Mohan Diwakar, LeFevre Amnesty E, George Asha, Mpembeni Rose, Bazant Eva, Rusibamayila Neema, Killewo Japhet, Winch Peter J, Baqui Abdullah H
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, School of Public Health & Social Sciences P.O.Box 65015, Dar es Salaam, Tanzania.
Health Policy Plan. 2017 Jul 1;32(6):791-799. doi: 10.1093/heapol/czx005.
The 'continuum of care' is proposed as a key framework for the delivery of maternal, neonatal and child health services. This study examined the extent of dropout as well as factors associated with retention across the MNCH continuum from antenatal care (ANC), through skilled birth attendance (SBA), to postnatal care (PNC).We analyzed data from 1931 women who delivered in the preceding 2-14 months, from a two-stage cluster sampling household survey in four districts of Tanzania's Morogoro region. The survey was conducted in 2011 as a part of a baseline for an independent evaluation of a maternal health program. Using the Anderson model of health care seeking, we fitted logistic models for three transition stages in the continuum.Only 10% of women received the 'recommended' care package (4+ ANC visits, SBA, and 1+ PNC visit), while 1% reported not having care at any stage. Receipt of four ANC visits was positively associated with women being older in age (age 20-34 years-OR: 1.77, 95%CI: 1.22-2.56; age 35-49 years-2.03, 1.29-3.2), and knowledge of danger signs (1.75, 1.39 -2.1). A pro-rich bias was observed in facility-based deliveries (proxy for SBA), with women from the fourth (1.66, 1.12-2.47) and highest quintiles of household wealth (3.4, 2.04-5.66) and the top tertile of communities by wealth (2.9, 1.14-7.4). Higher rates of facility deliveries were also reported with antenatal complications (1.37, 1.05-1.79), and 4+ ANC visits (1.55, 1.14-2.09). Returning for PNC was highest among the wealthiest communities (2.25, 1.21-4.44); catchment areas of a new PNC program (1.89, 1.03-3.45); knowledge of danger signs (1.78, 1.13-2.83); community health worker counselling (4.22, 1.97-9.05); complicated delivery (3.25, 1.84-5.73); and previous health provider counselling on family planning (2.39, 1.71-3.35).Dropout from maternal care continuum is high, especially for the poorest, in rural Tanzania. Interactions with formal health system and perceived need for future services appear to be important factors for retention.
“连续护理”被提议作为提供孕产妇、新生儿和儿童健康服务的关键框架。本研究调查了从产前护理（ANC）、熟练接生（SBA）到产后护理（PNC）整个妇幼保健连续过程中的退出程度以及与留存相关的因素。我们分析了来自坦桑尼亚莫罗戈罗地区四个区的两阶段整群抽样家庭调查中，在之前2至14个月内分娩的1931名妇女的数据。该调查于2011年进行，作为一项孕产妇健康项目独立评估基线的一部分。使用医疗服务寻求的安德森模型，我们针对连续过程中的三个过渡阶段拟合了逻辑模型。
只有10%的妇女接受了“推荐”的护理套餐（4次及以上产前检查、熟练接生和1次及以上产后检查），而1%的妇女报告在任何阶段都未接受护理。接受4次产前检查与年龄较大的妇女呈正相关（20至34岁 - 比值比：1.77，95%置信区间：1.22 - 2.56；35至49岁 - 2.03，1.29 - 3.2），以及与危险信号知识呈正相关（1.75，1.39 - 2.1）。在设施分娩（熟练接生的替代指标）中观察到有利于富裕人群的偏差，来自家庭财富第四（1.66，1.12 - 2.47）和最高五分位数（3.4，2.04 - 5.66）以及社区财富最高三分位数（2.9，1.14 - 7.4）的妇女。产前并发症（1.37，1.05 - 1.79）和4次及以上产前检查（1.55，1.14 - 2.09）也报告了较高的设施分娩率。返回接受产后护理在最富裕的社区中最高（2.25，1.21 - 4.44）；新的产后护理项目的服务区域（1.89，1.03 - 3.45）；危险信号知识（1.78，1.13 - 2.83）；社区卫生工作者咨询（4.22，1.97 - 9.05）；复杂分娩（3.25，1.84 - 5.73）；以及之前卫生服务提供者关于计划生育的咨询（2.39，1.71 - 3.35）。
在坦桑尼亚农村地区，孕产妇护理连续过程中的退出率很高，尤其是最贫困的人群。与正规卫生系统的互动以及对未来服务的感知需求似乎是留存的重要因素。
