : Le comité de pilotage dresse le bilan [Internet]. Actualité. 2024 [cited 2025 Jun 10]. Available from: https://burkina24.com/2024/01/18/projet-de-renforcement-des-services-de-sante-prss-le-comite-de-pilotage-dresse-le-bilan/#:~:text=Il convient de rappeler que,’épidémie de COVID-19. Health Cluster. Strengthening healthcare for women and children in Burkina Faso [Internet]. News. 2025 [cited 2025 Jun 8]. Available from: https://healthcluster.who.int/newsroom/news/item/07-04-2025-strengthening-healthcare-for-women-and-children-in-burkina-faso Ridde V, Lechat L, Meda IB. Terrorist attack of 15 January 2016 in Ouagadougou: how resilient was Burkina Faso’s health system? BMJ Glob Health [Internet]. 2016 [cited 2024 Oct 25];1(1):e000056. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5321324/ ACAPS. Burkina Faso Conflict [Internet]. Countries. 2022 [cited 2022 Dec 12]. Available from: https://www.acaps.org/country/burkina-faso/crisis/conflict UNHCR. Burkina Faso [Internet]. Country Operations. 2024 [cited 2025 Jan 10]. Available from: https://reporting.unhcr.org/operational/operations/burkina-faso#:~:text=According to the Government%2C over,refugees%2C mostly of Malian origin. Semaan A, Banke-Thomas A, Amongin D, Babah O, Dioubate N, Kikula A, et al. ‘We are not going to shut down, because we cannot postpone pregnancy’: a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic. BMJ Glob Health [Internet]. 2022 Feb 1 [cited 2022 Feb 13];7(2):e008063. Available from: https://gh.bmj.com/content/7/2/e008063 Semaan A, Audet C, Huysmans E, Afolabi B, Assarag B, Banke-Thomas A, et al. Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic. BMJ Glob Health. 2020;5(6):e002967. Beňová L, Semaan A, Afolabi BB, Amongin D, Babah OA, Dioubate N, et al. Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania. BMJ Open. 2023;13:e076364. Compaoré GD, Sombié I, Ganaba R, Hounton S, Meda N, Brouwere V De, et al. Readiness of district and regional hospitals in Burkina Faso to provide caesarean section and blood transfusion services: a cross-sectional study. BMC Pregnancy Childbirth. 2014;14:158. Ilboudo D, Sombié I, Koffi AK, Asiki G, Yaméogo TM, Kirakoya-Samadoulougou F. Temporal trends analysis of emergency obstetric and newborn care availability and readiness index of healthcare facilities in Burkina Faso. BMC Health Serv Res [Internet]. 2024 Dec 1 [cited 2024 Dec 1];24:1295. Available from: https://link.springer.com/articles/10.1186/s12913-024-11818-y Makoni M. Burkina Faso crisis hits health care. The Lancet. 2022;399(10325):616. US Department of State. Country Reports on Terrorism 2020: Burkina Faso [Internet]. Country Reports on Terrorism 2020. 2020 [cited 2025 Mar 15]. Available from: https://www.state.gov/reports/country-reports-on-terrorism-2020/burkina-faso/#:~:text=Early 2020 saw a sharp,for any of the incidents. Africa Center for Strategic Studies. Sahel and Somalia Drive Rise in Africa’s Militant Islamist Group Violence [Internet]. Infographic. 2022 [cited 2025 Mar 15]. Available from: https://africacenter.org/spotlight/sahel-and-somalia-drive-uninterrupted-rise-in-african-militant-islamist-group-violence-over-past-decade/#:~:text=A review of violence involving,50-percent increase since 2019. Norwegian Refugee Council. Here are five crises you should know about in 2025 [Internet]. Perspectives. 2025 [cited 2025 Mar 16]. Available from: https://www.nrc.no/perspectives/2024/here-are-five-crises-you-should-know-about-in-2025#:~:text=Burkina Faso: 2 million people internally displaced&text=With 37 blockaded towns across,insecurity and lack of aid. Institut National de la Statistique et de la Démographie. Annuaire Statistique 2021 [Internet]. Ouagadougou; 2021 [cited 2024 Jan 29]. Available from: https://www.sante.gov.bf/fileadmin/annuaire_2021_mshp.pdf World Bank. GDP per capita (current US$) [Internet]. General Data Portal. 2022 [cited 2024 Oct 19]. Available from: https://genderdata.worldbank.org/en/indicator/ny-gdp-pcap-cd Institut National de la Statistique et de la Démographie. Annuaire Statistique 2022 [Internet]. Ouagadougou; 2022. Available from: https://www.insd.bf/sites/default/files/2023-12/Annuaire_statistique_national_2022.pdf INSD, ICF. Enquête Démographique et de Santé 2021 [Internet]. Ouagadougou, Burkina Faso and Rockville, Maryland; 2023 [cited 2024 Jan 30]. p. 1–815. Available from: https://dhsprogram.com/pubs/pdf/FR378/FR378.pdf Cissé K, Samadoulougou S, Kaboré J, Somda P, Zongo A, Traoré S, et al. Healthcare system’s preparedness to provide cardiovascular and diabetes-specific care in the context of geopolitical crises in Burkina Faso: a trend analysis from 2012 to 2018. BMJ Open [Internet]. 2023 May 23 [cited 2024 Oct 21];13(5):e065912. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10230877/ Millogo O, Doamba JEO, Sié A, Utzinger J, Vounatsou P. Constructing a malaria-related health service readiness index and assessing its association with child malaria mortality: an analysis of the Burkina Faso 2014 SARA data. BMC Public Health [Internet]. 2021 [cited 2024 Oct 21];21:20. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7784320/ Rouamba T, Samadoulougou S, Compaoré CS, Tinto H, Gaudart J, Kirakoya-Samadoulougou F. How to Estimate Optimal Malaria Readiness Indicators at Health-District Level: Findings from the Burkina Faso Service Availability and Readiness Assessment (SARA) Data. Int J Environ Res Public Health [Internet]. 2020 Jun 1 [cited 2024 Oct 21];17(11):3923. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7312483/ Fassinou LC, Hien H, Yombi JC, Nagot N, Kirakoya-Samadoulougou F. Availability and readiness of the health facilities to provide HIV counseling and testing and prevention of mother-to-child transmission services in Burkina Faso: a trend analysis from 2012 to 2018. BMC Health Serv Res [Internet]. 2023 [cited 2024 Oct 21];23:757. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10347843/ World Health Organization. Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery [Internet]. Version 2. Geneva: World Health Organization; 2015. 1–55 p. Available from: https://cdn.who.int/media/docs/default-source/service-availability-and-readinessassessment(sara)/sara_reference_manual_chapter3.pdf World Health Organization. Harmonized Health Facility Assessment (HHFA): Combined questionnaire [Internet]. Geneva; 2021. Available from: https://cdn.who.int/media/docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07.pdf?sfvrsn=698754fa_17&download=true Stierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health [Internet]. 2021 Oct 5 [cited 2025 Jun 8];6(10):e006698. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8493923/ Institut National de la Statistique et de la Démographie. Annuaire Statistique 2020 [Internet]. Ouagadougou; 2020. Available from: https://www.sante.gov.bf/fileadmin/user_upload/storages/annuaire_statistique_ms_2020_signe.pdf Offosse MJ, Cissé K, Somda D, Gage A, Haakenstad A, Banke-Thomas A. Availability and readiness of health facilities in Burkina Faso to provide antenatal care: trend analysis from 2012 to 2020. Reproductive Health 2025 22:1. 2025;22:133. Kouanda S, Ouédraogo AM, Ouédraogo GH, Sanon D, Belemviré S, Ouédraogo L. Emergency obstetric and neonatal care needs assessment: Results of the 2010 and 2014 surveys in Burkina Faso. International Journal of Gynecology & Obstetrics. 2016;135(S1):S11–5. Bailey P, van Roosmalen J, Mola G, Evans C, de Bernis L, Dao B. Assisted vaginal delivery in low and middle income countries: an overview. BJOG. 2017;124(9):1335–44. Spiegel DA, Droti B, Relan P, Hobson S, Cherian MN, O’Neill K. Retrospective review of Surgical Availability and Readiness in 8 African countries. BMJ Open [Internet]. 2017 Mar 1 [cited 2025 Jun 9];7(3):e014496. Available from: https://bmjopen.bmj.com/content/7/3/e014496 Zon H, Pavlova M, Groot W. Regional health disparities in Burkina Faso during the period of health care decentralization. Results of a macro-level analysis. Int J Health Plann Manage. 2020;35(4):939–59. Banke-Thomas A, Ayomoh FI, Abejirinde IOO, Banke-Thomas O, Eboreime EA, Ameh CA. Cost of Utilising Maternal Health Services in Low- and Middle-Income Countries: A Systematic Review. Int J Health Policy Manag. 2021;10(9):564–77. Wright K, Banke-Thomas A, Sonoiki O, Ajayi B, Ilozumba O, Akinola O. Opinion of women on emergency obstetric care provided in public facilities in Lagos, Nigeria: A qualitative study. Health Care Women Int. 2017;38(6):527–43. Banke-Thomas A, Wright K, Sonoiki O, Ilozumba O, Ajayi B, Okikiolu O, et al. Multi-stakeholder perspectives on access, availability and utilization of emergency obstetric care services in Lagos, Nigeria: A mixed-methods study. J Public Health Afr. 2017;8(2):717. Gwacham-Anisiobi U, Banke-Thomas A. Experiences of Health Facility Childbirth in Sub-Saharan Africa: A Systematic Review of Qualitative Evidence. Matern Child Health J. 2022;26(3):481–92. Balogun M, Banke-Thomas A, Gwacham-Anisiobi U, Yesufu V, Ubani O, Afolabi BB. Actions and Adaptations Implemented for Maternal, Newborn and Child Health Service Provision During the Early Phase of the COVID-19 Pandemic in Lagos, Nigeria: Qualitative Study of Health Facility Leaders. Ann Glob Health. 2022;88(1):13. Maïga A, Bougma M, Wilson E, Kaboré TS, Tou GG, Munos MK, et al. Effects of the COVID-19 pandemic on maternal, newborn, and child health service coverage in Burkina Faso. J Glob Health [Internet]. 2024 Dec 20 [cited 2025 Jun 8];14:05037. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11658717/ Wong KL, Banke-Thomas A, Sholkamy H, Dennis ML, Pembe AB, Birabwa C, et al. A tale of 22 cities: utilisation patterns and content of maternal care in large African cities. BMJ Glob Health. 2022;7(3):e007803. Lefaso. Burkina/ Projets de renforcement des services de santé et de riposte au Covid-19 : Les acteurs passent en revue la mise en œuvre des activités sur le terrain. Société [Internet]. 2023 Nov 21 [cited 2025 Jun 9]; Available from: https://lefaso.net/spip.php?article125906 Ntambue AM, Malonga FK, Cowgill KD, Dramaix-Wilmet M, Donnen P. Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011. BMC Pregnancy Childbirth [Internet]. 2017 Jan 19 [cited 2025 Jun 9];17:40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5244553/ Bintabara D, Ernest A, Mpondo B. Health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a Tanzania National Survey. BMJ Open [Internet]. 2019 Feb 9 [cited 2019 Feb 10];9(2):bmjopen-2017-020608. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2017-020608 Offosse MJ, Cissé K, Somda D, Gage A, Haakenstad A, Banke-Thomas A. Availability and Readiness of Health Facilities in Burkina Faso to Provide Antenatal Care: Trend Analysis from 2012 to 2020. Reprod Health. 2025;In Press. Onadja Y, Compaoré R, Yugbaré DB, Thomas HL, Guiella G, Lougué S, et al. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res [Internet]. 2024 Dec 1 [cited 2024 Dec 26];24:84. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-10538-z Banke-Thomas A, Offosse MJ, Yameogo P, Manli AR, Goumbri A, Avoka C, et al. Stakeholder perceptions and experiences from the implementation of the Gratuité user fee exemption policy in Burkina Faso: a qualitative study. Health Res Policy Syst. 2023;21:46. Offosse MJ, Avoka C, Yameogo P, Manli AR, Goumbri A, Eboreime E, et al. Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis. Confl Health. 2023;17:33. Banke-Thomas A, Avoka CK on, Gwacham-Anisiobi U, Omololu O, Balogun M, Wright K, et al. Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study. BMJ Glob Health. 2022 Apr 1;7(4):e008604. Souza JP, Day LT, Rezende-Gomes AC, Zhang J, Mori R, Baguiya A, et al. A global analysis of the determinants of maternal health and transitions in maternal mortality. Lancet Glob Health [Internet]. 2024 Feb 1 [cited 2024 Oct 21];12(2):e306–16. Available from: http://www.thelancet.com/article/S2214109X23004680/fulltext Banke-Thomas A, Abejirinde IOO, Ayomoh FI, Banke-Thomas O, Eboreime EA, Ameh CA. The cost of maternal health services in low-income and middle-income countries from a provider’s perspective: a systematic review. BMJ Glob Health. 2020;5(6):e002371. Schneeberger C, Mathai M. Emergency obstetric care: Making the impossible possible through task shifting. International Journal of Gynecology & Obstetrics [Internet]. 2015 Oct 1 [cited 2017 Oct 20];131(Suppl 1):S6–9. Available from: http://www.sciencedirect.com/science/article/pii/S0020729215000831?via%3Dihub Seidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. Hum Resour Health. 2017;15(1):29. Banke-Thomas A, Madaj B, van den Broek N. Social return on investment of emergency obstetric care training in Kenya. BMJ Glob Health. 2019;4(1):e001167. Banke-Thomas A, Wilson-Jones M, Madaj B, van den Broek N. Economic evaluation of emergency obstetric care training: a systematic review. BMC Pregnancy Childbirth. 2017;17:403. Otolorin E, Gomez P, Currie S, Thapa K, Dao B. Essential basic and emergency obstetric and newborn care: From education and training to service delivery and quality of care. International Journal of Gynecology & Obstetrics. 2015;130(Supplement 2):S46–53. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":151810,"visible":true,"origin":"","legend":"\u003cp\u003eReadiness for routine perinatal and basic EmONC by health region and year\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463045/v1/8fd85bb399405ebcdb92d4bf.jpg"},{"id":93015027,"identity":"cd60b8d0-fb90-4885-86ce-6678fa739ee5","added_by":"auto","created_at":"2025-10-08 07:51:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152423,"visible":true,"origin":"","legend":"\u003cp\u003eReadiness for comprehensive EmONC by health region and year\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463045/v1/fd0a9e192ab6f86c149cc78d.jpg"},{"id":93018566,"identity":"764d0153-93a0-4418-8df2-f6257b9994de","added_by":"auto","created_at":"2025-10-08 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class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately 70% of the estimated maternal deaths occurred in sub-Saharan Africa (SSA), with Burkina Faso, a landlocked country in the region, being reported to have had an estimated 1,800 maternal deaths and over ໿14,000 stillbirths in 2023 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Maternal mortality ratio (MMR) in Burkina Faso has improved from 524 to 334 deaths per 100,000 live births between 2000 and 2020 and by 2023, a further drop to 242 deaths per 100,000 live births was reported [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Stillbirth rate declined from 34\u0026middot;2 to 23.8 per 1,000 births between 2000 and 2020, further reducing to 18.9 by 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite these declining trends in MMR and stillbirth rate, maternal and perinatal mortality remain major public health challenges in the country, as both constitute some of its leading causes of death [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, the strategy to reduce deaths related to pregnancy and childbirth, re-emphasised by the Sustainable Development Goals (SDGs), has predominantly focused on increasing access to prompt emergency obstetric and newborn care (EmONC), provided by skilled health personnel [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Evidence from research indicates that prompt access to EmONC can prevent up to 50% of maternal deaths and 45\u0026ndash;75% of stillbirths occurring after the onset of labour but before birth [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Within the healthcare system, EmONC is provided at two levels of care: basic and comprehensive. Facilities that provide care at the basic level are expected to be able to perform seven interventions otherwise referred to as \u0026lsquo;signal functions\u0026rsquo;: administer injectable antibiotics, oxytocics, anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery (AVD), and basic neonatal resuscitation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There has been recognition that there are other key interventions needed for routine and emergency newborn care, in addition to the basic neonatal resuscitation in the WHO framework. This includes interventions such as thermal protection for newborns, hygienic cord care, kangaroo mother care (KMC), immediate and exclusive breastfeeding, corticosteroids for treating preterm babies, and injectable antibiotics for neonatal sepsis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Facilities at the comprehensive level are expected to provide blood transfusion and caesarean section in addition to all seven basic interventions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These services are all in addition to routine perinatal services needed by pregnant women who have not developed an emergency.\u003c/p\u003e\u003cp\u003eA robust health system is the bedrock for availability and operational readiness of health facilities to be able to provide routine perinatal and EmONC services to pregnant women who need them. As per global guidance, routine perinatal and basic EmONC interventions in Burkina Faso are expected to be performed at all health facilities including those at the primary level and form a critical component of the referral system which ensures that pregnant women with less complex emergency needs can be managed at that level without overburdening the higher-level facilities such as hospitals [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. On the other hand, hospitals which are typically comprehensive EmONC facilities are extremely important for complex care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, new policies, changes in management and leadership, fluctuation in health financing, conflict, and several other factors can affect service availability and readiness across levels of care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOver the past decade, there have been several events in Burkina Faso that may have influenced EmONC service availability and readiness positively or negatively. For example, in 2014, the Burkinab\u0026eacute; government implemented a performance-based financing scheme in six of the 13 administrative regions in the country (Boucle du Mouhoun, Centre Est, Centre Nord, Centre Ouest, Nord, and Sud Ouest) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In 2016, a national policy known locally as Gratuit\u0026eacute; exempted user fees for maternity care and permitted health facilities to use funds generated through reimbursements to invest in service improvement in order to increase access and improve quality of care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Other schemes, such as the Health Services Strengthening Programme 2018\u0026ndash;2024 and the Strengthening Access to Primary Health Care Integrating Sexual and Reproductive Health Initiative which started in 2020, focused on improving quality of maternal, newborn, and child health services, including EmONC [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. On the contrary, the popular insurrection in Burkina Faso in 2014 and terrorist attack in the capital, Ouagadougou that occurred in January 2016 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], could have negatively affecting availability and readiness. Also, the country has had an active conflict since 2016 across the Boucle du Mouhoun, Centre-Nord, Est, Nord, and Sahel regions, with over two million people said to be internally displaced as of July 2024 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. More recently, there was the 2019 Coronavirus Disease (COVID-19) pandemic, which disrupted service provision globally [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere is minimal research assessing availability and health facility readiness of routine perinatal and EmONC services in Burkina Faso. A previously published study assessed readiness of hospitals in Burkina Faso to provide blood transfusion and caesarean section using data from a facility survey conducted in 2007 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. More recently, another study assessed availability and readiness of EmONC in Burkina Faso from 2014 to 2018 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, since 2018, Burkina Faso has been faced with numerous terrorist attacks predominantly in 2019 and 2020 which not only forced several Burkinab\u0026egrave; to flee their places of residence, but it also massively crippled the health system [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As per available reports, majority of violent attacks that occurred in the Sahel area of West Africa between July 2019 to June 2020 were in Burkina Faso (516 versus 361 in Mali and 118 in Niger) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Evidence capturing the wider timelines will be crucial to capture the impact of the conflict on health service provision and provide a comprehensive understanding of EmONC availability and readiness in the country, especially as the crisis continues to affect the health system [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The objective of this study was to analyze the trends in availability and health facility readiness to provide routine perinatal and EmONC services in Burkina Faso between 2014 and 2020.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eThis study is a trend analysis of repeated cross-sectional surveys conducted between 2014 and 2020. It incorporates data from all 13 health regions of Burkina Faso, which had an estimated population in 2021 of 22\u0026nbsp;million, with women accounting for over half of this number [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The gross domestic product (GDP) per capita of Burkina Faso is US\u003cspan\u003e$\u003c/span\u003e857, lower than the average in SSA of US\u003cspan\u003e$\u003c/span\u003e1,501 and US\u003cspan\u003e$\u003c/span\u003e10,918 globally [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. As of 2018, an estimated 41% of the population lives below the national poverty line of US\u003cspan\u003e$\u003c/span\u003e1.90 daily [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Burkina Faso, the national health system is managed centrally by the Ministry of Health which sets out major strategic orientations and policies for health. At the regional level, there are 13 regional directorates which oversee implementation and coordination of health policies and provide support to the lowest administrative level, health districts. In all, there are 70 health districts, responsible for operational planning and implementing health policy directives. While the healthcare system in the country is administratively and geographically organized in three levels: district, regional, and national, service provision is structured across three levels of care: primary, secondary, and tertiary. Primary level care which includes routine perinatal and basic EmONC services is expected to be available at health centres locally known as the Health and Social Promotion Centre (CSPS) and medical centres, both at the district level. Secondary level care which includes routine perinatal and basic and comprehensive EmONC services should be available district hospitals, also referred to as medical centres with surgical units (CMA) and regional hospitals, both of which serve as referral hospitals for the primary level facilities. The tertiary level includes national and university teaching hospitals, which are expected to offer the most advanced health care including routine perinatal and basic and comprehensive EmONC services. Health facilities are spread across the public and private sectors though most births take place in public facilities. As of 2022, there were just over 3,700 health facilities [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Based on the 2021 Demographic and Health Survey, health facility delivery rates remain sub-optimal nationally with regional variations ranging from 43.9% in the Sahel region, where significant conflict is ongoing, to 98.2% in Cascades region [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDescription of data source\u003c/h3\u003e\n\u003cp\u003eWe used the Service Availability and Readiness Assessment (SARA) surveys and the Harmonized Health Facility Assessment (HHFA) survey for this analysis. SARA is a health facility-based survey used to assess availability (i.e. physical presence of services and the necessary resources to deliver them within a health facility) and readiness (operational capacity) of health facilities to provide health services based on the presence or absence of \u0026lsquo;tracer items\u0026rsquo; needed for providing services including trained staff, guidelines, equipment, laboratory services, and medicine and supplies. The survey, which was developed by the World Health Organization (WHO) has been conducted in many low- and middle-income countries, including Burkina Faso. Specifically in Burkina Faso, the SARA survey, which has been used in published readiness assessment studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], four rounds of the survey were conducted biannually between 2012 and 2018. The survey sampled public and private health facilities and was conducted across all three levels of the Burkinab\u0026egrave; healthcare system. All health facilities expected to provide secondary and tertiary levels of care in the country were included, while a random sample of health facilities expected to provide primary level care were included. The standard tool for the SARA survey as designed by the WHO was used for data collection in Burkina Faso [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], with the tool administered by trained data collectors to health facility leads or their designated alternatives who themselves were health personnel. Insights gathered from the interviewer-administered surveys were combined with direct observation to establish the availability and readiness of services. For this study, we used only the latest three rounds of the SARA survey (2014, 2016, and 2018) and excluded 2012 because some maternal health indicators were not included in the SARA survey that year [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe HHFA, also designed by the WHO, includes all the SARA indicators on service availability and readiness along with other indicators on quality and safety of care, management, and finance [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, there are some distinctions between both surveys. For example, in SARA, any manoeuvre done during childbirth to reposition babies was counted as \u0026lsquo;assisted delivery\u0026rsquo; in Burkina Faso and as such part of AVD availability, but the more precise definition involving use of forceps or ventouse was applied in HHFA [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The question on KMC availability queried if the service was \u0026ldquo;offered\u0026rdquo; in SARA compared to if it was \u0026ldquo;used\u0026rdquo; in HHFA, which also advised verification from a KMC unit, if this was available [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. HHFA was conducted as a census of all 2,758 health facilities operational in the year 2020. The Ministry of Health in collaboration with the Research Institute of Health Sciences led data collection which was conducted across all 13 regions from November 2020 to January 2021. After an initial pilot survey to validate the tool, which was adapted to the context, health workers were deployed to lead data collection. The HHFA tool was administered using a face-to-face interview with the heads of health facilities or their designated alternatives.\u003c/p\u003e\n\u003ch3\u003eStudy variables\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eOutcome variables\u003c/h2\u003e\u003cp\u003eThe two outcome variables of interest in this study were the availability and readiness of EmONC services. In the survey, availability and readiness of basic and comprehensive EmONC services are reported separately. Service availability refers to \u003cem\u003e\u0026ldquo;the physical presence of the delivery of services, encompassing health infrastructure, core health personnel, and service utilization\u0026rdquo;\u003c/em\u003e [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This outcome focuses on whether a health facility offers a specific service. For routine perinatal and basic EmONC services, there are three domains (obstetric signal functions, newborn signal functions, and perinatal routine practices) with 16 tracer elements. For comprehensive EmONC, there is one domain with the two signal functions (blood transfusion and caesarean section). Service readiness is \u0026ldquo;\u003cem\u003ethe availability of components required to provide services\u0026rdquo;\u003c/em\u003e. It assesses the operational capacity of a health facility to provide a specific service [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. For service readiness, there are 27 indicators spread across three domains relating to staff and guidelines, equipment, and medicine and supplies for basic EmONC and 23 indicators across four domains relating to staff and guidelines, equipment, diagnostics, and medicine and supplies for comprehensive EmONC [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. For both availability and readiness outcomes, each constituent indicator was defined as a binary variable, coded as \u0026lsquo;1\u0026rsquo; if the indicator was confirmed as available in the health facility and \u0026lsquo;0\u0026rsquo; if not. For our analysis, we selected only tracer elements that were common to SARA and HHFA, with three of 68 indicators reported in HHFA but not in SARA, excluded from our analysis. In addition, for indicators available in both surveys, we checked for alignment between their definition and the questions asked to elicit their availability and readiness status across both surveys. In instances of misalignment, for example, KMC availability, this was excluded from our analysis [\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAdditional file 1\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIndependent variables\u003c/h3\u003e\n\u003cp\u003eThe independent variables in this study were health facility location (urban or rural), level of health care (primary, secondary or tertiary), ownership (public or private), and health regions (Boucle du Mouhoun, Cascades, Centre, Centre Est, Centre-Nord, Centre-Ouest, Centre Sud, Est, Haut-Bassins, Nord, Plateau Central, Sahel, and Sud-Ouest).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe analytical approach prescribed by the WHO for analysis of the SARA data was used for this study [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. For the descriptive analysis, the number of health facilities surveyed per year was estimated and summarised by health facility characteristics (healthcare level, facility ownership, rural or urban location, and region).\u003c/p\u003e\u003cp\u003eAll component tracer items for basic (henceforth combined with routine perinatal) and comprehensive EmONC service availability were assessed and availability index estimated based on the availability of each EmONC signal function amongst facilities offering birthing services for basic EmONC and secondary and tertiary facilities for comprehensive EmONC. Availability index was calculated using the equal weight approach, which consisted of an aggregate sum of all available items divided by the total number of expected items. This score was then expressed as a percentage by multiplying the score by 100, representing the proportion of elements available.\u003c/p\u003e\u003cp\u003eSubsequently, the readiness index for the health facilities where required services were available at basic and comprehensive levels was calculated. For this, readiness score for each component tracer item was evaluated using the defined indicators for the respective three readiness domains for basic EmONC and four for comprehensive EmONC. Readiness score was expressed in percentage and interpreted as the percentage of tracer elements available for basic and comprehensive EmONC services on the date of the survey. The equal weight approach was used to calculate readiness index with \u003cem\u003en\u003c/em\u003e being the number of tracer elements available in a health facility and N the total number of tracers for the given domain [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The domain score was calculated using the formula: n/N*100. For a domain with seven items (like medicine and supplies), the domain score was equal to n/7*100. Overall readiness index was calculated as the mean of all items in the domains and presented by health facility characteristics [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This index expressed the percentage of necessary items for offering essential high quality EmONC available at the health facilities. The shortage of these items denotes the inability of health facilities to provide quality services.\u003c/p\u003e\u003cp\u003eTemporal trend of availability and readiness score for both basic and comprehensive EmONC by domain and tracer elements was presented in tables and maps were used to highlight regional differences. Sampling weights were used for the 2014 to 2018 SARA surveys. The crude trend of availability of basic and comprehensive EmONC services was estimated using the Chi-square test for trend and measured the adjusted trend of the readiness index using weighted multivariate linear regression. The model was adjusted with the independent variables. The slope and \u003cem\u003ep\u003c/em\u003e-value of the trend was assessed with 0.05 taken as the level of statistical significance. Multicollinearity between healthcare facility characteristics was checked before each regression analysis.\u003c/p\u003e\u003cp\u003eAnalysis was done using STATA 18.0 (StataCorp, College Station, Texas, US), while availability and readiness indices were mapped using QGIS (QGIS Development Team, London, UK).\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics of the healthcare facilities surveyed by year\u003c/h2\u003e\u003cp\u003eThe number of healthcare facilities surveyed was 766 in 2014, 677 in 2016, and 794 in 2018 and 2728 in 2020. Most included facilities operated at the primary level, ranging from 82.2% (2018) to 93.7% (2020) of health facilities surveyed. Similarly, between 68.6% (2018) and 79.5% (2014) of health facilities were publicly owned, and 57.2% (2018) to 66.8% (2020) of health facilities were in rural areas. Most surveyed facilities (18.7% in 2014 and 21.0% in 2016) were situated in Centre region, followed by Haut-Bassins (11.2% in 2016 and 11.9% in 2020) [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the surveyed healthcare facilities\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facilities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll health facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e766 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e677 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e794 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2728 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e659 (86.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e567 (83.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e653 (82.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2 557 (93.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e89 (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93 (13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e119 (15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e144 (5.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27 (1.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOwnership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e609 (79.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e504 (74.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e545 (68.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2 102 (77.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e157 (20.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e173 (25.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e249 (31.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e626 (22.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e265 (34.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e256 (37.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e340 (42.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e905 (33.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003erural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e501 (65.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e421 (62.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e454 (57.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1 823 (66.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoucle du Mouhoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75 (9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e54 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e254 (9.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCascades\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30 (3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e130 (4.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e143 (18.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e142 (21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e145 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e432 (15.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Est\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e218 (8.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Nord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e168 (6.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69 (9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e277 (10.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Sud\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41 (5.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e147 (5.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e133 (4.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaut-Bassins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84 (11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76 (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89 (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e324 (11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e227 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlateau central\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44 (5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e191 (7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSahel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44 (5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e69 (2.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSud Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e46 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e158 (5.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAvailability of basic EmONC services\u003c/h2\u003e\u003cp\u003eThe proportion of health facilities offering birthing services was 88.1% in 2014 reducing to 78.4% by 2020 in a statistically significant decreasing trend (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.020;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. For obstetric signal functions, AVD reduced from 99.8% in 2014 to 57.8% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.066;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e while all other obstetric signal functions showed statistically significant increasing trends, including, manual removal of placenta which increased from 80.6% in 2014 to 85.8% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.055;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, manual removal of retained products from 16.9% in 2014 to 47.2% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.010;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, parenteral administration of anticonvulsants from 21.9% in 2014 to 48.8% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.045;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, parenteral administration of antibiotics from 88.7% in 2014 to 92.1% in 2020, after a decline in 2018 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.023;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, and parenteral administration of oxytocic from 90.2% in 2014 to 94.6% in 2020, after an initial decline in 2016 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.077;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePercentage of availability of tracer indicators for basic EmONC and routine perinatal services\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain and tracer elements\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eslope\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilities offering birthing services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e88.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e86.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e78.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstetric signal functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParenteral administration of antibiotics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e88.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e91.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e92.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParenteral administration of oxytocic drug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e90.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e94.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParenteral administration of anticonvulsants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e48.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssisted vaginal delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e96.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e57.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManual removal of placenta\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManual removal of retained products\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e39.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNewborn signal function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal resuscitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e45.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAntibiotics for preterm or prolonged premature rupture of membranes to prevent infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorticosteroids in preterm labour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInjectable antibiotics for neonatal sepsis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e87.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRoutine perinatal services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdministration of oxytocin for the prevention of postpartum haemorrhage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e98.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e97.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e94.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonitoring and management of labour using partograph\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e96.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e96.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e93.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e95.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate and exclusive breastfeeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e99.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e99.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.120\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHygienic cord care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e99.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e98.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e94.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrying and wrapping the newborn and immediate skin to skin contact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e99.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e98.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e99.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e98.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor newborn signal functions, though generally low showed statistically significant increasing trends in availability. For example, neonatal resuscitation increased from 33.2% in 2014 to 45.4% in 2020 after a decline in 2018 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.025;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, antibiotics for preterm or prolonged premature rupture of membranes increased from 66.3% in 2014 to 85.6% in 2020 after a decline in 2016 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.024;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, corticosteroids in preterm labour increased from 16.0% in 2014 to 21.1% in 2020 after a slight decline in 2018 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.008;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, and injectable antibiotics for neonatal sepsis from 46.9% in 2014 to 87.8% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.065;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThough all routine perinatal services were \u0026gt;\u0026thinsp;94% available across years, there were slight statistically significant reductions in administration of oxytocin for postpartum haemorrhage (PPH) prevention (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.007;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, monitoring and management of labour using partograph (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.003;\\text{p}\u0026lt;0.005)\\)\u003c/span\u003e\u003c/span\u003e, hygienic cord care (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.009;\\text{p}\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, and drying and wrapping the newborn and immediate skin to skin contact (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.002;\\text{p}=0.004)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRoutine perinatal and basic EmONC service availability index by health facility characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted trend\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e for trend\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll health facilities providing birthing services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e72.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e91.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e85.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.099\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e93.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e89.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.579\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.454\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e70.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.924\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e81.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e79.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.474\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e72.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e73.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.725\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoucle du Mouhoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e81.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e79.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCascades\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e71.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Est\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e76.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.942\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Nord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.627\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Sud\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e71.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.457\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaut-Bassins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e76.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e73.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.090\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.512\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlateau central\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e67.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e70.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSahel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e78.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e89.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSud Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e65.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e70.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.682\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBasic EmONC availability index increased from 69.8% in 2014 to 74.9% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.825;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. After adjustment for facility characteristics, there was a statistically significant increment of basic EmONC availability index in primary facilities (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:68.7\\%\\:to\\:74.3\\%;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, however, secondary and tertiary facilities showed a general declining trend, but neither was statistically significant [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]. For public facilities, there was a slight statistically significant improvement in basic EmONC availability index, initially increasing from 69.7% in 2014 to 75.7% in 2018 but subsequently reduced to 75.1% by 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.676;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. For health facilities in urban settings, the basic EmONC availability index initially increased from 76.3% in 2014 to 81.7% in 2018 but then reduced to 79.4% in 2020 in an overall decreasing trend that was statistically significant (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.474;p\u0026lt;0.042)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere was a general trend of improvement in basic EmONC across almost all regions, including seven which showed statistically significant increments, including Boucle du Mouhoun (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=2.142;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, Cascades (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.149;p=0.005)\\)\u003c/span\u003e\u003c/span\u003e, Centre-Ouest (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.073;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, Est (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.138;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, Haut-Bassins (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.090;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, Plateau central (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.021;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e and Sahel (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.568;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. The one exception was in Centre, but this trend was not statistically significant [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eService readiness of routine perinatal and basic EmONC services, tracers, and domain\u003c/h2\u003e\u003cp\u003eAmong health facilities that provide birthing services, there was a declining trend in overall readiness, but this was non-significant. Staff and guidelines reduced from 72.1% in 2014 to 52.0% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-3.214;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. Medicines and products reduced from 55.4% in 2014 to 53.0% in 2018 before increasing to 64.0% by 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.743;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. Equipment remained largely unchanged over the period [Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]. Reviewing specific tracer indicators for each domain, three of the four indicators for staff and guidelines, 10 of 17 indicators for equipment, and two of seven indicators for medicine and product showed a significant downward trend [\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAdditional file 2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverall readiness score and readiness score for routine perinatal and basic EmONC services\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted trend\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e for trend\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaff and guideline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e52.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-3.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEquipment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e67.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.397\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicine and products\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.743\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.432\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe adjusted trend showed statistically significant reduction in readiness index over time in secondary (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.004;p=0.005)\\)\u003c/span\u003e\u003c/span\u003e and tertiary (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.709;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e health facilities while primary health facilities showed a non-significant increment over time. The adjusted trend also showed that the readiness index significantly decreased in private facilities (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.076;p=0.004)\\)\u003c/span\u003e\u003c/span\u003e but no significant change was observed in public facilities. Further, a statistically significant decline was observed in health facilities located in urban areas (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.716;p=0.001)\\)\u003c/span\u003e\u003c/span\u003e. Analysis by health region shows a statistically significant increase in Boucle du Mouhoun (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.012;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e and Cascades (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=1.029;p=0.005)\\)\u003c/span\u003e\u003c/span\u003e and a converse statistically significant decrease in Centre (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.615;p=0.045)\\)\u003c/span\u003e\u003c/span\u003e and Centre Nord (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.947;p=0.003)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e]. Centre Nord and Sahel consistently had some of the highest service readiness across the survey years [Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReadiness for routine perinatal and basic EmONC by healthcare facilities characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eService readiness scores over the survey years\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted slope\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll health facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.432\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e63.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.487\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e71.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e74.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.040\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.676\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e65.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e65.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.716\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.223\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoucle du Mouhoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCascades\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e59.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Est\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.751\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Nord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e66.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.947\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e63.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.790\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Sud\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.948\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.874\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaut-Bassins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e60.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.134\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e68.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.749\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlateau central\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e62.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.710\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSahel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e68.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e72.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.738\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSud Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.564\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAvailability of comprehensive EmONC services by year\u003c/h2\u003e\u003cp\u003eOverall, availability of caesarean section and blood transfusion in secondary and tertiary health facilities has not significantly changed over time. In 2014, 84.1% of secondary and tertiary health facilities offered caesarean sections reducing slightly to 83.2% by 2020. For blood transfusion, 89.0% of these facilities offered the service in 2014 reducing to 77.4% in 2018 and increasing to 82.3% by 2020.\u003c/p\u003e\u003cp\u003eAvailability index for comprehensive EmONC decreased from 82.9% in 2014 to 75.7% in 2018, then increased to 79.6% by 2020, depicting an overall non-statistically significant decreasing trend (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.009;p=0.310)\\)\u003c/span\u003e\u003c/span\u003e. After adjustment for facility characteristics, there was a statistically significant increment in comprehensive EmONC availability index in public facilities (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.012;p=0.048)\\)\u003c/span\u003e\u003c/span\u003e and those located in Boucle du Mouhoun (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:71.4\\%\\:to\\:87.5\\%;p=0.049)\\)\u003c/span\u003e\u003c/span\u003e, while facilities in most of the health regions mostly showed a general declining or increasing trend, which was not statistically significant [Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAvailability index of comprehensive EmONC by healthcare facilities characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eAvailability index scores over the survey years\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eslope\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll secondary and tertiary facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e79.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.310\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e70.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e77.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.429\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e94.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e94.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.267\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e89.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e88.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e97.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e93.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e50.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.447\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e86.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e80.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e83.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.449\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoucle du Mouhoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.049\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCascades\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.916\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e59.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Est\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e73.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e77.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.555\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Nord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre-Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.166\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Sud\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.742\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaut-Bassins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e83.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e81.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e81.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.935\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlateau central\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.508\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSahel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e80.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSud Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.046\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eService readiness of comprehensive EmONC services by year\u003c/h2\u003e\u003cp\u003eThere was an overall significant reduction in readiness score for comprehensive EmONC across the years, with scores reducing from 62.5% in 2014 to 46.5% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.981;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. Staff and guidelines reduced from 75.6% in 2014 to 52.6% in 2018 before increasing to 59.5% by 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.961;p=0.008)\\)\u003c/span\u003e\u003c/span\u003e. Diagnosis reduced from 62.8% in 2014 to 47.3% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-2.643;p=0.001)\\)\u003c/span\u003e\u003c/span\u003e. Medicines and products reduced from 62.5% in 2014 to 24.4% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.981;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e]. Reviewing specific tracer indicators for each domain, one of the three indicators for staff and guidelines, two of five indicators for equipment, both indicators for diagnosis, and five of nine indicators for medicine and product showed significant downward trends [\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAdditional file 2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverall readiness score and readiness score for comprehensive EmONC\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted trend\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e for trend\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaff and guideline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e59.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.961\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEquipment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.978\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.089\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.643\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedicine and products\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.399\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall readiness score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.981\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe adjusted trend showed statistically significant reduction in comprehensive EmONC readiness index over time across all facilities expected to provide the service (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.981;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. Specifically, adjusted trend showed that the readiness index significantly decreased in secondary (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.927;p=0.001)\\)\u003c/span\u003e\u003c/span\u003e and tertiary (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-2.112;p=0.007)\\)\u003c/span\u003e\u003c/span\u003e health facilities over time. The adjusted trend also showed that the readiness index significantly decreased in public (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.715;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e and private (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-2.316;p=0.031)\\)\u003c/span\u003e\u003c/span\u003e facilities. Further, a statistically significant decline was observed in health facilities located in urban areas (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.939;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. Analysis by health region shows a statistically significant reduction in Centre (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-3.336;p=0.005)\\)\u003c/span\u003e\u003c/span\u003e, Centre Est (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-2.155;p=0.046)\\)\u003c/span\u003e\u003c/span\u003e, Centre Nord (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-4.536;p=0.026)\\)\u003c/span\u003e\u003c/span\u003e and Centre Sud (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-3.041;p=0.003)\\)\u003c/span\u003e\u003c/span\u003e [Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e]. Plateau Central had one of the lowest service readiness indices across the survey years [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReadiness of comprehensive EmONC by healthcare facilities characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eService readiness scores over the survey years\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdjusted slope\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAll health facilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e46.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.981\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e58.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e42.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e71.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth facility type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePublic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e54.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.715\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e37.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.316\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.939\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.292\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoucle du Mouhoun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e56.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.218\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCascades\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e77.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e55.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.939\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" 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colname=\"c1\"\u003e\u003cp\u003eCentre-Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e55.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e62.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.461\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentre Sud\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e43.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-3.041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.461\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaut-Bassins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e57.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e41.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.240\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNord\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e58.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.494\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlateau central\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-1.335\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.440\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSahel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e57.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e52.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSud Ouest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e34.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-3.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe conducted a trend analysis of the availability and readiness of health facilities to provide childbirth and EmONC services in Burkina Faso between 2014 and 2020. Our results showed a statistically significant reduction in availability of birthing services, despite the increasing number of CSPS in Burkina Faso during the period reviewed, increasing from 1760 in year 2014 to 2041 in 2020, according to the Annuaire Statistique [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Almost all basic EmONC services, excluding AVD, showed statistically significant slightly increasing trends in availability. For newborn signal functions, though generally low, all included services, showed statistically significant increasing trends in availability. For perinatal services, there were slight statistically significant reductions in administration of oxytocin for PPH prevention, monitoring and management of labor using, hygienic cord care, and drying and wrapping the newborn and immediate skin to skin contact. The trends in availability of routine perinatal and basic EmONC services that we observed mostly mirror findings from the previous study in Ilboudo et al. which ended their analysis with data from the 2018 SARA survey [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, with our study extending beyond 2018, we were able to observe declining, incremental, and stabilizing trends in availability which are reflective of events between 2018 and 2020.\u003c/p\u003e\u003cp\u003eAfter adjustment, though routine perinatal and basic EmONC availability index significantly increased over the survey years in primary facilities, there were non-significant declining trends in secondary and tertiary facilities. In addition, increasing trends were observed in public facilities and in six of 13 regions but decline in urban facilities. The generally increasing trends in service availability observed especially in primary facilities and those in conflict-affected regions such as Boucle du Mouhoun and Sahel have been reported during most of the same period (2014 to 2018) for other maternal health services in Burkina Faso including ante-natal care [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. It is possible that some of these observed temporal improvements might be linked to the government and donor-funded interventions such as the Strengthening Access to Primary Health Care Integrating Sexual and Reproductive Health Initiative which focused on strengthening health systems in regions most affected by humanitarian crisis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. One of the key deliverables of the initiative was training of over 350 health workers to provide care to women and adolescents [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Considering that routine perinatal and basic EmONC availability had significantly reduced from 2010 to 2014 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], it is notable that efforts to improve services have made a difference, though parenteral administration of anticonvulsants, manual removal of retained products, neonatal resuscitation, and corticosteroids in preterm labour were only available in less than half of the surveyed facilities. One surprising finding was from our study the massive drop in AVD from 96.1% in 2018 to 57.8% in 2020. The high figures from 2014 up to 2018 had been reported in the study by Ilboudo et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], however, these do not seem to tally with earlier trends from the country or across similar African countries. AVD is well-established as being the least-available EmONC signal function in many low- and middle-income countries [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. As such, it appears the estimated high proportions for AVD has more to do with the ascribed operational definition of AVD in Burkina Faso during the years of the SARA survey as opposed to a real problem with service availability.\u003c/p\u003e\u003cp\u003eFor comprehensive EmONC availability, after adjustment, this was about 80% for both caesarean section and blood transfusion across all years. This estimate is not so dissimilar from that reported for the country in 2012 prior to our survey years [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In that same study, Burkina Faso was ranked as having one of the least number of facilities per 100,000 population for caesarean section and blood transfusion, with a rate of 0.3 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In our study, there was a slightly significant increasing trend in public facilities and those in Boucle du Mouhoun after adjustments. This might have more to do with the decentralization of health service delivery. including for comprehensive EmONC, across the country [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The increase in comprehensive EmONC availability within the public sector is a notable finding, as services are usually less costly to use in public facilities compared to private ones [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and women in similar settings have tended to associate technical capacity for comprehensive EmONC with public facilities [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This means if the service is available in the public sector, they will most likely seek care there.\u003c/p\u003e\u003cp\u003eOn the other hand, there was an overall non-significant decline in facility readiness for basic and a significant decline for comprehensive EmONC from 2014 to 2020. This is similar to the overall trend reported in an earlier study showing trends until 2018 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Within the public sector where the vast investments in health system strengthening have been made, only a marginal improvement in readiness, which was not statistically significant, was observed. For basic EmONC, there was a notable slight increment by 2020, which appears to be primarily driven by the medicine and products domain. This suggests that any improvements observed relate to actions or interventions between 2018 and 2020. At a time when the country was faced with conflict and the COVID-19 pandemic, both of which have been reported to have disrupted services globally [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], it appears these had minimal negative impact, if at all any, on readiness for childbirth and basic EmONC services. Indeed, a study by Ma\u0026iuml;ga et al. reported that the pandemic did not cause major service disruptions in routine perinatal and basic EmONC services in Burkina Faso [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. We postulate that support from programmes being implemented at the time shielded any negative effect on service readiness. For example, across four regions of Boucle du Mouhoun, Centre-North, North, and Sahel, seven health centers and 24 laboratories were equipped with essential medicines, medical-technical materials, and laboratory supplies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Another project, the Health Services Strengthening Project which started in 2018 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], might explain some the improvements in readiness for basic EmONC that we observed in our study, since we found that their target interventions and sites showed improvements. Contrarily, urban poles in the country like the Centre region, and, secondary and tertiary as well as private facilities, which are expected to have high readiness for providing EmONC generally [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], were the ones driving the decline we observed in our study, after adjusting for facility characteristics. This might be because these facilities were not the focus of the 2018 health system strengthening intervention [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In any case, despite the investment, readiness for basic EmONC was consistently higher among secondary and tertiary facilities than in primary facilities in our study. Researchers have reported a similar pattern in the Democratic Republic of Congo and Tanzania [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor readiness for comprehensive EmONC service provision, our analysis showed a significant and sustained decline on overall readiness reducing from 62.5% in 2014 to 46.5% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, based on the equal-weighted approach. It appears the trends are heading to a pre-2010 period when less a third of hospitals in Burkina Faso were assessed to be able to continuously provide caesarean and blood transfusion [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Assessing the domains, the decline was more so notable for staff and guidelines, medicine and products, and diagnosis. Unlike basic EmONC services, comprehensive EmONC services including caesarean and blood transfusion do not seem to have been avoided disruptions caused by the pandemic. As was widely reported at the time, the COVID-19 pandemic exposed weaknesses of health systems [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and in Burkina Faso, there was a reduction in caesarean section coverage [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding study strengths, we used the two largest datasets that are representative of the country. In doing this, we were also able to use the most recent available dataset, the HHFA, to ensure recency of our analysis. Second, our analysis considered sampling weights for the 2014 to 2018 SARA surveys, allowing comparability of our estimates from the SARA and HHFA surveys. Third, we included tracer elements that had not been considered in previous analysis, including adult bag and mask, thermometer, and Betamethasone or dexamethasone injectable [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], thereby ensuring that the full range of readiness elements are incorporated in our analysis. Fourth, we prioritized accurate and complete definition of outcome measures in line with WHO guidance and alignment between SARA and HHFA surveys used for our analysis in terms of tracer elements included [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, there are limitations to bear in mind in interpreting our results. First, we used secondary data from a cross-sectional survey conducted at health facilities in Burkina Faso for which we were not responsible for its quality or completeness. Irrespective, the standardised SARA approach, which was also used to collect the data in Burkina Faso [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], would have limited the risk of poor-quality data being collected, though it does not preclude issues with imprecise service definition such as was the case with the definition used for AVD in Burkina Faso before 2020. In any case, the dataset has been used for several similar analyses in Burkina Faso [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Second, we could not use the 2012 data because some maternal health indicators were not included in the SARA survey that year [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The previously published study by Ilboudo et al. could also not report 2012 data [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Third, the survey questionnaire was completed by the head of health facilities or their appointed representative. This might cause a desirability bias, especially for availability indicators. Fourth, we could not accurately assess the trend in KMC availability as the question to establish its status was posed differently across both surveys; from a supply side lens (asking if service was \u0026ldquo;offered\u0026rdquo;) in SARA and a demand side lens (asking if service was \u0026ldquo;used\u0026rdquo;) in HHFA, with the latter also requiring verification from KMC units [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This might have led to some heads of health facilities interpreting the question differently across both surveys. When KMC availability was assessed previously, it was assessed as increasing from 58.6% in 2014 to 71.9% in 2018 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these limitations, our results point to some key implications for policy. First, despite the decreasing trend in proportion of health facilities offering birthing services, efforts to enhance the availability and readiness of health facilities to manage pregnant women including those with obstetric emergencies have had a more significant impact on routine perinatal and basic EmONC service provision. Indeed, these initiatives, which have been implemented since 2018, targeted improvements in facility readiness at the primary level[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and it appears they have either stabilised or improved readiness for routine perinatal and basic EmONC services. This development will facilitate the early detection of obstetric emergencies, especially in the context of the user fee exemption policy, Gratuit\u0026eacute;, being implemented in the country since 2016, which has led to increased service utilisation, even in conflict-affected parts of the country [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. However, the stagnation in availability, which pre-dates our study needs to be addressed. To optimise location of facilities, government need to consider access to care, as evidence shows that journeys of over 30 minutes increased odds of maternal deaths [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Also, the non-significant increase in readiness across the public sector and the decline in readiness for comprehensive EmONC are concerning. The public sector is the more widely sought for care while comprehensive EmONC facilities are designated to handle the most complex cases, which often lead to poor pregnancy outcomes including maternal and perinatal mortality.\u003c/p\u003e\u003cp\u003eFurthermore, within the existing facilities, several components for comprehensive EmONC still require improvement, including lifesaving oxygen, anaesthesia equipment, specific anaesthesia medications and diagnostic resources. There are also notable gaps in the proportion of trained staff for comprehensive EmONC. Going forward, it is essential to develop a targeted capacity development programme to strengthen the ability of skilled health personnel to manage complicated obstetric emergencies in referral health facilities. The programme should also include provision of practical management guidelines. Direct investment in service readiness of EmONC is one of the main approaches to reducing maternal mortality and though cost of its provision could be high [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], several strategies for cost savings and ensuring value for money have been highlighted in the literature including task shifting of comprehensive EmONC services like caesarean to lower cadre health personnel [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], building capacity using local consultants [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], and adaptation of generic global guidance on provision of low-cost effective EmONC interventions [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFuture research should consider understanding the \u0026lsquo;why\u0026rsquo; underpinning the observed trends. This might be better served by qualitative research conducted in purposively selected health facilities across the country. Future analysis should be used to continue monitoring trends in routine perinatal and EmONC service availability and readiness, and impact of interventions.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis is an update of the trend in availability and readiness of routine perinatal and EmONC services in Burkina Faso, within a dynamic context marked by plurality of health system strengthening efforts and health system disruptions including institutional instability, insecurity and the COVID-19 pandemic. Our results show that, despite the difficult context, there has been an improvement in availability and readiness for routine perinatal and basic EmONC services, mostly attributable to targeted health system strengthening efforts starting from 2018 that focused on the primary level of care, rural areas, and in many of the most conflict-affected regions of the country. However, with the observed declining trend in availability and readiness for comprehensive EmONC in referral health facilities, the government must prioritize strengthening the operational capacity of health facilities to match its efforts to provide fee-exempt EmONC to all women through the Gratuit\u0026eacute; program. Government intervention must focus on ensuring the availability of medicines, diagnostic resources, and qualified staff to deal with complicated obstetric emergencies. This will ensure that the hard gains in maternal mortality and stillbirth reductions that have been reported in Burkina Faso are not reversed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained ethical approval from the Burkina Faso Ethics Committee for Research in Health (Comité d’Ethique pour la Recherche en Santé - CERS) under protocol 2024-01-02. As our study utilises only aggregated secondary data, informed consent to participate was not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince our study uses aggregated secondary data, in which individual information is not identifiable, informed consent for publication was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAB-T and M-JO conceptualized the study. All authors contributed to the study design. Material preparation, data collection and analysis were performed by M-JO, KC and AB-T. The first draft of the manuscript was written by KC and AB-T. All authors, including DS, AG and AH reviewed the manuscript, contributed to the drafting of the final manuscript and agreed for it to be submitted for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no external funding for this article's research, authorship, and/or publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study's conclusions are accessible via the Ministry of Health of Burkina Faso. However, restrictions apply to the availability of these data, which are accessed by the authors for the current study, rendering them unavailable to the public. The data are accessible upon request and with the authorisation of the Ministry of Health of Burkina Faso.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eComfort H, McHugh TA, Schumacher AE, Harris A, May EA, Paulson KR, et al. Global, regional, and national stillbirths at 20 weeks\u0026rsquo; gestation or longer in 204 countries and territories, 1990\u0026ndash;2021: findings from the Global Burden of Disease Study 2021. The Lancet. 2024;404(10466):1955\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eWHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. Trends in maternal mortality 2000 to 2023: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [Internet]. New York; 2025. Available from: https://data.unicef.org/wp-content/uploads/2025/04/Trends-in-maternal-mortality-2020-2023.pdf\u003c/li\u003e\n\u003cli\u003eIGME, UNICEF, WHO, World Bank Group, United Nations. Standing up for stillbirth: Current estimates and key interventions - Report of the United Nations Inter-agency Group for Child Mortality Estimation 2024 [Internet]. New York; 2025. Available from: https://childmortality.org/wp-content/uploads/2025/03/UNIGME-Stillbirth-Report-2024.pdf\u003c/li\u003e\n\u003cli\u003eWHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. Trends in maternal mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva, Switzerland: World Health Organization; 2023. 1\u0026ndash;108 p. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Health data overview for Burkina Faso [Internet]. Data. 2024 [cited 2024 Oct 19]. Available from: https://data.who.int/countries/854\u003c/li\u003e\n\u003cli\u003eUnited Nations. Sustainable Development Goals: 17 goals to transform our world [Internet]. Sustainable Development Goals. 2016 [cited 2020 Oct 12]. Available from: http://www.un.org/sustainabledevelopment/sustainable-development-goals/\u003c/li\u003e\n\u003cli\u003eWHO, UNFPA, UNICEF, Averting Maternal Deaths and Disabilities. Monitoring emergency obstetric care: a handbook. Geneva, Switzerland: WHO Press; 2009. \u003c/li\u003e\n\u003cli\u003ePaxton A, Maine D, Freedman L. The evidence for emergency obstetric care. International journal of gynaecology and obstetrics. 2005;88:181\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eGabrysch S, Civitelli G, Edmond KM, Mathai M, Ali M, Bhutta ZA, et al. New Signal Functions to Measure the Ability of Health Facilities to Provide Routine and Emergency Newborn Care. 2012;9(11). \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Wright K, Sonoiki O, Banke-Thomas O, Ajayi B, Ilozumba O, et al. Assessing emergency obstetric care provision in low- and middle-income countries: a systematic review of the application of global guidelines. Glob Health Action. 2016;9:31880. \u003c/li\u003e\n\u003cli\u003evan den Hoed MW, Backhaus R, de Vries E, Hamers JPH, Dani\u0026euml;ls R. Factors contributing to innovation readiness in health care organizations: a scoping review. BMC Health Serv Res [Internet]. 2022 [cited 2024 Oct 21];22:997. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08185-x\u003c/li\u003e\n\u003cli\u003eMohammadpour M, Zarifinezhad E, Ghanbarzadegan A, Naderimanesh K, Shaarbafchizadeh N, Bastani P. Main Factors Affecting the Readiness and Responsiveness of Healthcare Systems during Epidemic Crises: A Scoping Review on Cases of SARS, MERS, and COVID-19. Iran J Med Sci [Internet]. 2021 [cited 2024 Oct 21];46(2):81. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7966936/\u003c/li\u003e\n\u003cli\u003eSeppey M, Ridde V, Som\u0026eacute; PA. Scaling-Up Performance-Based Financing in Burkina Faso: From PBF to User Fees Exemption Strategic Purchasing. Int J Health Policy Manag [Internet]. 2020 May 1 [cited 2024 Oct 21];11(5):670. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9309920/\u003c/li\u003e\n\u003cli\u003eBoxshall M, Kiendr\u0026eacute;b\u0026eacute;ogo JA, Kafando Y, Tapsoba C, Straubinger S, Metangmo PM. An Overview of the User Fee Exemption Policy (Gratuit\u0026eacute;) in Burkina Faso [Internet]. Ouagadougou; 2020 [cited 2024 Jan 24]. p. 1\u0026ndash;69. Available from: https://thinkwell.global/wp-content/uploads/2020/09/Gratuite-in-Burkina-Faso_18-September-2020.pdf\u003c/li\u003e\n\u003cli\u003eSanou AC. Projet de renforcement des services de sant\u0026eacute; (PRSS) : Le comit\u0026eacute; de pilotage dresse le bilan [Internet]. Actualit\u0026eacute;. 2024 [cited 2025 Jun 10]. Available from: https://burkina24.com/2024/01/18/projet-de-renforcement-des-services-de-sante-prss-le-comite-de-pilotage-dresse-le-bilan/#:~:text=Il convient de rappeler que,\u0026rsquo;\u0026eacute;pid\u0026eacute;mie de COVID-19.\u003c/li\u003e\n\u003cli\u003eHealth Cluster. Strengthening healthcare for women and children in Burkina Faso [Internet]. News. 2025 [cited 2025 Jun 8]. Available from: https://healthcluster.who.int/newsroom/news/item/07-04-2025-strengthening-healthcare-for-women-and-children-in-burkina-faso\u003c/li\u003e\n\u003cli\u003eRidde V, Lechat L, Meda IB. Terrorist attack of 15 January 2016 in Ouagadougou: how resilient was Burkina Faso\u0026rsquo;s health system? BMJ Glob Health [Internet]. 2016 [cited 2024 Oct 25];1(1):e000056. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5321324/\u003c/li\u003e\n\u003cli\u003eACAPS. Burkina Faso Conflict [Internet]. Countries. 2022 [cited 2022 Dec 12]. Available from: https://www.acaps.org/country/burkina-faso/crisis/conflict\u003c/li\u003e\n\u003cli\u003eUNHCR. Burkina Faso [Internet]. Country Operations. 2024 [cited 2025 Jan 10]. Available from: https://reporting.unhcr.org/operational/operations/burkina-faso#:~:text=According to the Government%2C over,refugees%2C mostly of Malian origin.\u003c/li\u003e\n\u003cli\u003eSemaan A, Banke-Thomas A, Amongin D, Babah O, Dioubate N, Kikula A, et al. \u0026lsquo;We are not going to shut down, because we cannot postpone pregnancy\u0026rsquo;: a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic. BMJ Glob Health [Internet]. 2022 Feb 1 [cited 2022 Feb 13];7(2):e008063. Available from: https://gh.bmj.com/content/7/2/e008063\u003c/li\u003e\n\u003cli\u003eSemaan A, Audet C, Huysmans E, Afolabi B, Assarag B, Banke-Thomas A, et al. Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic. BMJ Glob Health. 2020;5(6):e002967. \u003c/li\u003e\n\u003cli\u003eBeňov\u0026aacute; L, Semaan A, Afolabi BB, Amongin D, Babah OA, Dioubate N, et al. Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania. BMJ Open. 2023;13:e076364. \u003c/li\u003e\n\u003cli\u003eCompaor\u0026eacute; GD, Sombi\u0026eacute; I, Ganaba R, Hounton S, Meda N, Brouwere V De, et al. Readiness of district and regional hospitals in Burkina Faso to provide caesarean section and blood transfusion services: a cross-sectional study. BMC Pregnancy Childbirth. 2014;14:158. \u003c/li\u003e\n\u003cli\u003eIlboudo D, Sombi\u0026eacute; I, Koffi AK, Asiki G, Yam\u0026eacute;ogo TM, Kirakoya-Samadoulougou F. Temporal trends analysis of emergency obstetric and newborn care availability and readiness index of healthcare facilities in Burkina Faso. BMC Health Serv Res [Internet]. 2024 Dec 1 [cited 2024 Dec 1];24:1295. Available from: https://link.springer.com/articles/10.1186/s12913-024-11818-y\u003c/li\u003e\n\u003cli\u003eMakoni M. Burkina Faso crisis hits health care. The Lancet. 2022;399(10325):616. \u003c/li\u003e\n\u003cli\u003eUS Department of State. Country Reports on Terrorism 2020: Burkina Faso [Internet]. Country Reports on Terrorism 2020. 2020 [cited 2025 Mar 15]. Available from: https://www.state.gov/reports/country-reports-on-terrorism-2020/burkina-faso/#:~:text=Early 2020 saw a sharp,for any of the incidents.\u003c/li\u003e\n\u003cli\u003eAfrica Center for Strategic Studies. Sahel and Somalia Drive Rise in Africa\u0026rsquo;s Militant Islamist Group Violence [Internet]. Infographic. 2022 [cited 2025 Mar 15]. Available from: https://africacenter.org/spotlight/sahel-and-somalia-drive-uninterrupted-rise-in-african-militant-islamist-group-violence-over-past-decade/#:~:text=A review of violence involving,50-percent increase since 2019.\u003c/li\u003e\n\u003cli\u003eNorwegian Refugee Council. Here are five crises you should know about in 2025 [Internet]. Perspectives. 2025 [cited 2025 Mar 16]. Available from: https://www.nrc.no/perspectives/2024/here-are-five-crises-you-should-know-about-in-2025#:~:text=Burkina Faso: 2 million people internally displaced\u0026amp;text=With 37 blockaded towns across,insecurity and lack of aid.\u003c/li\u003e\n\u003cli\u003eInstitut National de la Statistique et de la D\u0026eacute;mographie. Annuaire Statistique 2021 [Internet]. Ouagadougou; 2021 [cited 2024 Jan 29]. Available from: https://www.sante.gov.bf/fileadmin/annuaire_2021_mshp.pdf\u003c/li\u003e\n\u003cli\u003eWorld Bank. GDP per capita (current US$) [Internet]. General Data Portal. 2022 [cited 2024 Oct 19]. Available from: https://genderdata.worldbank.org/en/indicator/ny-gdp-pcap-cd\u003c/li\u003e\n\u003cli\u003eInstitut National de la Statistique et de la D\u0026eacute;mographie. Annuaire Statistique 2022 [Internet]. Ouagadougou; 2022. Available from: https://www.insd.bf/sites/default/files/2023-12/Annuaire_statistique_national_2022.pdf\u003c/li\u003e\n\u003cli\u003eINSD, ICF. Enqu\u0026ecirc;te D\u0026eacute;mographique et de Sant\u0026eacute; 2021 [Internet]. Ouagadougou, Burkina Faso and Rockville, Maryland; 2023 [cited 2024 Jan 30]. p. 1\u0026ndash;815. Available from: https://dhsprogram.com/pubs/pdf/FR378/FR378.pdf\u003c/li\u003e\n\u003cli\u003eCiss\u0026eacute; K, Samadoulougou S, Kabor\u0026eacute; J, Somda P, Zongo A, Traor\u0026eacute; S, et al. Healthcare system\u0026rsquo;s preparedness to provide cardiovascular and diabetes-specific care in the context of geopolitical crises in Burkina Faso: a trend analysis from 2012 to 2018. BMJ Open [Internet]. 2023 May 23 [cited 2024 Oct 21];13(5):e065912. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10230877/\u003c/li\u003e\n\u003cli\u003eMillogo O, Doamba JEO, Si\u0026eacute; A, Utzinger J, Vounatsou P. Constructing a malaria-related health service readiness index and assessing its association with child malaria mortality: an analysis of the Burkina Faso 2014 SARA data. BMC Public Health [Internet]. 2021 [cited 2024 Oct 21];21:20. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7784320/\u003c/li\u003e\n\u003cli\u003eRouamba T, Samadoulougou S, Compaor\u0026eacute; CS, Tinto H, Gaudart J, Kirakoya-Samadoulougou F. How to Estimate Optimal Malaria Readiness Indicators at Health-District Level: Findings from the Burkina Faso Service Availability and Readiness Assessment (SARA) Data. Int J Environ Res Public Health [Internet]. 2020 Jun 1 [cited 2024 Oct 21];17(11):3923. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7312483/\u003c/li\u003e\n\u003cli\u003eFassinou LC, Hien H, Yombi JC, Nagot N, Kirakoya-Samadoulougou F. Availability and readiness of the health facilities to provide HIV counseling and testing and prevention of mother-to-child transmission services in Burkina Faso: a trend analysis from 2012 to 2018. BMC Health Serv Res [Internet]. 2023 [cited 2024 Oct 21];23:757. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10347843/\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery [Internet]. Version 2. Geneva: World Health Organization; 2015. 1\u0026ndash;55 p. Available from: https://cdn.who.int/media/docs/default-source/service-availability-and-readinessassessment(sara)/sara_reference_manual_chapter3.pdf\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Harmonized Health Facility Assessment (HHFA): Combined questionnaire [Internet]. Geneva; 2021. Available from: https://cdn.who.int/media/docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07.pdf?sfvrsn=698754fa_17\u0026amp;download=true\u003c/li\u003e\n\u003cli\u003eStierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health [Internet]. 2021 Oct 5 [cited 2025 Jun 8];6(10):e006698. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8493923/\u003c/li\u003e\n\u003cli\u003eInstitut National de la Statistique et de la D\u0026eacute;mographie. Annuaire Statistique 2020 [Internet]. Ouagadougou; 2020. Available from: https://www.sante.gov.bf/fileadmin/user_upload/storages/annuaire_statistique_ms_2020_signe.pdf\u003c/li\u003e\n\u003cli\u003eOffosse MJ, Ciss\u0026eacute; K, Somda D, Gage A, Haakenstad A, Banke-Thomas A. Availability and readiness of health facilities in Burkina Faso to provide antenatal care: trend analysis from 2012 to 2020. Reproductive Health 2025 22:1. 2025;22:133. \u003c/li\u003e\n\u003cli\u003eKouanda S, Ou\u0026eacute;draogo AM, Ou\u0026eacute;draogo GH, Sanon D, Belemvir\u0026eacute; S, Ou\u0026eacute;draogo L. Emergency obstetric and neonatal care needs assessment: Results of the 2010 and 2014 surveys in Burkina Faso. International Journal of Gynecology \u0026amp; Obstetrics. 2016;135(S1):S11\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eBailey P, van Roosmalen J, Mola G, Evans C, de Bernis L, Dao B. Assisted vaginal delivery in low and middle income countries: an overview. BJOG. 2017;124(9):1335\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eSpiegel DA, Droti B, Relan P, Hobson S, Cherian MN, O\u0026rsquo;Neill K. Retrospective review of Surgical Availability and Readiness in 8 African countries. BMJ Open [Internet]. 2017 Mar 1 [cited 2025 Jun 9];7(3):e014496. Available from: https://bmjopen.bmj.com/content/7/3/e014496\u003c/li\u003e\n\u003cli\u003eZon H, Pavlova M, Groot W. Regional health disparities in Burkina Faso during the period of health care decentralization. Results of a macro-level analysis. Int J Health Plann Manage. 2020;35(4):939\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Ayomoh FI, Abejirinde IOO, Banke-Thomas O, Eboreime EA, Ameh CA. Cost of Utilising Maternal Health Services in Low- and Middle-Income Countries: A Systematic Review. Int J Health Policy Manag. 2021;10(9):564\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eWright K, Banke-Thomas A, Sonoiki O, Ajayi B, Ilozumba O, Akinola O. Opinion of women on emergency obstetric care provided in public facilities in Lagos, Nigeria: A qualitative study. Health Care Women Int. 2017;38(6):527\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Wright K, Sonoiki O, Ilozumba O, Ajayi B, Okikiolu O, et al. Multi-stakeholder perspectives on access, availability and utilization of emergency obstetric care services in Lagos, Nigeria: A mixed-methods study. J Public Health Afr. 2017;8(2):717. \u003c/li\u003e\n\u003cli\u003eGwacham-Anisiobi U, Banke-Thomas A. Experiences of Health Facility Childbirth in Sub-Saharan Africa: A Systematic Review of Qualitative Evidence. Matern Child Health J. 2022;26(3):481\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eBalogun M, Banke-Thomas A, Gwacham-Anisiobi U, Yesufu V, Ubani O, Afolabi BB. Actions and Adaptations Implemented for Maternal, Newborn and Child Health Service Provision During the Early Phase of the COVID-19 Pandemic in Lagos, Nigeria: Qualitative Study of Health Facility Leaders. Ann Glob Health. 2022;88(1):13. \u003c/li\u003e\n\u003cli\u003eMa\u0026iuml;ga A, Bougma M, Wilson E, Kabor\u0026eacute; TS, Tou GG, Munos MK, et al. Effects of the COVID-19 pandemic on maternal, newborn, and child health service coverage in Burkina Faso. J Glob Health [Internet]. 2024 Dec 20 [cited 2025 Jun 8];14:05037. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11658717/\u003c/li\u003e\n\u003cli\u003eWong KL, Banke-Thomas A, Sholkamy H, Dennis ML, Pembe AB, Birabwa C, et al. A tale of 22 cities: utilisation patterns and content of maternal care in large African cities. BMJ Glob Health. 2022;7(3):e007803. \u003c/li\u003e\n\u003cli\u003eLefaso. Burkina/ Projets de renforcement des services de sant\u0026eacute; et de riposte au Covid-19 : Les acteurs passent en revue la mise en \u0026oelig;uvre des activit\u0026eacute;s sur le terrain. Soci\u0026eacute;t\u0026eacute; [Internet]. 2023 Nov 21 [cited 2025 Jun 9]; Available from: https://lefaso.net/spip.php?article125906\u003c/li\u003e\n\u003cli\u003eNtambue AM, Malonga FK, Cowgill KD, Dramaix-Wilmet M, Donnen P. Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011. BMC Pregnancy Childbirth [Internet]. 2017 Jan 19 [cited 2025 Jun 9];17:40. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5244553/\u003c/li\u003e\n\u003cli\u003eBintabara D, Ernest A, Mpondo B. Health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a Tanzania National Survey. BMJ Open [Internet]. 2019 Feb 9 [cited 2019 Feb 10];9(2):bmjopen-2017-020608. Available from: http://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2017-020608\u003c/li\u003e\n\u003cli\u003eOffosse MJ, Ciss\u0026eacute; K, Somda D, Gage A, Haakenstad A, Banke-Thomas A. Availability and Readiness of Health Facilities in Burkina Faso to Provide Antenatal Care: Trend Analysis from 2012 to 2020. Reprod Health. 2025;In Press. \u003c/li\u003e\n\u003cli\u003eOnadja Y, Compaor\u0026eacute; R, Yugbar\u0026eacute; DB, Thomas HL, Guiella G, Lougu\u0026eacute; S, et al. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res [Internet]. 2024 Dec 1 [cited 2024 Dec 26];24:84. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-10538-z\u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Offosse MJ, Yameogo P, Manli AR, Goumbri A, Avoka C, et al. Stakeholder perceptions and experiences from the implementation of the Gratuit\u0026eacute; user fee exemption policy in Burkina Faso: a qualitative study. Health Res Policy Syst. 2023;21:46. \u003c/li\u003e\n\u003cli\u003eOffosse MJ, Avoka C, Yameogo P, Manli AR, Goumbri A, Eboreime E, et al. Effectiveness of the Gratuit\u0026eacute; user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis. Confl Health. 2023;17:33. \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Avoka CK on, Gwacham-Anisiobi U, Omololu O, Balogun M, Wright K, et al. Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study. BMJ Glob Health. 2022 Apr 1;7(4):e008604. \u003c/li\u003e\n\u003cli\u003eSouza JP, Day LT, Rezende-Gomes AC, Zhang J, Mori R, Baguiya A, et al. A global analysis of the determinants of maternal health and transitions in maternal mortality. Lancet Glob Health [Internet]. 2024 Feb 1 [cited 2024 Oct 21];12(2):e306\u0026ndash;16. Available from: http://www.thelancet.com/article/S2214109X23004680/fulltext\u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Abejirinde IOO, Ayomoh FI, Banke-Thomas O, Eboreime EA, Ameh CA. The cost of maternal health services in low-income and middle-income countries from a provider\u0026rsquo;s perspective: a systematic review. BMJ Glob Health. 2020;5(6):e002371. \u003c/li\u003e\n\u003cli\u003eSchneeberger C, Mathai M. Emergency obstetric care: Making the impossible possible through task shifting. International Journal of Gynecology \u0026amp; Obstetrics [Internet]. 2015 Oct 1 [cited 2017 Oct 20];131(Suppl 1):S6\u0026ndash;9. Available from: http://www.sciencedirect.com/science/article/pii/S0020729215000831?via%3Dihub\u003c/li\u003e\n\u003cli\u003eSeidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. Hum Resour Health. 2017;15(1):29. \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Madaj B, van den Broek N. Social return on investment of emergency obstetric care training in Kenya. BMJ Glob Health. 2019;4(1):e001167. \u003c/li\u003e\n\u003cli\u003eBanke-Thomas A, Wilson-Jones M, Madaj B, van den Broek N. Economic evaluation of emergency obstetric care training: a systematic review. BMC Pregnancy Childbirth. 2017;17:403. \u003c/li\u003e\n\u003cli\u003eOtolorin E, Gomez P, Currie S, Thapa K, Dao B. Essential basic and emergency obstetric and newborn care: From education and training to service delivery and quality of care. International Journal of Gynecology \u0026amp; Obstetrics. 2015;130(Supplement 2):S46\u0026ndash;53. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7463045/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7463045/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite significant reductions in recent decades, maternal mortality and stillbirth remain some of the leading causes of death in Burkina Faso. Routine perinatal and emergency obstetric and newborn care (EmONC) can reduce these deaths. This study analyses the trends in availability and health facility readiness to provide routine perinatal and EmONC in Burkina Faso between 2014 and 2020.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a trend analysis of repeated cross-sectional facility-based data using nationally representative 2014, 2016 and 2018 Service Availability and Readiness Assessment surveys and census-based 2020 Health Harmonised Facilities Assessment. Following descriptive analysis of included facilities, we used tracer elements in both surveys to estimate availability and readiness indices by survey year and health facility characteristics. Both indices were calculated using the equal-weighted approach, while the domain-weighted approach was used for readiness only. We assessed trends using a weighted multivariate linear regression, with trends adjusted for facility characteristics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eRoutine perinatal and basic EmONC availability index increased from 69.8% in 2014 to 74.9% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=0.825;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e. After adjustment for facility characteristics, there was a statistically significant increment in routine perinatal and basic EmONC availability index from 2014 to 2020 in primary and public facilities, and in those in seven of 13 regions, but significant decline in urban-based facilities. There was also a significant reduction in readiness score for this service (65.0% in 2014 to 61.1% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-0.515;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e), driven mostly by staff and guidelines. Adjusted trends showed statistically significant reduction in readiness index in secondary, tertiary, and private facilities. Availability index for comprehensive EmONC had a non-significant decline from 82.9% in 2014 to 79.6% by 2020, while its readiness score declined significantly, from 62.5% in 2014 to 46.5% in 2020 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:=-1.981;p\u0026lt;0.001)\\)\u003c/span\u003e\u003c/span\u003e, driven by all domains. Adjusted trends showed statistically significant reduction in secondary, tertiary, public, private, and urban-based facilities.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWhile availability of routine perinatal and EmONC services have mostly withstood effects of recent health system shocks, facilities\u0026rsquo; readiness to provide these services declined. Staff capacity development and equipping of hospitals are needed to ensure that hard gains made in maternal mortality and stillbirth reductions in Burkina Faso are not reversed.\u003c/p\u003e","manuscriptTitle":"Availability and readiness of routine perinatal and emergency obstetric and newborn care services in health facilities in Burkina Faso: trend analysis from 2014 to 2020","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 07:51:45","doi":"10.21203/rs.3.rs-7463045/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"29973086447912613395451884756036972504","date":"2025-10-05T15:32:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97279650146838264013124593474439390742","date":"2025-10-03T15:03:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191944427002296084208862759619333120279","date":"2025-09-29T14:08:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121505185546553750405044905593827112626","date":"2025-09-29T07:14:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T15:09:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-29T03:24:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T00:47:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-28T00:46:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-26T12:35:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a09195b8-a794-4c75-915a-d09bc756def8","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T07:51:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 07:51:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7463045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7463045","identity":"rs-7463045","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}