Inequity in uptake of hospital-based childbirth care in rural Tanzania: analysis of the 2015-16 Tanzania Demographic and Health Survey.

Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.

A new use for an old tool: maternity waiting homes to improve equity in rural childbirth care. Results from a cross-sectional hospital and community survey in Tanzania.

Limited quality of childbirth care in sub-Saharan Africa primarily affects the poor. Greater quality is available in facilities providing advanced management of childbirth complications. We aimed to determine whether Maternity Waiting Homes (MWHs) may be a tool to improve access of lower socio-economic women to such facilities. Secondary analysis of a cross-sectional hospital survey from Iringa District, Tanzania was carried out. Women who delivered between October 2011 and May 2012 in the only District facility providing comprehensive Emergency Obstetric Care were interviewed. Their socio-economic profile was obtained by comparison with District representative data. Multivariable logistic regression was used to compare women who had stayed in the MWH before delivery with those who had accessed the hospital directly. Out of 1072 study participants, 31.3% had accessed the MWH. In multivariable analysis, age, education, marital status and obstetric factors were not significantly associated with MWH stay. Adjusted odds ratios for MWH stay increased progressively with distance from the hospital (women living 6-25 km, OR 4.38; 26-50 km, OR 4.90; >50 km, OR 5.12). In adjusted analysis, poorer women were more likely to access the MWH before hospital delivery compared with the wealthiest quintile (OR 1.38). Policy makers should consider MWH as a tool to mitigate inequity in rural childbirth care.

On the way to universal coverage of maternal services in Iringa rural District in Tanzania. Who is yet to be reached?

BACKGROUND: Strategies to tackle maternal mortality in sub-Saharan Africa include expanding coverage of reproductive services. Even where high, more vulnerable women may not access services. No data is available on high coverage determinants. We investigated this in Tanzania in a predicted high utilization area. METHODS: Data was collected through a household survey of 464 women with a recent delivery. Primary outcomes were facility delivery and ≥4 ANC visits. Determinants were analysed using multivariate regression. RESULTS: Almost all women had attended ANC, though only 58.3% had ≥4 visits. ≥4 visits were more likely in the youngest age group (OR 2.7 95% CI 1.32-5.49, p=0.008), and in early ANC attenders (OR 3.2 95% CI 2.04-4.90, p<0.001). Facility delivery was greater than expected (87.7%), more likely in more educated women (OR 2.7 95% CI 1.50-4.75, p=0.002), in those within 5 kilometers of a facility (OR 3.2 95% CI 1.59-6.48, p=0.002), and for early ANC attenders (OR 2.4 95% CI 1.20-4.91, p=0.02). CONCLUSION: Rural contexts can achieve high facility delivery coverage. Based on our findings, strategies to reach women yet unserved should include promotion of early ANC start particularly for the less educated, and improvement of distant communities' access to facilities.

How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania.

INTRODUCTION: Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access. METHODS: Data on health facilities' location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites. RESULTS: About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours' walking time. CONCLUSIONS: Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings.

Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania.

INTRODUCTION: As part of maternal mortality reducing strategies, coverage of delivery care among sub-Saharan African rural poor will improve, with a range of facilities providing services. Whether high coverage will benefit all socio-economic groups is unknown. Iringa rural District, Southern Tanzania, with high facility delivery coverage, offers a paradigm to address this question. Delivery services are available in first-line facilities (dispensaries, health centres) and one hospital. We assessed whether all socio-economic groups access the only comprehensive emergency obstetric care facility equally, and surveyed existing delivery services. METHODS: District population characteristics were obtained from a household community survey (n = 463). A Hospital survey collected data on women who delivered in this facility (n = 1072). Principal component analysis on household assets was used to assess socio-economic status. Hospital population socio-demographic characteristics were compared to District population using multivariable logistic regression. Deliveries' distribution in District facilities and staffing were analysed using routine data. RESULTS: Women from the hospital compared to the District population were more likely to be wealthier. Adjusted odds ratio of hospital delivery increased progressively across socio-economic groups, from 1.73 for the poorer (p = 0.0031) to 4.53 (p<0.0001) for the richest. Remarkable dispersion of deliveries and poor staffing were found. In 2012, 5505/7645 (72%) institutional deliveries took place in 68 first-line facilities, the remaining in the hospital. 56/68 (67.6%) first-line facilities reported ≤100 deliveries/year, attending 33% of deliveries. Insufficient numbers of skilled birth attendants were found in 42.9% of facilities. DISCUSSION: Poorer women remain disadvantaged in high coverage, as they access lower level facilities and are under-represented where life-saving transfusions and caesarean sections are available. Tackling the challenges posed by low caseloads and staffing on first-line rural care requires confronting a dilemma between coverage and quality. Reducing number of delivery sites is recommended to improve quality and equity of care.