Who is Left Behind on the Road to Universal Facility Delivery? A Cross-sectional Multilevel Analysis in Rural Tanzania

Objectives: To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.

Methods: Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multilevel logistic models to examine individual and community factors associated with home delivery.

Results: A total of 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education [odds ratio (OR) 0.62; 95% confidence interval (CI): 0.50, 0.79], were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96) or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88).

Conclusions: Poverty, multiparity, weak ANC and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.