Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets

It is almost two decades now since the initiation of the Safe Motherhood Initiative, but maternal mortality is still soaring high in most of the developing countries. In the year 2000, WHO estimated maternal mortality ratio of 920/100000 live births for Sub-Saharan Africa with a lifetime risk of a maternal death of 1 in 16. These rates are very high when compared to the developed countries lifetime risk of 1 in 2800 estimated during the same time period [1].

Reports show that more than three quarters of maternal deaths are due to direct obstetric causes such as haemorrhage, abortion, sepsis, ruptured uterus and hypertensive diseases of pregnancy [2]. Most of these maternal deaths can be averted because the technical and political means to prevent them have been available for many decades. For example, it is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality and morbidity [3–6]. In the technical consultation held ten years of Safe motherhood initiative it was clearly stated that: "Having a health worker with midwifery skills present at child birth, backed up with transport in case of emergency referral is perhaps the most critical intervention for making motherhood safe" [2]. Due to this fact, the proportion of births attended by skilled health personnel is used as one of the important indicators to monitor progress towards the achievement of the millennium development goal of reducing maternal mortality ratios. The targets set at the International Conference on Population and Development+5 (ICPD+) is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2015 [7].

In Tanzania, like other Sub Saharan Africa countries, maternal mortality remains to be a problem of public health importance. The 2004 Tanzania Demographic and Health Survey (TDHS) published a maternal mortality ratio (MMR) of 578/100000 live births [8] but other community based studies found MMR as high as 990/100000 live births in some districts [9]. The life time risk of a maternal death in Tanzania has been estimated at 1 in 38 [10]. Tanzania was ranked 6^th among the 13 countries with highest levels of maternal mortality which account for 67% of all world maternal deaths [1].

Use of health facilities for delivery is still very low in Tanzania. It is reported that only 47% of deliveries occur in the health facilities and the remaining more than half deliver at home assisted by unskilled attendants [8]. This is happening amidst the fact that Tanzania has a good network of health facilities with about 72% of the population residing within 5 km and 90% reside within 10 km of a health facility. Also maternal health care services are provided free of charge in almost all public facilities.

The objective of this study was to assess the use determinants of skilled attendants at delivery in Mtwara rural district. The information obtained will help the district health management team to develop interventions to improve use of delivery care services and ultimately achieve the millennium goal to reduce the high rates of maternal mortality.

Almost half (49.4%) of the respondents had never been to school and of those who reported to have attended formal schools, almost three quarters (72.2%) reported only seven years of schooling. An overwhelming majority of respondents (94%) were Muslims and of Makonde tribe. Major occupation of respondents was subsistence farming, accounting for 95.7% of the respondents. Over three quarters (77.2%) were married or cohabiting but also a significant proportion (12.2%) were divorced (Table 1). Number of children ever born ranged from 1 to 11 with a median of 3.

Use of skilled care at delivery

Less than half, (46.7%) of respondents reported to have delivered in a health facility in their most recent delivery. Of these, 35% delivered in a hospital level and 65% delivered in dispensaries or in health centers. Skilled attendance at delivery was reported by only 433 (44.5%) of the respondents and of these 16 (3.6%) were home deliveries. Maternal and Child Health Aids (MCHA) assisted over a quarter (27.1%) of all deliveries while nurse midwifes attended only 14.4% of the deliveries. Among women who delivered at home, 50.1% were assisted by untrained relatives or friends while 46.3% were assisted by Traditional Birth Attendants (TBA's) and 3.6% were assisted by skilled midwives (Fig 1).

Antenatal care especially when thought early allows regular checkups for the health of the pregnant woman and early interventions incase of any complications. Findings of this study show that almost all women (99%) sought antenatal care at least once during their last pregnancy. These findings compare well with those of the Tanzania Demographic and Health Surveys [8]. Main reasons reported earlier for this universal ANC attendance included seeking for immunizations for tetanus, prophylaxis for anaemia and malaria and the fact that women want to be assured that their unborn babies are well [12, 13]. Majority of women delayed their first ANC visit and about a third went for fewer than recommended number of visits. Late start of ANC and too few visits reduces the effectiveness of the ANC as some necessary interventions are started either very late in pregnancy or they are not completed before the time of delivery. These results also agree with a study conducted in Nigeria, where the median time for first ANC visit was found to be 23.7 weeks [14]. Women book late to avoid going for many ANC visits particularly in circumstances where the facility is quite far and there are no reliable means of transport.

Proportion of women who delivered in the health facility was only 46.7% where as the proportion who had skilled assistance was 44.5%. These estimate compares well with the national level rates (47% Vs 46%) observed in the most recent demographic and Health survey but higher compared to the rates obtained from the study region (37%) in the same survey [8]. The low coverage rate in the TDHS sample in this region may be the cause of these discrepancies. Low rates of health facility deliveries in developing countries have been reported by several other researchers [15–20]. Fear of being referred to hospital, availability of TBA's, emergency nature of labour were mentioned to be the major causes of home deliveries. This low utilization of skilled attendants at delivery represents the great challenge to achieve the MDG's in the next nine years.

A number of socio demographic and economic factors were found to have a significant influence on use of skilled care at delivery. They include women's age, education level, and marital status. Younger women are just starting child bearing and are told to be in a high risk group and so they tend to fear home deliveries. It is also possible that the new generation with a higher proportion of women who have formal education have different perspectives on delivery care when compared to the older generations. These variables also influence the status of the woman in the society which has been found to influence decision making. A woman who is educated, single and of higher socio economic status is able to make wise decisions about her own health than their counterparts. Similar findings were reported by previous researchers [16, 18, 19, 21, 22]. It has been reported that both economic and social dimensions of the distribution of power between spouses influence the use of services [23].

Women who were knowledgeable of risk factors were more likely to utilize health facilities for delivery compared to those with no knowledge. Similar findings were reported in Malawi and in Zambia [18, 24]. It is expected that a better informed individual is better placed to make reasonable decisions.

Distance to the health facility was a significant determinant of type of delivery care. This was said to be made worse by the fact that there are no means of transport to the facility. Similar findings were reported by a number of researchers previously [16, 18, 25].

Women who had more than 4 ANC visits were more likely to deliver with a skilled attendant than those with fewer visits. Similar findings were reported in Cambodia [16, 26]. This may be due to the fact that women with more ANC visits also showed a higher satisfaction with the care quality and hence more likely to use health services for delivery. It is also a fact that many ANC visits expose the women to more health education and counseling which are both likely to increase service utilization. This finding lead previously to a recommendation that although antenatal care may not be efficient in identifying women who are most in need of obstetric care, if promoted it may become an effective instrument to facilitate better use of emergency obstetric care services [26].

Surprisingly women who reported illnesses/pregnancy complications during pregnancy did not have an increased chance to use health facilities. This may be due to wrong perceptions of causation which lead them to seek care from traditional healers instead of modern health facilities.

In contrast to findings of several other studies, perceived quality of ANC care was not seen to influence the choice of a delivery attendant. This may be due to the fact that majority (85%) of women in this study perceived the ANC care quality as good.

In the study area, although almost all pregnant women seek antenatal care, less than half of deliveries are attended by skilled personnel. The proportion of births attended by skilled personnel is far below the ICPD+ target of having 80% births attended by skilled attendants by the year 2005. Distance to the facility, advice by a health worker on place of delivery, knowledge of danger signs and a higher number of ANC visits were found to be significantly associated with the type of delivery attendant.

We recommend the following in order to increase our pace towards the millennium development goal targets: To improving coverage of health facilities which provide skilled delivery care, To raise the status of women in terms of education and socio-economic status, and to improve provision of health education to women especially on danger signs during pregnancy and delivery and also intensify individual counselling of women on hospital delivery and on individual birth preparedness.