Individual, Community, and Health Facility Predictors of Postnatal Care Utilization in Rural Tanzania: A Multilevel Analysis

Florina Serbanescu; Purni Abeysekara; Alicia Ruiz; Michelle Schmitz; Sunday Dominico; Jason Hsia; Paul Stupp

doi:10.9745/GHSP-D-22-00502

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Analysis of Health Facility Attributes That Are Essential for Adequate Routine Obstetric and Newborn Care, Kigoma Region, Tanzania
Abbreviation: D&C, dilation and curettage.

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TABLE 1.

Attributes of Health Facility Readiness^a in Routine Maternal Care

Domain	Definition^b	Attribute
Human resources	Adequacy of staff providing delivery care (positions designated are occupied)	1. Adequate number of delivering personnel, per Ministry of Health staffing guidelines⁴⁰ 2. At least 1 staff trained in basic emergency obstetric care^c
Infrastructure	Basic physical features and resources at the health facility that improve and maintain the health of the mother and infant	3. Electricity available 24 hours/day and 7 days/week 4. Improved water source within 500 m of facility 5. Private room for patient consultation 6. Access to clean and functioning toilets 7. Communication equipment 8. Safe disposal of sharps and infectious waste
Essential equipment and supplies	Presence of essential and lifesaving necessary items that may improve or maintain health of the mother and infant	9. Newborn bag and mask 10. Blood pressure cuff 11. Adult stethoscope 12. Fetal stethoscope 13. Oxygen source 14. Suction apparatus (mucus extractor) 15. Sterilization equipment 16. Vacuum aspirator or D&C kit 17. Manual vacuum extractor for assisted vaginal delivery 18. Adequate delivery instrument set 19. Gloves
Essential drug stock	Supply of essential and lifesaving medicines that may improve or maintain health of the mother and infant	20. Injectable uterotonic 21. Injectable antibiotics 22. Injectable magnesium sulfate 23. Intravenous solution 24. 24. Antihypertensive medication 25. Antibiotic eye ointment for newborns
Processes	Series of tasks or methods applied at the health facility that may improve or maintain health of the mother and infant	26. Guidelines for IMPAC present in labor and delivery room 27. Partograph forms and proof of use
Facility capacity and functionality	Ability for the health facility to occupy patient beds and accomplish functions and tasks that may improve or maintain health of the mother and infant	28. Adequate number of delivery beds 29. Availability of labor and delivery services 24 hours/day and 7 days/week^c
Transportation	Supply of transportation that is functional and available to staff that may facilitate medical care at the health facility	30. Motorized vehicle with motor fuel available for emergency referrals

Abbreviations: D&C, dilation and curettage; IMPAC, Integrated Management of Pregnancy and Childbirth.
↵a 2015 World Health Organization’s Service Availability and Readiness Assessment Guidelines.³⁴
↵b To construct a facility readiness index, a score of 1 was assigned to each attribute for a maximum score of 30 attributes; a facility that met 28 or more attributes (corresponding to the highest decile of 30 attributes of the quality index) was considered to have adequate readiness of its routine maternity services.
↵c Having at least 1 staff member who provided delivery care trained in emergency obstetric and neonatal care and availability of services 24 hours/day and 7 days/week were added in the index construct, as proposed by other researchers.³⁵

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TABLE 2.

Presence of Readiness Attributes in 197 Facilities Providing Maternity Care by Facility Type in Kigoma Region, Tanzania

Attribute	Dispensary, No. (%)^a (N=164)	Health Center, No. (%)^a (N=27)	Hospital, No. (%)^a (N=6)
Adequate staffing	112 (68.3)	15 (55.6)	5 (81.3)
At least 1 staff trained in emergency obstetric care	87 (53.1)	18 (66.8)	4 (66.7)
Electricity available 24 hours/day and 7 days/week	153 (93.3)	22 (81.5)	6 (100.0)
Improved water source within 500 m	150 (91.5)	27 (100.0)	6 (100.0)
Private room for patient consultation	137 (83.5)	25 (92.6)	6 (100.0)
Access to clean and functional toilets	164 (100.0)	27 (100.0)	6 (100.0)
Communication equipment	60 (36.6)	18 (66.7)	5 (83.3)
Safe disposal of sharps and infectious waste	144 (87.8)	27 (100.0)	6 (100.0)
Newborn bag and mask	162 (98.8)	27 (100.0)	6 (100.0)
Blood pressure cuff	163 (99.4)	27 (100.0)	6 (100.0)
Adult stethoscope	163 (99.4)	27 (100.0)	6 (100.0)
Fetal stethoscope	164 (100.0)	27 (100.0)	6 (100.0)
Oxygen source	18 (11.0)	22 (81.5)	6 (100.0)
Suction apparatus (mucus extractor)	153 (93.3)	26 (96.3)	6 (100.0)
Sterilization equipment	159 (97.0)	27 (100.0)	6 (100.0)
Manual vacuum extractor for assisted vaginal delivery	76 (46.3)	19 (70.4)	6 (100.0)
Vacuum aspirator or D&C kit	121 (73.8)	23 (85.2)	6 (100.0)
Adequate delivery instrument sets	157 (95.7)	27 (100.0)	6 (100.0)
Gloves	158 (96.3)	27 (100.0)	6 (100.0)
Injectable uterotonic	164 (100.0)	27 (100.0)	6 (100.0)
Injectable antibiotics	157 (95.7)	26 (96.3)	6 (100.0)
Injectable magnesium sulfate	163 (99.4)	27 (100.0)	6 (100.0)
Intravenous solution	145 (88.4)	26 (96.3)	5 (83.3)
Antihypertensive medication	119 (72.6)	27 (100.0)	6 (100.0)
Antibiotic eye ointment for newborns	145 (88.4)	24 (88.9)	5 (88.3)
Guidelines for Integrated Management of Pregnancy and Childbirth	137 (83.5)	19 (70.4)	5 (83.3)
Partograph forms and proof of use	122 (74.4)	21 (77.8)	6 (100.0)
Adequate number of delivery beds	17 (10.4)	15 (55.6)	6 (100.0)
Availability of labor and delivery services 24 hours/day and 7 days/week	159 (97.0)	27 (100.0)	6 (100.0)
Motorized vehicle with motor fuel	6 (3.7)	18 (66.7)	3 (50.0)
Quality index of 28 attributes or more (highest tercile)	1 (0.61)	11 (40.7)	5 (83.3)
Mean number of attributes (SD)	23.4 (23.0–23.7)	26.5 (25.5–27.4)	28.3 (26.9–29.8)

Abbreviations: D&C, dilation and curettage; SD, standard deviation.
↵^a Counts and percentages represent unweighted frequencies of a specified element within a facility type.

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TABLE 3.

Selected Individual and Community Characteristics and Use of PNC After Last Birth Among Women Aged 15–49 Years in Kigoma Region, Tanzania

Individual Characteristic	All Women, No. (%)^a (N=4,353)	Used PNC, No. (%)^a (N=683)	Did Not Use PNC, No. (%)^a (N=3,670)	P Value^b
Maternal age at birth, years				.46
Under 25	1719 (39.8)	286 (41.1)	1,433 (39.6)
25–34	1,712 (39.4)	252 (37.1)	1,460 (39.8)
35–49	922 (20.8)	145 (21.8)	777 (20.6)
Literacy				.60
No	1,589 (36.2)	242 (35.3)	1,347 (36.4)
Yes	2,764 (63.8)	441 (64.7)	2,323 (63.6)
Work status				.17
Does not work outside home	2,982 (68.5)	450 (64.9)	2,532 (69.3)
Works outside home	1,371 (31.5)	233 (35.1)	1,138 (30.7)
Wealth tercile				.06
Low	1,601 (35.7)	224 (30.2)	1,377 (36.8)
Middle	1,575 (34.5)	258 (35.9)	1,317 (34.2)
High	1,177 (29.8)	201 (33.9)	976 (29.0)
Current marital status				.05
Married	3,752 (86.3)	600 (88.9)	3,152 (85.8)
Not married	601 (13.7)	83 (11.1)	518 (14.2)
Decision-making index				<.0001
Low/medium	2,840 (65.7)	384 (55.9)	2,456 (67.7)
High	1,513 (34.3)	299 (44.1)	1,214 (32.3)
Parity				.49
1 child	847 (19.7)	148 (20.6)	699 (19.5)
2–4 children	1,810 (42.1)	282 (44.3)	1,528 (41.8)
5 or more children	1,696 (38.2)	253 (35.1)	1,443 (38.7)
ANC utilization				.33
0–3 visits	1,842 (41.8)	302 (43.8)	1,540 (41.3)
4 or more visits	2,511 (58.2)	381 (56.2)	2,130 (58.7)
Counseled for birth plan during pregnancy				.0144
No	382 (9.0)	46 (6.7)	336 (8.8)
Yes	3,971 (91.0)	637 (93.3)	3,334 (91.2)
Place of delivery and its adequacy^c				<.0001
Home/on the way	1,261 (22.4)	98 (13.2)	916 (24.2)
Dispensary any readiness	1,515 (34.5)	241 (36.1)	1,274 (34.2)
Hospital/HC with less than adequate readiness	563 (11.7)	83 (10.5)	480 (11.9)
Hospital/HC with adequate readiness	1,515 (31.4)	261 (40.2)	1,000 (29.7)
Mode of delivery				<.0001
Normal vaginal	4,150 (95.0)	619 (89.4)	3,531 (96.1)
Cesarean	203 (5.0)	64 (10.6)	139 (3.9)
Companionship at birth				.0104
No companion during labor or delivery	3,021 (68.9)	430 (61.8)	2,591 (70.3)
Companion during labor or delivery	1,332 (31.1)	253 (38.2)	1,079 (29.7)
Pregnancy intendedness				.2463
Intended	3,174 (73.2)	518 (75.5)	2,656 (72.8)
Unintended	1,179 (26.8)	165 (24.5)	1,014 (27.2)
Birth outcome				.6074
Live birth	4,302 (98.9)	675 (98.7)	3,627 (98.9)
Stillbirth	51 (1.1)	8 (1.3)	43 (1.1)
Postpartum complications				.1342
Absent	2,651 (60.9)	444 (64.7)	2,207 (60.1)
Present	1,702 (39.1)	239 (35.3)	1,463 (39.9)
Satisfaction with delivery services				.0002
Not satisfied/did not deliver in facility	1,099 (24.5)	111 (15.2)	988 (26.4)
Satisfied/somewhat satisfied	3,254 (75.5)	572 (84.8)	2,682 (73.6)
Frequency of radio listening				.1128
Never	1,975 (45.3)	276 (41.6)	1,699 (46.1)
Sometimes	2,378 (54.7)	407 (58.4)	1,971 (53.9)
Community Characteristic
Area of residence				.12
Rural	3,752 (84.5)	565 (80.9)	3,187 (85.2)
Urban	601 (15.5)	118 (19.1)	483 (14.8)
Community socioeconomic status
Low	1,683 (39.8)	265 (35.5)	1,418 (40.6)	.50
Middle	1,453 (31.2)	218 (33.2)	1,235 (30.8)
High	1,217 (29.0)	200 (31.3)	1,017 (31.3)
District				<.0001
Kigoma Rural	1,315 (27.4)	92 (11.2)	1,223 (30.5)
Kigoma Urban	388 (11.2)	77 (13.8)	311 (10.6)
Kibondo	1,031 (23.3)	198 (26.3)	833 (22.7)
Kasulu	1,619 (38.2)	316 (48.7)	1,303 (36.2)
Distance to nearest facility providing maternity care^d				.10
0–5 km	3,421 (76.7)	575 (82.7)	2,846 (75.6)
5.1–10 km	490 (12.0)	83 (12.4)	407 (11.9)
More than 10 km	442 (11.3)	25 (4.9)	417 (12.5)
Adequate facility^c^,d within 5 km				.0031
No	3,632 (81.9)	516 (74.5)	3,116 (83.3)
Yes	721 (18.1)	167 (25.5)	554 (16.7)
Adequate facility^c^,d within 5–10 km				.4237
No	3,670 (84.1)	489 (72.2)	2,818 (75.5)
Yes	683 (15.9)	194 (27.8)	852 (24.5)
Community perception that quality of care at nearest health facility is poor^e				.0844
Low	1,399 (32.1)	245 (34.6)	1,154 (31.7)
Middle	1,571 (38.9)	287 (44.3)	1,284 (37.8)
High	1,383 (29.0)	151 (21.1)	1,232 (30.5)
Community perception that it is very important to deliver in a health facility^e				.0305
Low	1,655 (41.4)	196 (31.8)	1,459 (43.2)
Middle	1,422 (33.3)	259 (38.4)	1,163 (32.4)
High	1,276 (25.2)	228 (29.8)	1,048 (24.4)

Abbreviations: ANC, antenatal care; HC, health center; PNC, postnatal care.
↵a Frequencies in the study population are presented as unweighted counts and weighted percentages. Percentages may not sum up to 100 due to rounding.
↵b P values were derived from Rao-Scott chi-square test.
↵c Facility adequacy was estimated using the World Health Organization guidelines of assessing facility readiness for routine maternity care.³⁴ Each facility was assessed based on presence or absence of 30 attributes necessary for performing routine maternity services. We created an index score ranging from 0 to 30 based on the presence of each attribute. Facilities that had a score in the highest decile (i.e., having 28 or more attributes) were classified as having adequate readiness for routine maternal care services. The other facilities were classified as having “less than adequate readiness.” There were 68 women who delivered in the region in small-volume dispensaries that were not included in the health facility assessment. Their delivery facilities were classified as having less than adequate readiness based on inputs from health managers in the region.
↵d Distance estimated using ArcGIS models for traveling by roads or paths accessible to walking.
↵e Created by aggregating dichotomized individual level responses in each community and categorizing the resulting aggregate variables as terciles (low [0–32.9%], middle [33.0–65.9%], and high [66% or more]).

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TABLE 4.

Unadjusted and Adjusted Statistical Associations of Individual and Community Characteristics and PNC Use in Kigoma Region Tanzania Based on 3 Random Intercept Models

	Unadjusted			Model 1 Individual Characteristics			Model 2 Community Characteristics			Model 3 Individual and Community
Individual Characteristic	OR	95% CI	P Value	aOR	95% CI	P Value	aOR	95% CI	P Value	aOR	95% CI	P Value
Maternal age at birth, years
Under 25	1.00 (ref)			1.00 (ref)						1.00 (ref)
25–34	0.90	0.74–1.09	.2074	0.92	0.72–1.18	.4896				0.91	0.71–1.17	.4727
35–49	1.02	0.88–1.30	.5028	1.02	0.67–1.57	.9234				1.01	0.65–1.56	.981
Literacy
No	1.00 (ref)			1.00 (ref)						1.00 (ref)
Yes	1.05	0.85–1.25	.613	0.84	0.68–1.04	.1027				0.83	0.67–1.02	.0767
Work status
Does not work outside home	1.00 (ref)			1.00 (ref)						1.00 (ref)
Works outside home	1.22	0.91–1.63	.1760	1.02	0.75–1.40	.8992				0.99	0.73–1.35	.9456
Wealth tercile
Low	1.00 (ref)			1.00 (ref)						1.00 (ref)
Middle/high	1.34	1.05–1.72	.0207^a	1.25	1.00–1.59	.0628				1.25	0.99–1.59	.0705
Current marital status
Married	1.33	1.03–1.76	.0472^a	1.05	0.78–1.41	.7436				1.07	0.80–1.45	.6709
Not married	1.00 (ref)			1.00 (ref)						1.00 (ref)
Decision-making index
Low/medium	1.00 (ref)			1.00 (ref)						1.00 (ref)
High	1.65	1.29–2.12	.0001^a	1.57	1.12–2.19	.0093^a				1.56	1.11–2.17	.011^a
Parity
1 child	1.00 (ref)			1.00 (ref)						1.00 (ref)
2–4 children	1.01	0.69–1.47	.59	1.00	0.72–1.40	.9865				1.01	0.72–1.42	.9297
5 or more children	0.86	0.66–1.13	.1473	0.92	0.60–1.43	.725				0.95	0.61–1.48	.8302
ANC utilization
0–3 visits	1.00 (ref)			1.00 (ref)						1.00 (ref)
4 or more visits	0.90	0.73–1.11	.328	0.84	0.68–1.04	.124				0.85	0.68–1.05	.1364
Counseled for birth plan
No	1.00 (ref)			1.00 (ref)						1.00 (ref)
Yes	1.46	1.09–2.00	.0114^a	1.47	1.00–2.19	.0629				1.40	0.93–2.12	.1089
Place of delivery and its adequacy^b
Home/on the way	1.00 (ref)			1.00 (ref)						1.00 (ref)
Dispensary, any readiness	1.94	1.24–3.01	.169	0.86	0.37–2.00	.7315				0.79	0.34–1.86	.5969
Hospital/HC with less than adequate readiness	1.61	1.02–2.55	.7793	0.98	0.41–2.36	.9761				0.87	0.36–2.09	.8869
Hospital/HC with adequate readiness	2.48	1.62–3.81	.0003^a	1.17	0.51–2.66	.7161				1.06	0.46–2.48	.7509
Mode of delivery
Normal vaginal	1.00 (ref)			1.00 (ref)						1.00 (ref)
Cesarean	2.88	1.95–4.27	<.0001^a	2.29	1.50–3.49	.0002^a				2.27	1.47–3.48	.0002^a
Companionship at birth
No companion during labor or delivery	1.00 (ref)			1.00 (ref)						1.00 (ref)
Companion during labor or delivery	1.46	1.12–1.91	.0059^a	1.54	1.16–2.04	.0024^a				1.57	1.19–2.07	.0013^a
Pregnancy intendedness
Intended	1.16	0.91–1.47	.2463	1.11	0.87–1.42	.4081				1.11	0.87–1.42	.4086
Unintended	1.00 (ref)			1.00 (ref)						1.00 (ref)
Birth outcome
Live birth	0.82	0.38–1.78	.6074	1.13	0.57–2.24	.7199				1.04	0.53–2.06	.9057
Stillbirth	1.00 (ref)			1.00 (ref)						1.00 (ref)
Postpartum complications
Absent	1.00 (ref)			1.00 (ref)						1.00 (ref)
Present	0.82	0.64–1.06	.1342	0.85	0.64–1.14	.2755				0.89	0.66–1.19	.4184
Satisfaction with delivery services
Not satisfied/did not deliver in facility	1.00 (ref)			1.00 (ref)						1.00 (ref)
Satisfied/somewhat satisfied	2.00	1.39–2.87	.0002^a	1.32	0.64–2.71	.4519				1.33	0.64–2.71	.4493
Frequency of radio listening
Never	1.00 (ref)			1.00 (ref)						1.00 (ref)
Sometimes	1.21	0.96–1.54	.1128	1.09	0.87–1.37	.4457				1.06	0.84–1.32	.6263
Community Characteristic
Area of residence
Rural	1.00 (ref)						1.00 (ref)			1.00 (ref)
Urban	1.79	1.15–2.79	.0099^a				1.51	0.78–2.96	.2233	1.34	0.67–2.76	.4156
Community socioeconomic status
Low	1.00 (ref)						1.00 (ref)			1.00 (ref)
Middle	0.92	0.54–1.58	.769				1.03	0.60–1.77	.90	0.87	0.49–1.53	.6294
High	1.31	0.81–2.12	0.276				0.79	0.47–1.36	.4102	0.71	0.41–1.23	.2163
District
Kigoma Rural	1.00 (ref)						1.00 (ref)			1.00 (ref)
Kigoma Urban	3.61	2.00–6.51	<.0001^a				0.80	0.30–2.12	.657	0.88	0.32–2.44	.8148
Kibondo	2.94	1.66–5.24	.0002^a				2.03	1.03–4.01	.0407^b	1.80	0.88–3.67	.1096
Kasulu	3.68	2.38–5.70	<.0001^a				3.15	1.92–5.17	<.0001^c	3.28	1.94–5.52	<.0001^a
Distance to nearest facility with maternity care^c
0–5 km	3.48	1.38–8.69	.0080^a				2.01	0.97–4.17	.0598^a	1.95	0.92–4.16	.0868
5.1–10 km	2.72	0.83–8.94	.0988				2.06	0.89–4.80	.0936^a	2.13	0.90–5.05	.0876
More than 10 km	1.00 (ref)						1.00 (ref)			1.00 (ref)
Adequate facility ^b^,c within 5 km
Absent	1.00 (ref)						1.00 (ref)			1.00 (ref)
Present	2.31	1.53–3.49	<.0001^a				2.44	1.37–4.37	.0026^c	2.15	1.06–3.88	.032^a
Adequate facility ^b^,c within 5–10 km
Absent	1.00 (ref)						1.00 (ref)			1.00 (ref)
Present	1.30	0.82–2.06	.2698				0.98	0.57–1.69	.9496	1.04	0.59–1.81	.8878
Community perception that quality of care at nearest health facility is poor^d
Low	1.00 (ref)						1.00 (ref)			1.00 (ref)
Middle	1.05	0.67–1.65	.8365				1.16	0.76–1.78	.4915	0.94	0.57–1.56	.3356
High	0.52	0.31–0.87	.0128^a				0.88	0.53–1.45	.604	1.24	0.80–1.91	.818
Community perception that it is very important to deliver in a health facility^d
Low	1.00 (ref)						1.00 (ref)			1.00 (ref)
Middle	1.82	1.08–3.08	.0252^a				1.26	0.77–2.06	.3528	1.26	0.74–2.16	.3935
High	1.93	1.13–3.31	.0169^a				1.24	0.74–2.08	.4058	1.25	0.75–2.07	.3919
Variance (SE)				1.24 (0.21)			0.85 (0.16)			0.91 (0.17)
ICC				27%			21%			22%

Abbreviations: aOR, adjusted odds ratio; ANC, antenatal care; AVD, assisted vaginal delivery; CI, confidence interval; ICC, intraclass correlation coefficient; OR, odds ratio; PNC, postnatal care; ref., reference group; SE, standard error.
↵a Significant at P value <.05.
↵b Facility adequacy was estimated using the World Health Organization guidelines of assessing facility readiness for routine maternity care.³⁴ Each facility was assessed based on presence or absence of 30 attributes necessary for performing routine maternity services. We created an index score ranging from 0 to 30 based on the presence of each attribute. Facilities that had a score in the highest decile (i.e., having 28 or more attributes) were classified as having adequate readiness for routine maternal care services. The other facilities were classified as having less than adequate readiness. There were 68 women who delivered in the region in small-volume dispensaries that were not included in the health facility assessment. Their delivery facilities were classified as having less than adequate readiness based on inputs from health managers in the region.
↵c Distance estimated using ArcGIS models for travelling by roads or paths accessible to walking.
↵d Created by aggregating dichotomized individual level responses in each community and categorizing the resulting aggregate variables as terciles (low [0%–32.9%], middle [33.0%–65.9%], and high [≥66%]).