Community and health system factors associated with facility delivery in rural Tanzania: A multilevel analysis
Introduction
Maternal mortality is a great global health challenge and one for which progress has been most elusive [1], [2]. Almost all of the half million maternal deaths globally are in low- and middle-income countries [3]. In Africa, the continent with the highest maternal mortality ratio, three-quarters of deaths are due to direct obstetric causes, such as hemorrhage (33.9% of deaths), sepsis (9.7%), and hypertensive disorders (9.1%) [2], [4]. Many of these deaths can be averted through skilled delivery care and provision of emergency obstetric care for women who develop complications [5]. Yet utilization rates of these services are low: only one in three women in rural sub-Saharan Africa deliver with a skilled attendant (doctor, nurse, or midwife) [6].
Throughout much of sub-Saharan Africa and parts of Asia, low health budgets and shortages of providers, equipment, medicines, and clinics outside of cities have limited access to professionally-attended childbirth [7]. However, Tanzania, a low-income country in East Africa, has managed to build up an extensive health infrastructure with nearly 5000 dispensaries throughout the country. These first-level health clinics provide primary care and are expected to perform uncomplicated deliveries. [8] An estimated 90% of the population lives within 10 km of a health facility [9]. Although these figures suggest good physical availability of services, only 47% of Tanzanian women deliver in a health facility.
Several theoretical models of utilization have been proposed to explain variation in the use of health services, although few of these have been applied in low-income country settings. Andersen's influential behavioral model of health care utilization proposes that variation in utilization is due to differences in predisposing factors (age, income, parity, health beliefs), enabling resources (community and family resources), and need (perceived and actual) [10]. More recently Andersen revised his original model to include supply-side characteristics, such as the organization of the health care system, in the explanatory framework [11].
Donabedian was among the first to integrate the demand (patient) and supply (health system) characteristics in explaining differences in utilization. He noted that patients used health services when there was “correspondence” between their assessment of their health need and the ability of the available medical services to meet it [12]. Penchansky and Thomas used a similar notion of “fit” between providers and services on the one hand and characteristics and expectations of clients on the other to define access to health care [13]. One example of a “fit” variable is trust: Gilson has pointed out that in sub-Saharan Africa interactions with providers and village discussions can enhance (decrease) trust in the health care system, which in turn increases (decreases) use of health services [14]. A recent paper by McIntyre et al. on the policy applications of the concept of access in low- and middle-income countries described access as a multidimensional concept based on the interaction between health care systems and individuals, households, and communities [15].
However, empiric work on utilization has not reflected the growing theoretical emphasis on the fit between the individual, his or her community, and the health system. This is even more evident in the context of developing countries, where only recently researchers have begun to employ multilevel models to account for area-level determinants in studies of health service utilization. [16], [17], [18], [19]
In this paper, we focused on individual and community perceptions of the health system as explanatory factors for the decision to deliver in a health facility in rural, western Tanzania. Specifically, we explored how predisposing factors such as the demographic profile, obstetric risk, and health beliefs of individual women and their communities are modified by perceptions of the quality of the health system in explaining variation in the use of health facilities. We use the results of the analysis to identify appropriate entry-points for policy interventions to improve access to professional delivery care.
Section snippets
Study area and sampling
Kasulu District is one of four districts in Kigoma Region, on Tanzania's western border with a total population of 630,000. The district is rural with one main town, Kasulu (population 33,000) [20]. Kasulu District has 48 functioning government dispensaries that provide primary care and attend to uncomplicated deliveries. In addition, there are 22 other health facilities in the district, including one government district hospital where obstetric complications are treated. The majority of
Results
We contacted 1322 eligible respondents. Of these, 1205 (91.1%) women agreed to participate in the study. On average, women were 28.7 years old at the time of their most recent delivery (Table 1), and 72.2% had received some education. Few (12.5%) women were enrolled in community health insurance. Nearly three-quarters (74.2%) of women stated that delivering in a health facility was very important, while 7.1% stated the quality of care at their nearest facility was excellent. More than
Discussion
Using data from a population-based study of women in rural Tanzania we found evidence that community perceptions of the quality of the formal health system and informal providers were associated with facility delivery, adjusting for a range of individual-level variables. Our finding that a positive village opinion of the quality of formal providers and the nearest health facility was associated with higher likelihood of facility utilization for childbirth can help shed some light on the
Conclusions
Limitations considered, our study points to the importance of the reputation for quality of local clinics and providers in explaining variability in utilization of health services. In African regions such as Kasulu, where facilities are relatively plentiful, the implications of our findings are two-fold.
First, the reputation for quality of care influences mothers’ decisions about where to deliver. Improving this reputation requires tackling documented deficiencies in the performance of primary
Conflict of interest statement
The authors state that they have no conflict of interest.
Acknowledgments
This study was funded in part by the Averting Maternal Death and Disability Program of the Heilbrunn Department of Population and Family Health at Columbia University's Mailman School of Public Health. The Averting Maternal Death and Disability Program is funded in part by the Bill and Melinda Gates Foundation. The funders had no role in the study design, data analysis, or the decision to submit the paper for publication.
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