title: Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania.
abstract: OBJECTIVE
  To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.
  
  
  METHODS
  Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multilevel logistic models to examine individual and community factors associated with home delivery.
  
  
  RESULTS
  A total of 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education [odds ratio (OR) 0.62; 95% confidence interval (CI): 0.50, 0.79], were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96) or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88).
  
  
  CONCLUSIONS
  Poverty, multiparity, weak ANC and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.
authors: Harvard TH Chan School of Public Health, Boston, MA, USA.
authors: Margaret E
authors: ME
authors: Kruk
authors: Columbia University Mailman School of Public Health, New York, NY, USA.
authors: Sabrina
authors: S
authors: Hermosilla
authors: Harvard TH Chan School of Public Health, Boston, MA, USA.
authors: Elysia
authors: E
authors: Larson
authors: Columbia University Mailman School of Public Health, New York, NY, USA.
authors: Daniel
authors: D
authors: Vail
authors: Columbia University Mailman School of Public Health, New York, NY, USA.
authors: Qixuan
authors: Q
authors: Chen
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Festo
authors: F
authors: Mazuguni
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Beatrice
authors: B
authors: Byalugaba
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Godfrey
authors: G
authors: Mbaruku
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003625:Data Collection; D036861:Delivery, Obstetric; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006700:Home Childbirth; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D055361:Multilevel Analysis; D016017:Odds Ratio; D010298:Parity; D010342:Patient Acceptance of Health Care; D011203:Poverty; D011247:Pregnancy; D011295:Prenatal Care; D012424:Rural Population; D011795:Surveys and Questionnaires; D013636:Tanzania; D055815:Young Adult
keywords: facility utilisation; maternal health; modelos multinivel; modèles multi-niveaux; multilevel models; salud materna; santé maternelle; uso de centros sanitarios; utilisation des installations