Access to institutional delivery care and reasons for home delivery in three districts of Tanzania

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Study Justification:
– The study aims to assess the facilitators and barriers to institutional delivery in three districts of Tanzania.
– The study is important because access to facility-based delivery care is crucial in preventing maternal and neonatal morbidity and mortality.
– The findings of the study can help identify factors that influence institutional delivery and inform strategies to improve access to institutional delivery care.
Highlights:
– Overall, 74.5% of the 915 women in the study delivered at health facilities in the two years prior to the survey.
– The study found that the quality of antenatal care and socioeconomic status were associated with higher odds of institutional delivery.
– Women of Sukuma ethnic background were less likely to deliver at health facilities than others.
– Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery.
Recommendations:
– Improve the quality of antenatal care to increase the likelihood of institutional delivery.
– Promote socioeconomic empowerment to enhance access to institutional delivery care.
– Support and encourage inter-spousal discussion on family planning matters to improve institutional delivery rates.
– Target women from the Sukuma ethnic group to ensure universal access to institutional delivery care in the study area.
Key Role Players:
– Ministry of Health: Responsible for implementing and coordinating interventions to improve access to institutional delivery care.
– Health facilities: Provide quality antenatal care and delivery services.
– Community health workers: Promote and support inter-spousal discussion on family planning matters.
– Non-governmental organizations: Support programs aimed at improving access to institutional delivery care.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers to improve the quality of antenatal care.
– Infrastructure development and improvement of health facilities to accommodate increased demand for institutional delivery.
– Community outreach and education programs to promote socioeconomic empowerment and inter-spousal discussion on family planning matters.
– Monitoring and evaluation activities to assess the impact of interventions and ensure progress towards universal access to institutional delivery care.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a cross-sectional survey conducted in three districts of Tanzania. The study includes a large sample size of 915 women of reproductive age who had given birth in the two years prior to the survey. The analysis uses multivariate logistic regression to examine factors that influence institutional delivery. The study identifies several significant factors associated with institutional delivery, such as the quality of antenatal care, socioeconomic status, and inter-spousal communication about family planning. The conclusion provides actionable steps to improve institutional delivery, including improving the quality of antenatal care, socioeconomic empowerment, and promoting inter-spousal discussion on family planning matters. However, the abstract does not provide information on the representativeness of the sample or the generalizability of the findings to other populations. Additionally, the abstract does not mention any limitations of the study or potential biases that may have influenced the results. To improve the evidence, future studies could include a more diverse sample and address potential limitations and biases.

Introduction. Globally, health facility delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. However, access to facility-based delivery care remains low in many less developed countries. This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Methods. Data come from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Results: Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Conclusion: Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area. © 2014Exavery et al.; licensee BioMed Central Ltd.

Data for this study come from a cross-sectional household survey that was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania using two existing and ongoing Health and Demographic Surveillance System (HDSS) platforms, namely, Rufiji HDSS located in Rufiji district, and Ifakara HDSS which occupies portions of Kilombero and Ulanga districts. The data were collected using a closed-ended questionnaire and sought to obtain information on health seeking behaviors and service utilization patterns by women and children of less than five years of age. The main purpose of the survey was to provide baseline estimates for the Connect Project, which is currently being implemented in the three districts using the HDSS platforms. More details about the Connect Project can be found in [22,23] and [24]. In brief, Connect Project tests the hypothesis that introducing a new cadre of paid community health worker, known as Community Health Agent (CHA), into the system, with the necessary supporting operations, including improvement of emergency referral, reduces child mortality, including newborn mortality, improves key maternal health outcomes, and thus accelerates progress towards (or beyond) Millennium Development Goals 4 and 5. Since the HDSS platforms are longitudinal, population-based health and vital events registration systems which monitor demographic events such as births, deaths, pregnancies, and migrations of the individuals in the study area, they were envisioned as suitable forms to monitor the outcomes and impact of the CHAs. Households for the main survey were selected randomly from a list of all households (sampling frame) under surveillance by the Rufiji, and Ifakara HDSS. Selection of these households was accomplished using probability proportional to size (PPS) technique. Since these households came from villages with unequal number of households, PPS was the ideal method to use to ensure that each village is represented in the sample. In each of the households sampled, all women of reproductive age (15‒49 years) were eligible for interviews. A woman over 49 years of age was interviewed only if she wholly took care of at least one child less than five years of age in order to obtain information on health and health service utilization pattern for the child. The current analysis focused on 915 women of reproductive age whose last birth occurred in the two years prior to the survey. Therefore, data pertaining to this population were extracted from the parent database for analysis to answer the current research questions. The outcome variable was place of delivery for births that occurred in the two years prior to the survey. This variable was binary, with one category for health facility or institutional delivery and the other for non-facility delivery. Non-facility delivery referred to all births that occurred at home, in farms or on a way to a facility/birth before arrival. Institutional delivery was coded as ‘1’ and non-facility delivery was coded as ‘0’ for computational reasons. Several explanatory variables were considered. Household socioeconomic status was included, resulting from Principal Component Analysis (PCA) of household assets [25]. Five wealth quintiles were constructed based on ownership of a toilet, toilet type, and source of drinking water. The quintiles ranged from the poorest (Q1) to the wealthiest (Q5) such that the higher the quintile the wealthier the woman’s household. Other assets such as household building material were unfortunately unavailable for the PCA. Other explanatory variables included were education, age, marital status, ethnicity, religion, gravidity, pregnancy intentions, district of residence and type of residence (rural or urban). Gravidity was considered a proxy for fertility. Household headship, inter-spousal communication or discussion about family planning matters were also included in the analysis. Moreover, we included ANC score of 15 health services whose utilization status during pregnancy was available. Each of these had a ‘yes’ or ‘no’ response to whether a woman was weighed, had her blood pressure measured, height measured, urine sampled, blood sampled, abdomen measured, heart rate of the baby assessed, given an injection in the arm to prevent tetanus (TT), counseled on financial preparation for delivery, counseled on breastfeeding immediately after delivery, counseled on danger signs during delivery, counseled on family planning, counseled on identifying emergency transport options, counseled on danger signs of pregnancy, and counseled and tested for HIV. The scores ranged from 0, if a woman received none of the services, to 15 if she received all of these eservices. We assumed that the bigger the score the better the quality of ANC. The other variable included was the number of ANC visits a woman made during pregnancy. The sample was first analyzed descriptively to obtain frequency distribution of the women across several characteristics. Bivariate analysis was then conducted by cross-tabulating place of delivery against each of the explanatory variables. The explanatory variables were categorical, and those which were not were categorized and therefore the degree of association between each pair of variables cross-tabulated was tested using Chi-Square (χ2). Multivariate analysis was performed using logistic regression to assess factors associated with institutional delivery. Beforehand, an assessment of clustering at household level was carried out to check whether the assumption of independence of observations holds. This was prompted by the fact that during data collection, the interview included all eligible women from the same household for households which had more than one. The assumption was that women from the same household may have the same or similar health behaviours. The assessment ultimately showed that the observations were independent of one another because there was no significant evidence of clustering at household level. In performing the logistic regression analysis, a variable was retained in the multivariate model if the log likelihood ratio test showed that its presence improved the overall model [26]. In this case, ANC score of the ANC services was treated as a continuous variable in order to optimize its predictive power. The level of significance was set at 5%. The entire process of data analysis was carried out using STATA (version 11) statistical software. Ethical approval for the main survey was granted by the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR) in Tanzania. During the survey, participation was voluntary and each woman signed (or provided a thumb print if she was illiterate) a statement of an informed consent after which she was interviewed. For legal reasons, an assent was sought for participants less than 18 years of age. Data storage and processing were all handled securely within the Ifakara Health Institute where the Connect Project is based.

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Based on the study mentioned, here are some innovations that can be developed to improve access to maternal health:

1. Mobile ANC clinics: To improve the quality of antenatal care (ANC), mobile clinics can be set up to provide ANC services in remote areas where access to healthcare facilities is limited. These clinics can be equipped with necessary equipment and supplies, and staffed by trained healthcare providers who can provide comprehensive ANC services to pregnant women.

2. Microfinance programs: To address the socioeconomic empowerment recommendation, microfinance programs can be implemented to provide financial support to pregnant women and their families. These programs can offer small loans or grants to women to start or expand their own businesses, which can help improve their economic status and enable them to afford institutional delivery care.

3. Community-based family planning education: To promote and support inter-spousal discussion on family planning, community-based education programs can be implemented to raise awareness about the importance of family planning and involve both partners in the decision-making process. These programs can provide information on different family planning methods, their benefits, and how to access them.

4. Cultural sensitivity training for healthcare providers: To target specific ethnic groups, healthcare providers can receive cultural sensitivity training to better understand the beliefs, values, and practices of different ethnic groups. This training can help healthcare providers provide culturally appropriate care and address any barriers or misconceptions that may prevent women from certain ethnic backgrounds from seeking institutional delivery care.

These innovations can help improve access to maternal health by addressing the specific barriers identified in the study and ensuring that pregnant women receive the necessary care and support for a safe and healthy delivery.
AI Innovations Description
Based on the study mentioned, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve the quality of antenatal care (ANC): The study found that the better the quality of ANC, the higher the odds of institutional delivery. Therefore, efforts should be made to enhance the quality of ANC services provided to pregnant women. This can include training healthcare providers, ensuring the availability of necessary equipment and supplies, and implementing evidence-based guidelines for ANC.

2. Socioeconomic empowerment: The study also showed that better socioeconomic status was associated with an increase in the odds of institutional delivery. To improve access to maternal health, interventions should focus on empowering women economically. This can be done through providing income-generating opportunities, promoting financial literacy, and supporting women’s entrepreneurship.

3. Promote and support inter-spousal discussion on family planning: The presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Encouraging open communication and involvement of both partners in family planning decisions can help increase the likelihood of women seeking institutional delivery care. This can be achieved through community education programs, counseling services, and involving men in antenatal care visits.

4. Target specific ethnic groups: The study found that women from the Sukuma ethnic background were less likely to deliver at health facilities. To ensure universal access to institutional delivery care, targeted interventions should be implemented to address the specific barriers faced by this ethnic group. This can involve culturally sensitive outreach programs, community engagement, and collaboration with local leaders.

By implementing these recommendations, innovative approaches can be developed to improve access to maternal health, leading to a reduction in maternal and neonatal morbidity and mortality.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Identify the target population: Determine the specific population group that will be the focus of the simulation. This could be women of reproductive age in the Rufiji, Kilombero, and Ulanga districts of Tanzania.

2. Collect baseline data: Gather data on the current status of access to maternal health in the target population. This can include information on the percentage of women delivering at health facilities, the quality of antenatal care received, socioeconomic status, inter-spousal communication on family planning, and the delivery preferences of different ethnic groups.

3. Define the intervention: Based on the recommendations mentioned in the study, design an intervention that incorporates the suggested strategies for improving access to maternal health. This could involve implementing training programs for healthcare providers to improve the quality of antenatal care, implementing socioeconomic empowerment initiatives for women, promoting inter-spousal discussion on family planning, and developing targeted interventions for the Sukuma ethnic group.

4. Simulate the impact: Using statistical modeling techniques, simulate the impact of the intervention on access to maternal health. This can involve analyzing the potential changes in the percentage of women delivering at health facilities, the improvement in the quality of antenatal care, the increase in socioeconomic status, the increase in inter-spousal communication on family planning, and the change in delivery preferences among the Sukuma ethnic group.

5. Evaluate the results: Assess the outcomes of the simulation to determine the effectiveness of the intervention in improving access to maternal health. This can involve comparing the simulated results with the baseline data to measure the extent of improvement achieved.

6. Refine and iterate: Based on the evaluation results, refine the intervention and repeat the simulation process to further optimize the strategies for improving access to maternal health. This iterative process can help identify the most effective combination of interventions and refine the implementation approach.

By following this methodology, researchers and policymakers can gain insights into the potential impact of the recommended strategies on improving access to maternal health and make informed decisions on implementing innovative approaches in real-world settings.

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