Kruk Margaret E, Mbaruku Godfrey, McCord Colin W, Moran Molly, Rockers Peter C, Galea Sandro
University of Michigan School of Public Health, Department of Health Management and Policy, 109 Observatory Road, SPH II M3166, Ann Arbor, MI, 48109, USA.
Health Policy Plan. 2009 Jul;24(4):279-88. doi: 10.1093/heapol/czp011. Epub 2009 Mar 20.
In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who had a delivery within 5 years about the place of their most recent delivery. Information on all functioning health facilities in the area were obtained from the district health office. Women who delivered in a health facility that was not the nearest available facility were considered bypassers. Forty-four per cent (186/423) of women who delivered in a health facility bypassed their nearest facility. In adjusted analysis, women who bypassed were more likely than women who did not bypass to be 35 or older (OR 2.5, P </= 0.01), to have one or no living children (OR 2.2, P = 0.03), to have stayed in a maternity waiting home prior to delivery (OR 4.3, P </= 0.01), to choose a facility on the basis of quality or experience (OR 2.1, P </= 0.01), to have a high level of trust in health workers at the delivery facility (OR 2.7, P </= 0.01), and to perceive the nearest facility to be of low quality (OR 3.1, P </= 0.01). Bypassing for facility delivery is frequent among women in rural Tanzania. In addition to obstetric risk factors, a major reason for this appears to be a concern about the quality of care at government dispensaries and health centres. Investing in improved quality of care in primary care facilities may reduce bypassing and improve the efficiency and effectiveness of the health system in providing coverage for facility delivery in rural Africa.
为降低孕产妇死亡率，发展中国家一直在投资建设村级初级保健设施，以便为妇女提供更便捷的专业接生服务。我们通过一项具有人口代表性的家庭调查（N = 1204），探究了坦桑尼亚西部农村地区的妇女绕过最近的初级保健设施，前往更远的医疗机构分娩的情况。我们使用标准化工具，询问了在5年内分娩过的妇女其最近一次分娩的地点。该地区所有正常运营的医疗机构信息均从区卫生办公室获取。在非最近可用医疗机构分娩的妇女被视为“绕过者”。在医疗机构分娩的妇女中，44%（186/423）绕过了最近的医疗机构。在调整分析中，与未绕过的妇女相比，绕过的妇女更有可能年龄在35岁及以上（比值比2.5，P≤0.01）、育有一个孩子或没有在世子女（比值比2.2，P = 0.03）、在分娩前曾入住孕产妇候产之家（比值比4.3，P≤0.01）、基于质量或经验选择医疗机构（比值比2.1，P≤0.01）、对分娩机构的医护人员高度信任（比值比2.7，P≤0.01）以及认为最近的医疗机构质量较差（比值比3.1，P≤0.01）。在坦桑尼亚农村地区，妇女绕过最近医疗机构选择其他机构分娩的情况很常见。除了产科风险因素外，出现这种情况的一个主要原因似乎是对政府诊所和卫生中心护理质量的担忧。投资改善初级保健设施的护理质量，可能会减少这种绕过行为，并提高非洲农村地区卫生系统在提供机构分娩服务覆盖方面的效率和效果。
