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Introduction Good quality antenatal care plays an important role in reducing maternal and perinatal mortality, including in high-burden settings like Nepal. Electronic decision support systems (EDSS) aim to promote adherence to evidence-based guidelines. This protocol outlines the outcome and process evaluation of two tablet-based EDSS, the Mobile health Integrated Rural Antenatal care (mIRA) EDSS and the World Health Organization’s ANC Reference Application EDSS, on improving antenatal care quality in primary-level healthcare facilities in Nepal. The outcome evaluation aims to assess the effectiveness of the intervention on quality of antenatal care. The process evaluation aims to inform interpretation of outcome results and to improve understanding of the implementation process and intervention effects, addressing the research question: why or how does an EDSS influence quality of antenatal care and in what circumstances? Methods and analysis The pre-post outcome and theory-driven, mixed-methods process evaluation will assess implementation fidelity and improvements in the performance of selected antenatal care components, explore the implementation process and contextual factors, and examine causal mechanisms leading to change in antenatal care quality. Data for quantitative and qualitative analyses will be collected at multiple time points, and initial analyses of quantitative and qualitative data completed separately. Results will be integrated using convergent parallel-databases triangulation to develop explanations about the implementation process—over time and across settings—and the effects observed. Ethics and dissemination Ethical approval for this study was obtained from ethics committees at Kathmandu University School of Medical Sciences, Nepal Health Research Council and the London School of Hygiene & Tropical Medicine. Results will be disseminated through academic publications, stakeholder workshops, conference presentations and reports.

Additional file 1: Supplementary Figure S1. Percentage of ANC observations with components of respectful care, stratified by facility type. SupplementaryTable S1. Percentage of ANC consultations in which eachcomponent of measuring blood pressure correctly was observed (N=35, with oneANC observation excluded as there was no physical exam). Supplementary Figure S2. Percentage of ANC observations with in whichspecific symptoms were asked about in the ANC consultation, stratified byfacility type*Only includes ANCobservations at 22 weeks gestation onwards (N=22). SupplementaryFigure S3. Percentage of ANC observations with componentsof education, stratified by facility type.

Additional file 2: Appendix 2 Details of study design and sampling for UBTH patient records study (data source 3).

Additional file 1: Appendix 1 Copy of Nigeria 2018 DHS questionnaire, excerpt of obstetric referral questions.

Additional file 1. Indicators and definitions used [24, 42, 64–67, 69, 70].

BACKGROUND: Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa. METHODS: We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population. RESULTS: The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest. CONCLUSIONS: The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

Contraceptive unmet need, use, sector of care, and provider type by country and period. (DOCX 15Â kb)

Missing information on sector of care among current users of modern contraception aged 15â 24Â years. (DOCX 14Â kb)

DHS datasets & weighted sample sizes for populations included in analysis. (DOCX 16Â kb)

Figure S1. Nineteen SaTScan spatial clusters (drawn proportionate to cluster radii) of higher and lower than expected proportions of private facility birth among all most recent births. The DHS wards contained in each spatial clusters are also shown. (DOCX 130 kb)

Figure S1. Nineteen SaTScan spatial clusters (drawn proportionate to cluster radii) of higher and lower than expected proportions of private facility birth among all most recent births. The DHS wards contained in each spatial clusters are also shown. (DOCX 130 kb)