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 654 ANC visits. Determinants were analysed using multivariate regression. Results: Almost all women had attended ANC, though only 58.3% had 654 visits. 654 visits were more likely in the youngest age group (OR 2.7 95% CI 1.32\u20135.49, p=0.008), and in early ANC attenders (OR 3.2 95% CI 2.04\u20134.90, p<0.001). Facility delivery was greater than expected (87.7%), more likely in more educated women (OR 2.7 95% CI 1.50\u20134.75, p=0.002), in those within 5 kilometers of a facility (OR 3.2 95% CI 1.59\u20136.48, p=0.002), and for early ANC attenders (OR 2.4 95% CI 1.20\u20134.91, 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

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

<div><p>Introduction</p><p>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.</p><p>Methods</p><p>District population characteristics were obtained from a household <i>community survey</i> (<i>n = 463</i>). A <i>Hospital survey</i> collected data on women who delivered in this facility (<i>n = 1072</i>). 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.</p><p>Results</p><p>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.</p><p>Discussion</p><p>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.</p></div

Association between covariates. Study population from hospital survey compared to the study population from community survey.

<p>*Adjusted Wald test.</p><p>Association between covariates. Study population from hospital survey compared to the study population from community survey.</p

Odds ratios of belonging to hospital population compared to District population by socio-economic quintiles, with respective 95% confidence intervals.

<p>Iringa District, Tanzania. 2009–2012.</p

Data flow for the community and hospital surveys.

<p>Data flow for the community and hospital surveys.</p

Distribution of deliveries by facility caseload in Iringa District in 2012 (based on HMIS data).

<p>*District Hospital.</p><p>Distribution of deliveries by facility caseload in Iringa District in 2012 (based on HMIS data).</p

Socio-demographic characteristics of women who delivered at District hospital compared to women from the community of provenance.

<p>*adjusted for cluster design.</p><p>Iringa District, Tanzania. 2009–2012.</p><p>Socio-demographic characteristics of women who delivered at District hospital compared to women from the community of provenance.</p

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