Variation in Breastfeeding Initiation and Duration by Mode of Childbirth: A Prospective, Population-Based Study.

Introduction: Despite known benefits of breastfeeding, including prevention against infections for infants, in the presence of numerous barriers, less than half of infants in high-income countries breastfeed for 6 months. One potential barrier to breastfeeding is birth by cesarean section (C-Section), which can invoke long-term difficulties. However, our structured literature review found that existing empirical research does not fully elucidate this relationship due to differences in operationalization of C-section and breastfeeding, omission of important confounders, and failure to exclude those who did not initiate breastfeeding (or use time-to-event analyses). In this article, we attempt to overcome these limitations. Methods: We analyzed data from 14,414 mother-infant dyads enrolled in the United Kingdom-based prospective Millennium Cohort Study, beginning in 2001. Using multivariable logistic regression, we examined the association between mode of birth (vaginal, emergency C-section, and elective C-section) and likelihood of breastfeeding initiation. We then applied adjusted Accelerated Failure Time survival models to examine the associations between mode of birth and duration of any and exclusive breastfeeding. Results: Those with planned (but not emergency) C-section were less likely to initiate breastfeeding (odds ratio: 0.84, 95% confidence interval [CI]: 0.71-0.99) relative to vaginal births. However, those with either planned or unplanned C-section discontinued both any and exclusive breastfeeding sooner than vaginal births. This effect was more pronounced for those with planned C-section (time ratio [TR]: 0.75, 95% CI: 0.64-0.89) than unplanned C-section (TR: 0.85, 95% CI: 0.74, 0.97) compared with vaginal births. Conclusions: Through application of rigorous methods, this study provides compelling evidence that breastfeeding duration may be impeded by C-section birth. The findings suggest that additional support for mothers who intend to breastfeed and have a C-section birth may be warranted.

Breastfeeding Initiation by WIC Receipt After Formula Shortages in 2022.

This study assesses differences in breastfeeding initiation trends between Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants and WIC-eligible nonparticipants before, during, and after the 2022 infant formula disruption.

The role of doulas in respectful care for communities of color and Medicaid recipients.

BACKGROUND: Despite the tenets of rights-based, person-centered maternity care, racialized groups, low-income people, and people who receive Medicaid insurance in the United States experience mistreatment, discrimination, and disrespectful care more often than people with higher income or who identify as white. This study aimed to explore the relationship between the presence of a doula (a person who provides continuous support during childbirth) and respectful care during birth, especially for groups made vulnerable by systemic inequality. METHODS: We used data from 1977 women interviewed in the Listening to Mothers in California survey (2018). Respondents who reported high levels of decision making, support, and communication during childbirth were classified as having "high" respectful care. To examine associations between respectful care and self-reported doula support, we conducted multivariable logistic regressions. Interactions by race/ethnicity and private or Medi-Cal (Medicaid) insurance status were assessed. RESULTS: Overall, we found higher odds of respectful care among women supported by a doula than those without such support (odds ratios [OR]: 1.4, 95% CI: 1.0-1.8). By race/ethnicity, the association was largest for non-Hispanic Black women (2.7 [1.1-6.7]) and Asian/Pacific Islander women (2.3 [0.9-5.6]). Doula support predicts higher odds of respectful care among women with Medi-Cal (1.8 [1.3-2.5]), but not private insurance. CONCLUSIONS: Doula support was associated with high respectful care, particularly for low-income and certain racial/ethnic groups in California. Policies supporting the expansion of doulas for low-income and marginalized groups are consistent with the right to respectful care and may address disparities in maternal experiences.

Household Survey Measurement of Newborn Postnatal Care: Coverage, Quality Gaps, and Internal Inconsistencies in Responses.

BACKGROUND: Reliable measurement of newborn postnatal care is essential to understand gaps in coverage and quality and thereby improve outcomes. This study examined gaps in coverage and measurement of newborn postnatal care in the first 2 days of life. METHODS: We analyzed Demographic and Health Survey data from 15 countries for 71,366 births to measure the gap between postnatal contact coverage and content coverage within 2 days of birth. Coverage was a contact with the health system in the first 2 days (postnatal check or newborn care intervention), and quality was defined as reported receipt of 5 health worker-provided interventions. We examined internal consistency between interrelated questions regarding examination of the umbilical cord. RESULTS: Reported coverage of postnatal check ranged from 13% in Ethiopia to 78% in Senegal. Report of specific newborn care interventions varied widely by intervention within and between countries. Quality-coverage gaps were high, ranging from 26% in Malawi to 89% in Burundi. We found some internally inconsistent reporting of newborn care. The percentage of women who reported that a health care provider checked their newborn's umbilical cord but responded "no" to the postnatal check question was as high as 16% in Malawi. CONCLUSION: Reliable measurement of coverage and content of early postnatal newborn care is essential to track progress in improving quality of care. Postnatal contact coverage is challenging to measure because it may be difficult for women to distinguish postnatal care from intrapartum care and it is a less recognizable concept than antenatal care. Co-coverage measures may provide a useful summary of contact and content, reflecting both coverage and an aspect of quality.

Distance to available services for newborns at facilities in Malawi: A secondary analysis of survey and health facility data.

BACKGROUND: Malawi has halved the neonatal mortality rate between 1990-2018, however, is not on track to achieve the Sustainable Development Goal 12 per 1,000 live births. Despite a high facility birth rate (91%), mother-newborn dyads may not remain in facilities long enough to receive recommended care and quality of care improvements are needed to reach global targets. Physical access and distance to health facilities remain barriers to quality postnatal care. METHODS: Using data We used individual data from the 2015-16 Malawi Demographic and Health Survey and facility data from the 2013-14 Malawi Service Provision Assessment, linking households to all health facilities within specified distances and travel times. We calculated service readiness scores for facilities to measure their capacity to provide birth/newborn care services. We fitted multi-level regression models to evaluate the association between the service readiness and appropriate newborn care (receiving at least five of six interventions). RESULTS: Households with recent births (n = 6010) linked to a median of two birth facilities within 5-10 km and one facility within a two-hour walk. The maximum service environment scores for linked facilities median was 77.5 for facilities within 5-10 km and 75.5 for facilities within a two-hour walk. While linking to one or more facilities within 5-10km or a two-hour walk was not associated with appropriate newborn care, higher levels of service readiness in nearby facilities was associated with an increased risk of appropriate newborn care. CONCLUSIONS: Women's choice of nearby facilities and quality facilities is limited. High quality newborn care is sub-optimal despite high coverage of facility birth and some newborn care interventions. While we did not find proximity to more facilities was associated with increased risk of appropriate care, high levels of service readiness was, showing facility birth and improved access to well-prepared facilities are important for improving newborn care.

Equity in newborn care, evidence from national surveys in low- and middle-income countries.

BACKGROUND: High coverage of care is essential to improving newborn survival; however, gaps exist in access to timely and appropriate newborn care between and within countries. In high mortality burden settings, health inequities due to social and economic factors may also impact on newborn outcomes. This study aimed to examine equity in co-coverage of newborn care interventions in low- and low middle-income countries in sub-Saharan Africa and South Asia. METHODS: We analysed secondary data from recent Demographic and Health Surveys in 16 countries. We created a co-coverage index of five newborn care interventions. We examined differences in coverage and co-coverage of newborn care interventions by country, place of birth, and wealth quintile. Using multilevel logistic regression, we examined the association between high co-coverage of newborn care (4 or 5 interventions) and social determinants of health. RESULTS: Coverage and co-coverage of newborn care showed large between- and within-country gaps for home and facility births, with important inequities based on individual, family, contextual, and structural factors. Wealth-based inequities were smaller amongst facility births compared to non-facility births. CONCLUSION: This analysis underlines the importance of facility birth for improved and more equitable newborn care. Shifting births to facilities, improving facility-based care, and community-based or pro-poor interventions are important to mitigate wealth-based inequities in newborn care, particularly in countries with large differences between the poorest and richest families and in countries with very low coverage of care.

Initiation of Breastfeeding in Low- and Middle-Income Countries: A Time-to-Event Analysis.

OBJECTIVE: Early breastfeeding has numerous benefits for both the mother and her baby. Previous research typically analyzes breastfeeding initiation in binary terms (within the first hour or day). Although delays are associated with cesarean delivery and skin-to-skin contact may facilitate early breastfeeding, a more nuanced understanding of these relationships is needed. METHODS: With data from 31 countries that had a Demographic and Health Survey since 2015, we described breastfeeding initiation among babies most recently born in the last 2 years to women aged 15-49 years. In a subset of 21 countries, we conducted survival analysis with multivariable log-logistic accelerated failure time (AFT) regressions to examine factors associated with time to initiation of breastfeeding, specifically the mode of delivery and skin-to-skin contact, controlling for receipt of health care as well as socioeconomic and demographic characteristics of mothers and babies. FINDINGS: Babies in most countries began breastfeeding within a few hours after birth. The mean time to initiation of breastfeeding ranged from 1.7 hours in Burundi to 32 hours in Pakistan and 40 hours in Chad. In most countries (24 of 31), the median time was 0.5 hours. Median time to initiation was greater for births by cesarean delivery compared with vaginal births at health facilities. After controlling for covariates, AFT models showed significant delays in breastfeeding among cesarean deliveries in most countries, with as much as a 9-fold delay in Senegal. Immediate skin-to-skin contact was significantly associated with a shorter time to initiation. CONCLUSION: Efforts to promote early breastfeeding should encourage skin-to-skin and target cesarean deliveries.

Intimate partner violence and contraceptive discontinuation in Kenya.

Intimate partner violence (IPV) may interfere with women's contraceptive use. This study analyzed IPV and discontinuation while still in need (DWSIN) using detailed contraceptive calendar data from the 2014 Kenya Demographic and Health Survey and measures of IPV experience in the same 12-month observation period. Using multivariable regression analysis, it examined three forms of violence separately-emotional, physical, and sexual violence-and any IPV combined among 1,437 married women age 15-49 who were using a contraceptive method twelve months prior to the interview. DWSIN varied with the form of violence assessed. Emotional violence (odds ratio (OR) = 2.13, p <0.01) and any IPV (OR=1.88, p <0.05) were strongly, positively associated with higher odds of DWSIN. Sexual violence was weakly associated with higher odds of DWSIN, while there was no detected association with physical violence. Integrating IPV screening into family planning counseling may reduce DWSIN and support women to achieve their reproductive aspirations.

Facility readiness and counseling during antenatal care and the relationship with early breastfeeding in Haiti and Malawi.

BACKGROUND: Early initiation of breastfeeding (within an hour of birth) has benefits for newborn health and survival. Optimal breastfeeding supports growth, health, and development. Health facilities provide essential pregnancy, maternal, and newborn care and offer support for early breastfeeding. We examined the relationship between the breastfeeding-related health service environment during antenatal care (ANC) and early initiation of breastfeeding. METHODS: Using data from recent Service Provision Assessment (SPA) surveys in Haiti and Malawi, we defined three indicators of the health service environment: availability of facilities with ANC services reporting routine breastfeeding counseling; provider training on breastfeeding; and breastfeeding counseling during ANC. We linked SPA data geographically to Demographic and Health Surveys (DHS) data from Haiti and Malawi. Multilevel, multivariable logistic regressions examined associations between the health service environment and early initiation of breastfeeding, controlling for women's background characteristics, with separate analyses for urban and rural residence. RESULTS: Over 95% of facilities in Haiti and Malawi reported routinely providing breastfeeding counseling during ANC. Only 40% of both urban and rural providers in Malawi and 29 and 26% of providers at urban and rural facilities in Haiti (respectively) received recent training in counseling on breastfeeding. Further, only 4-10% of clients received counseling. Breastfeeding counseling was generally more common among clients who attended ANC with a provider who had received recent training. After linking SPA and DHS data, our analysis showed that having more providers recently trained on breastfeeding was significantly associated with increased odds of early breastfeeding among women in urban areas of Haiti and Malawi. Additionally, women in urban areas of Malawi lived near facilities with more counseling during ANC were more likely to begin breastfeeding within an hour of birth compared with women in areas with less counseling. CONCLUSIONS: Our study identified gaps in the health system's capacity to implement the recommended global guidelines in support of optimal breastfeeding practices. While breastfeeding counseling during ANC can promote early breastfeeding, counseling was not common. The study provides evidence that provider training could help improve counseling and support for early initiation of breastfeeding.

Variance estimation for effective coverage measures: A simulation study.

BACKGROUND: Effective coverage research is increasing rapidly in global health and development, as researchers use a range of measures and combine data sources to adjust coverage for the quality of services received. However, most estimates of effective coverage that combine data sources are reported only as point estimates, which may be due to the challenge of calculating the variance for a composite measure. In this paper, we evaluate three methods to quantify the uncertainty in the estimation of effective coverage. METHODS: We conducted a simulation study to evaluate the performance of the exact, delta, and parametric bootstrap methods for constructing confidence intervals around point estimates that are calculated from combined data on coverage and quality. We assessed performance by computing the number of nominally 95% confidence intervals that contain the truth for a range of coverage and quality values and data source sample sizes. To illustrate these approaches, we applied the delta and exact methods to estimates of adjusted coverage of antenatal care (ANC) in Senegal. We used household survey data for coverage and health facility assessments for readiness to provide services. RESULTS: With small sample sizes, when the true effective coverage value was close to the boundaries 0 or 1, the exact and parametric bootstrap methods resulted in substantial over or undercoverage and, for the exact method, a high proportion of invalid confidence intervals, while the delta method yielded modest overcoverage. The proportion of confidence intervals containing the truth in all three methods approached the intended 95% with larger sample sizes and as the true effective coverage value moved away from the 0 or 1 boundary. Confidence intervals for adjusted ANC in Senegal were largely overlapping across the delta and exact methods, although at the sub-national level, the exact method produced invalid confidence intervals for estimates near 0 or 1. We provide the code to implement these methods. CONCLUSIONS: The uncertainty around an effective coverage estimate can be characterized; this should become standard practice if effective coverage estimates are to become part of national and global health monitoring. The delta method approach outperformed the other methods in this study; we recommend its use for appropriate inference from effective coverage estimates that combine data sources, particularly when either sample size is small. When used for estimates created from facility type or regional strata, these methods require assumptions of independence that must be considered in each example.

Understanding the relationship between family planning method choices and modern contraceptive use: an analysis of geographically linked population and health facilities data in Haiti.

INTRODUCTION: This study linked data from the 2012 Haiti Demographic and Health Survey (DHS) and the 2013 Haiti Service Provision Assessment (SPA) to estimate the extent to which women's contraceptive use is associated with the method choices available in Haiti's health facilities. METHODS: Using Global Positioning System (GPS) data for DHS clusters and for health facilities, we linked each DHS cluster to all of the family planning facilities located within a specified distance, and then measured the cluster's level of contraceptive method choice based on the number of facilities within the buffer zone that offered three or more modern contraceptive methods. Random intercept logistic regressions were used to model the variation in individual modern contraceptive use and the availability of multiple method choices at the cluster level. RESULTS: Limited number of family planning facilities in Haiti offered at least three modern contraceptive methods (51% in urban and 23% in rural). Seventeen percent of both rural and urban women lived in an area with low availability of multiple methods-meaning that no facility in the specified buffer zone offered three or more contraceptive methods. Another 29% of rural women and 41% of urban women had medium availability-that is, only one facility in the buffer zone offered three or more methods. In rural areas, compared with women living in a cluster with low availability of multiple methods, the odds of using a modern method are 73% higher for women living in a cluster with medium availability, and over twice as high for women living in a cluster with high availability. A similar positive relationship was also found in urban areas. CONCLUSIONS: Women in Haiti have only limited proximity to a health facility offering a variety of contraceptive methods. Improving access to a range of methods available at health facilities near where people live is critical for increasing contraceptive use in both urban and rural areas of Haiti.

Trends, determinants, and newborn mortality related to thermal care and umbilical cord care practices in South Asia.

BACKGROUND: Although child mortality has decreased over the last several decades, neonatal mortality has declined less substantially. In South Asia, neonatal deaths account for the majority of all under-five deaths, calling for further study on newborn care practices. We assessed five key practices: immediate drying and wrapping, delayed bathing, immediate skin-to-skin contact after birth, cutting the umbilical cord with a clean instrument, and substances placed on the cord. METHODS: Using data from Demographic and Health Surveys conducted in Bangladesh, India, and Nepal between 2005 and 2016, we examined trends in coverage of key practices and used multivariable logistic regression to analyze predictors of thermal care and hygienic cord care practices and their associations with neonatal mortality among home births. The analysis excluded deaths on the first day of life to ensure that the exposure to newborn care practices would have preceded the outcome. Given limited neonatal mortality events in Bangladesh and Nepal, we pooled data from these countries. RESULTS: We found that antenatal care and skilled birth attendance was associated with an increase in the odds of infants' receipt of the recommended practices among home births. Hygienic cord care was significantly associated with newborn survival. After controlling for other known predictors of newborn mortality in Bangladesh and Nepal, antiseptic cord care was associated with an 80% reduction in the odds of dying compared with dry cord care. As expected, skilled care during pregnancy and birth was also associated with newborn survival. Missing responses regarding care practices were common for newborns that died, suggesting that recall or report of details surrounding the traumatic event of a loss of a child may be incomplete. CONCLUSIONS: This study highlights the importance of maternal and newborn care and services for newborn survival in South Asia, particularly antenatal care, skilled birth attendance, and antiseptic cord care.

Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania.

BACKGROUND: The persistence of preventable maternal and newborn deaths highlights the importance of quality of care as an essential element in coverage interventions. Moving beyond the conventional measurement of crude coverage, we estimated effective coverage of facility delivery by adjusting for facility preparedness to provide delivery services in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. METHODS: The study uses data from Demographic and Health Surveys (DHS) and Service Provision Assessments (SPA) in Bangladesh (2014 DHS and 2014 SPA), Haiti (2012 DHS and 2013 SPA), Malawi (2015-16 DHS and 2013-14 SPA), Nepal (2016 DHS and 2015 SPA), Senegal (2016 DHS and 2015 SPA), and Tanzania (2015-16 DHS and 2014-15 SPA). We defined effective coverage as the mathematical product of crude coverage and quality of care. The coverage of facility delivery was measured with DHS data and quality of care was measured with facility data from SPA. We estimated effective coverage at both the regional and the national level and accounted for type of facility where delivery care was sought. FINDINGS: The findings from the six countries indicate the effective coverage ranges from 24% in Haiti to 66% in Malawi, representing substantial reductions (20% to 39%) from crude coverage rates. Although Malawi has achieved almost universal coverage of facility delivery (93%), effective coverage was only 66%.vSuch gaps between the crude coverage and the effective coverage suggest that women delivered in health facility but did not necessarily receive an adequate quality of care. In all countries except Malawi, effective coverage differed substantially among the country's regions of the country, primarily due to regional variability in coverage. INTERPRETATION: Our findings reinforce the importance of quality of obstetric and newborn care to achieve further reduction of maternal and newborn mortality. Continued efforts are needed to increase the use of facility delivery service in countries or regions where coverage remains low.

Comparing summary measures of quality of care for family planning in Haiti, Malawi, and Tanzania.

Measuring quality of care in family planning services is essential for policymakers and stakeholders. However, there is limited agreement on which mathematical approaches are best able to summarize quality of care. Our study used data from recent Service Provision Assessment surveys in Haiti, Malawi, and Tanzania to compare three methods commonly used to create summary indices of quality of care-a simple additive, a weighted additive that applies equal weights among domains, and principal components analysis (PCA) based methods. The PCA results indicated that the first component cannot sufficiently summarize quality of care. For each scoring method, we categorized family planning facilities into low, medium, and high quality and assessed the agreement with Cohen's kappa coefficient between pairs of scores. We found that the agreement was generally highest between the simple additive and PCA rankings. Given the limitations of simple additive measures, and the findings of the PCA, we suggest using a weighted additive method.

The association between female genital fistula symptoms and gender-based violence: A multicountry secondary analysis of household survey data.

OBJECTIVE: The Demographic and Health Surveys (DHS), which include standardised questions on female genital fistula symptoms, provide a unique opportunity to evaluate the epidemiology of fistula. This study sought to examine associations between self-reported fistula symptoms and experience of gender-based violence (GBV) among women interviewed in DHS surveys. METHODS: This study used data from thirteen DHS surveys with standardised fistula and domestic violence modules. Data from the most recent survey in each country were pooled, weighting each survey equally. Multivariable logistic regressions controlled for maternal and demographic factors. RESULTS: Prevalence of fistula symptoms in this sample of 95 625 women ranges from 0.3% to 1.8% by country. The majority of women reporting fistula symptoms (56%) have ever experienced physical violence, and more than one-quarter have ever experienced sexual violence (27%), compared with 38% and 13% among women with no symptoms, respectively. Similarly, 16% of women with fistula symptoms report recently experiencing sexual violence-twice the percentage among women not reporting symptoms (8%). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with women who never experienced sexual violence. These associations indicate a need to investigate temporal and causal relationships between violence and fistula. CONCLUSIONS: The increased risk of physical and sexual violence among women with fistula symptoms suggests that fistula programmes should incorporate GBV into provider training and services.

Quality of care in family planning services in Senegal and their outcomes.

BACKGROUND: High quality of care in family planning (FP) services has been found to be associated with increased and continued use of contraceptive methods. The interpersonal skills and technical competence of the provider is one of the main components of quality of care. To study the process component of quality of care, the distribution of the FP counseling topics was examined by client, provider and facility characteristics. To assess the outcomes of quality of care, client satisfaction and their knowledge of their method's protection from STIs were used. This study examined the factors associated with these outcomes with a focus on provider counseling and training. METHODS: Data from the 2012-2013 Senegal Service Provision Assessment survey was used for the analysis. The survey included a representative sample of the health facilities in Senegal and collects data by observing the clients' FP visits and conducting exit interviews. The main outcomes of interest were provider's counseling in FP, client's satisfaction with FP services and client's knowledge of their method's protection from STIs. Several covariates were used in the analysis which represent client, provider and facility characteristics. RESULTS: The level of counseling was inadequate-- very low proportions of providers that performed different types of counseling. Counseling was more likely to be provided to new than returning clients. Approximately 84% of the clients were very satisfied with services but only 58% had correct knowledge of their method's protection from STIs. Clients were significantly less likely to be very satisfied when their providers counseled on side effects and when to return, and counseling provided on method's protection from STIs did not significantly improve knowledge in this area. Clients seen by a provider with FP training had almost twice the odds of having correct knowledge about their method's protection from STIs compared with clients seen by a provider with no recent training. CONCLUSIONS: The percentage of providers offering FP counseling to their clients was relatively low and was ineffective on the client-focused outcomes. Interventions may be required for more effective counseling methods that are client-centered as well as providing more FP training to providers.

The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda.

While research has assessed the impact of health insurance on health care utilization, few studies have focused on the effects of health insurance on use of maternal health care. Analyzing nationally representative data from the Demographic and Health Surveys (DHS), this study estimates the impact of health insurance status on the use of maternal health services in three countries with relatively high levels of health insurance coverage-Ghana, Indonesia and Rwanda. The analysis uses propensity score matching to adjust for selection bias in health insurance uptake and to assess the effect of health insurance on four measurements of maternal health care utilization: making at least one antenatal care visit; making four or more antenatal care visits; initiating antenatal care within the first trimester and giving birth in a health facility. Although health insurance schemes in these three countries are mostly designed to focus on the poor, coverage has been highly skewed toward the rich, especially in Ghana and Rwanda. Indonesia shows less variation in coverage by wealth status. The analysis found significant positive effects of health insurance coverage on at least two of the four measures of maternal health care utilization in each of the three countries. Indonesia stands out for the most systematic effect of health insurance across all four measures. The positive impact of health insurance appears more consistent on use of facility-based delivery than use of antenatal care. The analysis suggests that broadening health insurance to include income-sensitive premiums or exemptions for the poor and low or no copayments can increase use of maternal health care.

Assessment of health facility capacity to provide newborn care in Bangladesh, Haiti, Malawi, Senegal, and Tanzania.

BACKGROUND: Despite the importance of health facility capacity to provide comprehensive care, the most widely used indicators for global monitoring of maternal and child health remain contact measures which assess women's use of services only and not the capacity of health facilities to provide those services; there is a gap in monitoring health facilities' capacity to provide newborn care services in low and middle income countries. METHODS: In this study we demonstrate a measurable framework for assessing health facility capacity to provide newborn care using open access, nationally-representative Service Provision Assessment (SPA) data from the Demographic Health Surveys Program. In particular, we examine whether key newborn-related services are available at the facility (ie, service availability, measured by the availability of basic emergency obstetric care (BEmOC) signal functions, newborn signal functions, and routine perinatal services), and whether the facility has the equipment, medications, training and knowledge necessary to provide those services (ie, service readiness, measured by general facility requirements, equipment, medicines and commodities, and guidelines and staffing) in five countries with high levels of neonatal mortality and recent SPA data: Bangladesh, Haiti, Malawi, Senegal, and Tanzania. FINDINGS: In each country, we find that key services and commodities needed for comprehensive delivery and newborn care are missing from a large percentage of facilities with delivery services. Of three domains of service availability examined, scores for routine care availability are highest, while scores for newborn signal function availability are lowest. Of four domains of service readiness examined, scores for general requirements and equipment are highest, while scores for guidelines and staffing are lowest. CONCLUSIONS: Both service availability and readiness tend to be highest in hospitals and facilities in urban areas, pointing to substantial equity gaps in the availability of essential newborn care services for rural areas and for people accessing lower-level facilities. Together, the low levels of both service availability and readiness across the five countries reinforce the vital importance of monitoring health facility capacity to provide care. In order to save newborn lives and improve equity in child survival, not only does women's use of services need to increase, but facility capacity to provide those services must also be enhanced.