No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women

Abstract

Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

“…Furthermore, the effect of poverty was aggravated by high parity. This means that poorer, high-parity women were the subgroup that used hospitals least, expanding our previous findings from Tanzania 20 21. Socioeconomic inequality among high-parity women was larger in countries where rural hospital use was greater, such as Benin, Rwanda and Zambia.…”

“…Good accessibility is important particularly for women with obstetric risk factors, such as those with a high number of previous births. Though high-parity women in different SSA countries are advised to have a hospital birth,17–19 our previous analysis in Tanzania20 21 found high-parity, poor, rural women had low use of hospitals for childbirth.…”

Birth asphyxia and its association with grand multiparity and referral among hospital births: A prospective cross‐sectional study in Benin, Malawi, Tanzania and Uganda

“…Although there are policy guidelines for GM women on giving birth in higher level facilities, 32,33 the risk factor is poorly recognized by women, their families, and health care providers 15 . GM is linked to poverty; the complex interaction of having large families and limited economic means further results in limited proportions of women using hospitals for childbirth unless labor complications arise 16 . As early medical intervention during labor is critical to preventing severe birth asphyxia, 34 delayed hospital arrival increases risk for having an asphyxiated newborn.…”

“…Referrals to higher‐level of care should take place as complications surpass an institution's treatment capabilities 14,15 . GM women often have low antenatal care (ANC) attendance and facility‐based birth rates 10,12,16 . As a result, referrals are made late in the pregnancy course.…”

“… 14 , 15 GM women often have low antenatal care (ANC) attendance and facility‐based birth rates. 10 , 12 , 16 As a result, referrals are made late in the pregnancy course. Referral delays negatively impact birth outcomes, especially in emergencies 17 and could exacerbate the risk for birth asphyxia among GM women.…”