Where Women Give Birth Is Changing in Sub-Saharan Africa: Evidence From 30 Countries Using DHS Data

In sub-Saharan African region, high-maternal mortality is high due to complications of labor, delivery as well as low patronage of antenatal care and skilled birth attendants (SBAs), poverty and poor health-seeking behavior. Although considerable studies exist on drivers of choice of birth locations, there is a paucity of current, nationally representative samples from various SSA countries examining factors influencing birthplace choices. This study addresses this gap by employing a recent dataset to assess the determinants of changing birth locations in SSA.

This cross-sectional study used the most recent Demographic and Health Survey (DHS) data from 30 sub-Saharan African countries collected between 2014 and 2024, comprising 61,240 women aged 15-49. Two outcomes were examined: (i) any change in childbirth location between the two most recent births, and (ii) a shift from home to health-facility delivery. Two binary logistic regression models were fitted to identify factors associated with each outcome, with checks for multicollinearity conducted using variance inflation factors and tolerance indices. Survey design was accounted for in our regression analyses (sampling weights and clustering).

Overall, 13.59% (n = 8320) of women changed their childbirth location between their two most recent births, and more than half of these women (54.35%) shifted from home to a healthcare facility. The highest change is observed in Uganda where 20.36% (95% CI; 19.07-21.66) changed their location of childbirth, and the lowest is observed in Burkina Faso where only 5.24% (95% CI; 2.99-7.48) changed their location of childbirth. The probability of changing birth location from home to a healthcare facility increased with the level of education, with those with higher education having a higher likelihood of changing from home to a facility (AOR = 2.76, 95% CI: 1.53-4.97) compared with those with no education. The odds of changing birth location from home to a healthcare facility increase with wealth status, particularly for women in the richest category (AOR = 2.31, 95% CI: 1.79-2.97) relative to those in the poorest category. Women in rural areas are 34% less likely to change from home to a facility compared with those in urban areas (AOR = 0.66, 95% CI: 0.57-0.76).

Our study highlights significant disparities in changes in childbirth locations across SSA countries, driven primarily by education, wealth, and rural-urban residence. Although countries like Malawi and Zimbabwe demonstrate successful strategies for promoting facility-based deliveries, others like Chad and Burkina Faso face persistent barriers. Addressing these disparities requires targeted interventions, including expanding rural healthcare infrastructure and implementing pro-poor healthcare policies. Future research and program designs should prioritize longitudinal assessments of these determinants to tailor interventions for specific country contexts.