Reproductive Health and Wellness
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 (n5463). A Hospital survey collected data on women who delivered in this facility (n51072). Principal component analysis on household assets was used to assess socio-economic status. Hospital population sociodemographic 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 (p50.0031) 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.
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