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. The study was a cross-sectional household survey in Iringa District, one of eight districts of the then Iringa Region, in the Southern Highlands of Tanzania. It has a mostly rural population of approximately 260,000. Health facilities include the diocesan-owned district designated hospital, six health centres, and 59 dispensaries. Women can deliver in all levels of facilities. The district health system has a pyramidal structure, with dispensaries at the base. Each level refers complications to the one above, though services available in dispensaries and health centres generally do not differ. While the district hospital can offer all functions of comprehensive emergency obstetric care, none of the peripheral health facilities can be classed as basic emergency obstetric Care units. The District was part of a health system strengthening project implemented by a non-governmental organization from 2009–2012, which focused on access, quality and equity of reproductive health services. A representative sample of the district population was obtained through two-stage cluster sampling. The sample size of 431 women (730 households) was based on estimating the primary indicator of facility delivery, using an expected prevalence of 75% (TDHS 2010), sampling error of 5% and design effect of 1.515. Thirty villages were randomly chosen in the first stage with probability proportional to size, based on population projections from the Tanzania 2002 census. Twenty-five households were selected in each village in the second stage through random systematic sampling. A random walking direction was chosen by bottle spinning by the village office and consecutive households in the selected direction were visited. When inhabitants could not be located, the next household in the same direction was interviewed. Data was collected in October 2009 by trained female interviewers using a pre-tested structured questionnaire. The survey was conducted with the permission and the full cooperation of the council health management team. All selected households were asked about household access to water, sanitation and socio-economic assets, and where available one woman of childbearing age (15–49 years) who had delivered in the previous five years was interviewed on her care seeking. If the household had >1 eligible woman present, one was selected using a table of random numbers and interviewed. Information on distance to the nearest health facility was collected from village authorities. Data was double entered and cleaned in EpiData (version 3.1), and analysis was performed using STATA (version 9.2). The STATA svyset command were used to specify survey design characteristics. Svy commands were used both in bivariate and multivariate analysis to account for clustered design. The primary outcomes were ANC (≥4 visits) and health facility delivery. Socio-economic status (SES) was calculated based on household assets assessment16. Socio-economic scores were produced using durable household possessions, as applied by Bernard et al17 in rural Tanzania, a context very similar to that of the present study. Principal component analysis (PCA) was used to define weights for these assets18. The score from the first component, which accounted for 41.5% of data variability, was used to construct five socio-economic quintiles. Associations between the primary outcomes and potential explanatory variables (demographic characteristics, SES, distance to health facility and timing and number of ANC visits received) were assessed using crude odds ratios. Variables which were significant in bivariate analysis or which were associated with the relevant outcome in previous studies were included in multivariate regression models to calculate adjusted odds ratios. Ethical approval was obtained from the National Institute for Medical Research (Tanzania) and the London School of Hygiene and Tropical Medicine. All women provided written informed consent.