Athena Institute, VU Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands.
Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.
Health Policy Plan. 2021 Oct 12;36(9):1428-1440. doi: 10.1093/heapol/czab079.
Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.
撒哈拉以南非洲地区的医疗机构分娩比例正在上升，但各医疗机构的产科服务水平存在差异。在坦桑尼亚，高级别的分娩并发症处理（全面的紧急产科护理）仅在医院提供，而在基层、初级卫生保健设施（卫生中心和诊所）中，主要只提供常规分娩护理。由于有超过一半（54%）的农村分娩在医疗机构中进行，我们假设在坦桑尼亚农村，基于医院的分娩率存在社会经济不平等，并探讨了这种关系是否因产次而有所改变。这种不平等可能会使最贫困妇女及其婴儿的死亡率更高。我们对 2015-16 年坦桑尼亚人口与健康调查中 4456 名过去 5 年内活产的农村妇女的记录进行了检查。根据人口统计学和产科特征，计算了每个地点（家中/初级卫生保健/医院）的分娩比例。利用多分类逻辑回归，根据家庭财富获得了家庭/初级卫生保健和医院/初级卫生保健分娩的粗比值比和调整比值比，包括财富和产次之间的交互作用。在估计后，采用边际分析估计按财富和产次划分的分娩地点。基于医院的分娩利用率存在不平等。在初产妇中，最贫穷和最富裕家庭之间的差距不那么明显。最贫穷的多产妇中，利用医院分娩的比例最低（约 10%），尽管风险较高，但在高产次（≥5）时并未增加。在初产妇之后，一直有相当比例的妇女利用初级卫生保健的分娩护理（范围为 30-51%）。最贫穷的妇女在中等产次时利用它，但在产次≥5 时，大多数在家分娩。为了向所有妇女提供有效的分娩护理，需要制定特定于背景的策略来提高基于医院的护理利用率，而贫困、农村、高产次的妇女是一个特别脆弱的群体，需要特别关注。改善初级卫生保健中的分娩护理并加强转诊联系将使相当一部分妇女受益。
