title: Beyond utilization: measuring effective coverage of obstetric care along the quality cascade.
abstract: OBJECTIVE
  To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth.
  
  
  METHODS
  Cross-sectional structured interviews.
  
  
  METHODS
  Pwani Region, Tanzania.
  
  
  METHODS
  The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits.
  
  
  METHODS
  We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth.
  
  
  RESULTS
  In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3).
  
  
  CONCLUSIONS
  Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels.
  
  
  BACKGROUND
  ISRCTN 17107760.
authors.affiliation: Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Bldg 1, 11th floor, Boston, MA 02115, USA.
authors.forename: Elysia
authors.initials: E
authors.lastname: Larson
authors.affiliation: Stanford University School of Medicine, 291 Campus Drive, Palo Alto, CA 94305, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Vail
authors.affiliation: Ifakara Health Institute, P.O. Box 78373, Plot 463, Kiko Avenue, Mikocheni A, Mwai Kibaki Road, Dar es salaam, United Republic of Tanzania.
authors.forename: Godfrey M
authors.initials: GM
authors.lastname: Mbaruku
authors.affiliation: Tanzania Health Promotion Support, 3rd Floor, Coco Plaza Bldg, Plot 254, Masaki Dar es Salaam, United Republic of Tanzania.
authors.forename: Redempta
authors.initials: R
authors.lastname: Mbatia
authors.affiliation: Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Bldg 1, 11th floor, Boston, MA 02115, USA.
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Kruk
mesh_terms: D002983:Clinical Competence; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000592:standards / Q000706:statistics & numerical data*; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006282:Health Personnel / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D011203:Poverty; D011247:Pregnancy; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D013636:Tanzania
keywords: effective coverage; health services research; maternal and newborn health; measurement of quality