Where Do the Rural Poor Deliver When High Coverage of Health Facility Delivery Is Achieved? Findings from a Community and Hospital Survey in Tanzania

Abstract

IntroductionAs 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.MethodsDistrict 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.ResultsWomen 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.DiscussionPoorer 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.

Why women bypass front‐line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania

“…Women report bypassing dispensaries because they lack diagnostic facilities, drugs and skilled staff, because of their overall poor services and because women have lower trust in dispensary staff . Tanzanian policy stipulates that 70% of dispensaries should be able to provide basic EmONC services . However, recent studies demonstrate that dispensaries receive the fewest resources , lack staff to provide 24‐h coverage for delivery , and lack essential obstetric drugs, leading to mistrust of health workers and delays in care .…”

“…In Tanzania, national policy stipulates that dispensaries and health centres are the front‐line facilities to which women should present for delivery if they have not experienced a previous obstetric complication . Complicated cases, or women who have experienced a previous complication, are referred to hospitals .…”

“…Complicated cases, or women who have experienced a previous complication, are referred to hospitals . As part of the national plan to decentralise healthcare and increase access, the government plans for 70% of dispensaries to be able to provide basic emergency obstetric care by 2015 . However, dispensaries suffer from lack of resources and staff as well as essential drugs for delivery , and bypassing of both types of front‐line facilities (dispensaries and health centres) is frequent .…”

“…As part of the national plan to decentralise healthcare and increase access, the government plans for 70% of dispensaries to be able to provide basic emergency obstetric care by 2015 . However, dispensaries suffer from lack of resources and staff as well as essential drugs for delivery , and bypassing of both types of front‐line facilities (dispensaries and health centres) is frequent . In an attempt to better understand women's health‐seeking behaviour around delivery, we use a multilevel logistic regression model to assess the association between bypassing nearest FLF for childbirth and the number of emergency obstetric and newborn care (EmONC) signal functions recently performed at nearest FLFquality of care, controlling for individual and contextual factors.…”

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys

“…13 One important question in resource-constrained contexts concerns the safety and quality of low-volume, primary care delivery facilities where pregnant women deemed at low risk of complications are directed to deliver. 10,14 The positive association between volume of deliveries and improved maternal and newborn baby outcomes has been well established in high-income countries. For example, US hospitals and providers with the lowest delivery volumes (<25 deliveries per month in hospitals, <seven per year in health-care providers) had up to 50% more adverse maternal outcomes than hospitals and providers with higher delivery volumes.…”