Elysia Larson1, Daniel Vail2, Godfrey M Mbaruku3, Redempta Mbatia4, Margaret E Kruk1. 1. Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Bldg 1, 11th floor, Boston, MA 02115, USA. 2. Stanford University School of Medicine, 291 Campus Drive, Palo Alto, CA 94305, USA. 3. Ifakara Health Institute, P.O. Box 78373, Plot 463, Kiko Avenue, Mikocheni A, Mwai Kibaki Road, Dar es salaam, United Republic of Tanzania. 4. Tanzania Health Promotion Support, 3rd Floor, Coco Plaza Bldg, Plot 254, Masaki Dar es Salaam, United Republic of Tanzania.
Abstract
OBJECTIVE: To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth. DESIGN: Cross-sectional structured interviews. SETTING: Pwani Region, Tanzania. PARTICIPANTS: The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits. MAIN OUTCOME MEASURES: We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth. RESULTS: In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3). CONCLUSIONS: Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels. TRIAL REGISTRATION: ISRCTN 17107760.
OBJECTIVE: To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth. DESIGN: Cross-sectional structured interviews. SETTING: Pwani Region, Tanzania. PARTICIPANTS: The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits. MAIN OUTCOME MEASURES: We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth. RESULTS: In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3). CONCLUSIONS: Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels. TRIAL REGISTRATION: ISRCTN 17107760.
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