| Description: |
In this thesis I have studied where women give birth within the health system in sub-Saharan Africa, firstly in Tanzania and then in other countries, focusing on the use of hospitals in rural settings. Though childbirth care is available at different levels of the health system, hospitals are generally where advanced management of childbirth complications is available. This is particularly important for women with risk factors, at greater risk of complications and death. The research has examined the interaction of biological risk (high parity) with socio-economic vulnerability (poverty), identifying a subgroup of women who are poor, rural and of high parity who, despite greater risk of childbirth complications, have lower use of hospitals. In Iringa rural district in Tanzania, with nearly universal facility births coverage, my co-researchers and I found poor women were underrepresented in the only hospital in the district. This finding led to hypothesizing that women from poorer households were more likely to use primary care facilities for childbirth. Use of hospitals in all Tanzania was studied using nationally representative Demographic and Health Survey data. In rural Tanzania, we found that the effect of poverty on use of hospitals depended on the level of parity. Women who were both poor and at high parity used hospitals least: only around one in ten women who were poor and at high parity had given birth in a hospital in the period studied. The complex interacting and interdependant factors related to high parity, poverty and rurality are likely to be responsible. High parity, poor, rural women have remained marginalized in use of hospitals over the most recent 25 years for which data were available (1991-2016). This finding is particularly relevant as the country has been at the forefront in rolling out primary health care since independence. High population growth brought an increase of 35,000 births/year over this period. Health system expansion during this time to achieve universal coverage of ... |
