title: How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania.
abstract: BACKGROUND
  Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access.
  
  
  METHODS
  Data on health facilities' location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites.
  
  
  RESULTS
  About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours' walking time.
  
  
  CONCLUSIONS
  Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings.
authors.affiliation: Doctors with Africa-CUAMM, Padua, Italy.
authors.forename: Piera
authors.initials: P
authors.lastname: Fogliati
authors.affiliation: Doctors with Africa-CUAMM, Iringa, Tanzania.
authors.forename: Manuela
authors.initials: M
authors.lastname: Straneo
authors.affiliation: Department of Physical Sciences, Earth and Environment, University of Siena, Siena, Italy.
authors.forename: Cosimo
authors.initials: C
authors.lastname: Brogi
authors.affiliation: Department of Physical Sciences, Earth and Environment, University of Siena, Siena, Italy.
authors.forename: Pier Lorenzo
authors.initials: PL
authors.lastname: Fantozzi
authors.affiliation: Regional Medical Office, Iringa Region, Iringa, Tanzania.
authors.forename: Robert Mahimbo
authors.initials: RM
authors.lastname: Salim
authors.affiliation: Council Medical Office, Ludewa District Council, Ludewa, Tanzania.
authors.forename: Hamis Mwendo
authors.initials: HM
authors.lastname: Msengi
authors.affiliation: Doctors with Africa-CUAMM, Iringa, Tanzania.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Azzimonti
authors.affiliation: Doctors with Africa-CUAMM, Padua, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Putoto
mesh_terms: D006297:Health Services Accessibility; D008427:Maternal Health Services / Q000639:trends*; D036801:Parturition; D012424:Rural Population; D013636:Tanzania