title: Determinants of postnatal care use at health facilities in rural Tanzania: multilevel analysis of a household survey.
abstract: BACKGROUND
  Postnatal care (PNC) for the mother and infant is a neglected area, even for women who give birth in a health facility. Currently, there is very little evidence on the determinants of use of postnatal care from health facilities in Tanzania.
  
  
  METHODS
  This study examined the role of individual and community-level variables on the use of postnatal health services, defined as a check up from a heath facility within 42 days of delivery, using multilevel logistic regression analysis. We analyzed data of 1931 women, who had delivered in the preceding 2-14 months, from a two-stage household survey in 4 rural districts of Morogoro region, Tanzania. Individual level explanatory variables included i) Socio-demographic factors: age, birth order, education, and wealth, ii) Factors related to pregnancy: frequency of antenatal visits, history of complications, mode of delivery, place of delivery care, and counseling received. Community level variables included community levels of family planning, health service utilization, trust, poverty and education, and distance to health facility.
  
  
  RESULTS
  Less than one in four women in Morogoro reported having visited a health facility for postnatal care. Individual-level attributes positively associated with postnatal care use were women's education of primary level or higher [Odds Ratio (OR) 1.37, 95 % Confidence Interval (CI) 1.04-1.81], having had a caesarean section or forceps delivery (2.95, 1.8-4.81), and being counseled by a community health worker to go for postnatal care at a health facility (2.3, 1.36-3.89). Other positive associations included those recommended HIV testing for baby (1.94, 1.19-3.15), and whose partners tested for HIV (1.41, 1.07-1.86). High community levels of postpartum family planning usage (2.48, 1.15-5.37) and high level of trust in health system (1.77, 1.12-2.79) were two significant community-level predictors. Lower postnatal care use was associated with having delivered at a hospital (0.5, 0.33-0.76), health center (0.57, 0.38-0.85), or dispensary (0.48, 0.33-0.69), and having had severe swelling of face and legs during pregnancy (0.65, 0.43-0.97).
  
  
  CONCLUSIONS
  In the context of low postnatal care use in a rural setting, programs should direct efforts towards reaching women who do not avail themselves of postnatal care as identified in our study.
authors.affiliation: Department of International health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. dr.dmohan79@gmail.com.
authors.forename: Diwakar
authors.initials: D
authors.lastname: Mohan
authors.affiliation: Department of International health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. shivam.gupta@gmail.com.
authors.forename: Shivam
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Department of International health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. aelefevre@gmail.com.
authors.forename: Amnesty
authors.initials: A
authors.lastname: LeFevre
authors.affiliation: Jhpiego, Baltimore, Maryland. ebazant@jhpiego.net.
authors.forename: Eva
authors.initials: E
authors.lastname: Bazant
authors.affiliation: Department of Biostatistics & Epidemiology, Muhimbili University of Allied Health Sciences, Dar es Salaam, Tanzania. jkillewo@yahoo.co.uk.
authors.forename: Japhet
authors.initials: J
authors.lastname: Killewo
authors.affiliation: Department of International health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. abaqui@jhu.edu.
authors.forename: Abdullah H
authors.initials: AH
authors.lastname: Baqui
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data; D004522:Educational Status; D005191:Family Characteristics; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D055361:Multilevel Analysis; D016017:Odds Ratio; D010298:Parity; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011181:Postnatal Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D012111:Residence Characteristics; D012424:Rural Population / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013636:Tanzania; D055815:Young Adult