title: Why women bypass front-line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania.
abstract: OBJECTIVE
  In the Tanzanian health system, women are expected to first visit their nearest front-line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behaviour.
  
  
  METHODS
  Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered 'bypassers'. Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited, among 521 women with no previous complications, and among 407 women not primigravida and without previous complications.
  
  
  RESULTS
  More than 75.4% of women bypassed. In the fully adjusted model of all 597 women those who had experienced complications were more likely to bypass for delivery [OR = 6.31 (2.36, 16.86)]. In the fully adjusted model excluding women with previous complications, primigravida women were more likely to bypass [OR = 3.70 (1.71, 8.01)]. Fully adjusted models for each set of analysis found that, for each additional emergency obstetric and newborn care signal function (EmONC SF) available at the nearest FLF, women's odds of bypassing almost halved.
  
  
  CONCLUSIONS
  Bypassing is highly associated with EmONC SF score at nearest FLF, controlling for individual and community-level factors.
authors.affiliation: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.|Ifakara Health Institute, Dar-Es-Salaam, Tanzania.
authors.forename: A M
authors.initials: AM
authors.lastname: Kanté
authors.affiliation: Ifakara Health Institute, Dar-Es-Salaam, Tanzania.
authors.forename: A
authors.initials: A
authors.lastname: Exavery
authors.affiliation: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: J F
authors.initials: JF
authors.lastname: Phillips
authors.affiliation: Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA.
authors.forename: E F
authors.initials: EF
authors.lastname: Jackson
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric; D004632:Emergency Medical Services; D005260:Female; D020073:Gravidity; D006268:Health Facilities; D006297:Health Services Accessibility; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D008427:Maternal Health Services; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D011248:Pregnancy Complications; D011787:Quality of Health Care; D012424:Rural Population; D013636:Tanzania; D055815:Young Adult
keywords: Tanzania; Tanzanie; accouchement dans un établissement; analyse multi-niveaux; análisis multinivel; atención de emergencia obstétrica y partos; bypassing; calidad de cuidados; comportamiento de búsqueda de salud; comportement de recherche de santé; contournement; elusión; emergency obstetric and newborn care; facility delivery; health-seeking behaviour; multilevel analysis; parto hospitalario; quality of care; qualité des soins; soins obstétriques d'urgence et néonatals