title: Where do the rural poor deliver when high coverage of health facility delivery is achieved? Findings from a community and hospital survey in Tanzania.
abstract: BACKGROUND
  As part of maternal mortality reducing strategies, coverage of delivery care among sub-Saharan African rural poor will improve, with a range of facilities providing services. Whether high coverage will benefit all socio-economic groups is unknown. Iringa rural District, Southern Tanzania, with high facility delivery coverage, offers a paradigm to address this question. Delivery services are available in first-line facilities (dispensaries, health centres) and one hospital. We assessed whether all socio-economic groups access the only comprehensive emergency obstetric care facility equally, and surveyed existing delivery services.
  
  
  METHODS
  District population characteristics were obtained from a household community survey (n = 463). A Hospital survey collected data on women who delivered in this facility (n = 1072). Principal component analysis on household assets was used to assess socio-economic status. Hospital population socio-demographic characteristics were compared to District population using multivariable logistic regression. Deliveries' distribution in District facilities and staffing were analysed using routine data.
  
  
  RESULTS
  Women from the hospital compared to the District population were more likely to be wealthier. Adjusted odds ratio of hospital delivery increased progressively across socio-economic groups, from 1.73 for the poorer (p = 0.0031) to 4.53 (p<0.0001) for the richest. Remarkable dispersion of deliveries and poor staffing were found. In 2012, 5505/7645 (72%) institutional deliveries took place in 68 first-line facilities, the remaining in the hospital. 56/68 (67.6%) first-line facilities reported ≤100 deliveries/year, attending 33% of deliveries. Insufficient numbers of skilled birth attendants were found in 42.9% of facilities.
  
  
  CONCLUSIONS
  Poorer women remain disadvantaged in high coverage, as they access lower level facilities and are under-represented where life-saving transfusions and caesarean sections are available. Tackling the challenges posed by low caseloads and staffing on first-line rural care requires confronting a dilemma between coverage and quality. Reducing number of delivery sites is recommended to improve quality and equity of care.
authors.affiliation: Doctors with Africa, CUAMM, Iringa, Tanzania.
authors.forename: Manuela
authors.initials: M
authors.lastname: Straneo
authors.affiliation: Doctors with Africa, CUAMM, Iringa, Tanzania.
authors.forename: Piera
authors.initials: P
authors.lastname: Fogliati
authors.affiliation: Doctors with Africa, CUAMM, Iringa, Tanzania.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Azzimonti
authors.affiliation: Tosamaganga Council Designated Hospital, Iringa, Tanzania.
authors.forename: Sabina
authors.initials: S
authors.lastname: Mangi
authors.affiliation: Reproductive and Child Health, Council Medical Office, Iringa District Council, Tanzania.
authors.forename: Firma
authors.initials: F
authors.lastname: Kisika
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility; D006700:Home Childbirth / Q000706:statistics & numerical data; D006761:Hospitals; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data; D008428:Maternal Mortality; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011247:Pregnancy; D025341:Principal Component Analysis; D012424:Rural Population; D012959:Socioeconomic Factors; D013636:Tanzania