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

Abstract

IntroductionMaternal 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.MethodsData 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.ResultsAbout 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.ConclusionsOur 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.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…For Tanzania, some studies suggest that policies aiming to reduce distance or travel time, by expanding service provision, deteriorate service quality when scarce resources are diluted. This may put the poorest people who cannot pay the cost of bypassing their nearest facility at higher risk of receiving suboptimal care [54,55]. To ensure access to adequate care for all, concerted effort and innovative targeting are required.…”

“…In a setting of high facility density and limited resources, it has been shown that concentrating available resources in fewer, but strategically selected, facilities/ sites may promote geographic accessibility for all. In Tanzania and other LMICs, positive outcomes in physical accessibility and quality of care were achieved when interventions were supported by the right tools and approaches [55][56][57][58].…”

A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africa

“…Key features and landmarks are digitized to create shapefiles and vector layers of spatial objects that can then be imported and analysed in major analytical software packages broadly used in epidemiological studies (such as Stata, R, ArcGIS and QGIS). Multiple studies of maternity care determinants set in LMICs have already adopted this approach [ 33 , 58 – 61 ]. Prioritizing accurate, up to date, and reliable geospatial data availability has been highlighted in expert group meetings [ 62 ], but the compilation of geospatial data of health facility census and other ancillary data (e.g., road network) remains a challenge for local teams.…”

Subnational variation for care at birth in Tanzania: is this explained by place, people, money or drugs?

“…Strong effective managers and supportive supervision may be a key factor in quality health care in resource-poor settings with overwhelmed staff [ 65 , 66 ]. Emerging evidence from the Tanzanian context suggests that concentrating skilled staff in fewer front line facilities, with higher-volume case management, could improve care at birth, and cause minimal loss of population coverage in rural areas [ 67 , 68 ]. As poor rural women bypass facilities (and cross administrative boundaries) with inadequate care at birth provision [ 50 , 69 , 70 ], such a solution may be most pragmatic where skilled health workers are in critical shortage.…”