title: Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey.
abstract: BACKGROUND
  Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia.
  
  
  METHODS
  A population-based survey was conducted in 2007 as part of the 'REsponse to ACcountable priority setting for Trust in health systems' (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban-rural residence.
  
  
  RESULTS
  There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi.
  
  
  CONCLUSIONS
  Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.
authors.affiliation: Centre for International Health, Department of Global Health and Primary Care, University of Bergen, Bergen, Norway. snganjop@yahoo.com.
authors.forename: Selia
authors.initials: S
authors.lastname: Ng'anjo Phiri
authors.forename: Torvid
authors.initials: T
authors.lastname: Kiserud
authors.forename: Gunnar
authors.initials: G
authors.lastname: Kvåle
authors.forename: Jens
authors.initials: J
authors.lastname: Byskov
authors.forename: Bjørg
authors.initials: B
authors.lastname: Evjen-Olsen
authors.forename: Charles
authors.initials: C
authors.lastname: Michelo
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Echoka
authors.forename: Knut
authors.initials: K
authors.lastname: Fylkesnes
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D019538:Health Care Surveys; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006700:Home Childbirth / Q000706:statistics & numerical data*; D006801:Humans; D007630:Kenya; D017533:Marital Status; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards; D011787:Quality of Health Care; D012424:Rural Population / Q000706:statistics & numerical data*; D012923:Social Class; D013636:Tanzania; D035502:Trust; D014505:Urban Population / Q000706:statistics & numerical data*; D055815:Young Adult; D015024:Zambia