The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization

Utilization of Antenatal Care and Skilled Birth Delivery Services in Sub-Saharan Africa: A Systematic Scoping Review

Daily, the number of women who die around the world reaches an average of 800; these deaths are a result of obstetric complications in pregnancy and childbirth, and 99% of these deaths occur in low- and middle-income countries. This review probes the use of antenatal care (ANC) and skilled birth delivery (SBD) services in sub-Saharan Africa (SSA) and highlights research gaps using Arksey and O'Malley's methodological approach. The screening of abstracts and full text was carried out by two independent authors who ensured the eligibility of data extraction from the included articles. An exploration of the data was undertaken with descriptive analyses. In total, 350 potentially eligible articles were screened, and 137 studies were included for data extraction and analysis. From the 137 included studies, the majority were from Ethiopia (n = 40, 29.2%), followed by Nigeria (n = 30, 21.9%). Most of the studies were published between 2019 and 2023 (n = 84, 61%). Significant trends and challenges with ANC and SBD services emerged from the studies. It is revealed that there are wide gaps in the utilization of ANC and SBD services. Policy attention, intervention strategies to improve access, resources, rural-urban disparity, and women's literacy are recommended to improve the utilization of ANC and SBD services in SSA countries.

Assessing online sexual exploitation among secondary school students in Tanzania from a routine activity theory perspective

OBJECTIVES

In this study, we first assessed whether four routine activity theory (RAT) variables (Internet exposure, target suitability, proximity to offender, and guardianship) determine Tanzanian adolescents' online sexual exploitation (OSE). Second, we identified two types of guardianship that moderate the relationships between these variables and adolescents' OSE. Third, we assessed the moderating effect of locality (rural area) on the relationships among the RAT variables and OSE.

METHOD

Our analysis was based on a stratified random sample of 1014 secondary school adolescents aged 12-20 years (M = 15.67; SD = 1.35) recruited from urban and rural regions of Tanzania. We used Poisson regressions to test the main effects of the RAT variables and the moderating effects of two types of guardianship and locality on OSE.

RESULTS

We found that OSE increased with the suitability of the respondents and with online exposure. Social guardianship had a moderating effect on OSE by reducing the positive influence of target suitability. Living in a rural area also had a moderating effect on OSE through reinforcing the effect of proximity to potential perpetrators in cyberspace.

CONCLUSION

RAT can effectively increase our understanding of the OSE of minors in Tanzania. Furthermore, social rather than physical guardianship can mitigate the risk factors of OSE.

Co-occurrence of Overweight, Stunting, and Anemia among Adolescents (10-19 Years) in Tanzania Mainland: A School-Based Cross-Sectional Study

Background

Evidence on double and triple burdens of malnutrition among adolescents is an essential key to informing policy design, implementation, and tracking progress of adolescent nutritional programs. Tanzania has a scarcity of studies on the double and triple burden of malnutrition among adolescents.

Objective

The aim of this study was to assess the co-occurrence of malnutrition (overweight, stunting, and anemia) among adolescents (10-19 y) in mainland Tanzania.

Methods

A school-based cross-sectional study was conducted among 44,120 primary school adolescents aged 10 to 19 y in mainland Tanzania. Anthropometric assessments (weight, height, and body mass index), dietary assessments, and hemoglobin levels were used to calculate the single, double, and triple burden of malnutrition. Data were analyzed using Stata software 15. The chi-square test was used to test the association between the nutrition condition and social demographic variables, physical activity, and dietary quality. Log-binomial models were used to determine factors associated with stunting, overweight, and anemia. Multivariable log-binomial models were used to control confounders. All analyses were 2-tailed, and the significance level was set at 5%.

Results

The prevalence of anemia was 34.1%, while stunting and overweight had a prevalence of 32% and 4.2%, respectively. Approximately 41.7%, 13.5%, and 0.3% had single, double, and triple burden malnutrition-related conditions, respectively. Females were found to have a higher risk of being overweight compared with males (relative risk [RR]: 1.33; 95% confidence interval [CI]: 1.21, 1.45), while engaging in moderate to low levels of physical activity was associated with a decreased risk of being overweight. Additionally, residing in urban areas was linked to a decreased risk of stunting (RR: 0.78; 95% CI: 0.75, 0.80) and a 27% lower risk of anemia when compared with participants from rural areas.

Conclusion

The findings from this study suggest that the complex nature of malnutrition among school adolescents warrants consideration when designing policies and interventions to reduce the burden of malnutrition.

Correction: The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization

[This corrects the article DOI: 10.1371/journal.pone.0241746.].

Socioeconomic inequalities in maternal healthcare utilization: An analysis of the interaction between wealth status and education, a population-based surveys in Tanzania

Limited scientific, evidence has so far described the interactions between socioeconomic factors and the gap of inequalities in maternal healthcare utilization. This study assessed the interaction between wealth status and education to identify women with greater disadvantage. This analysis used secondary data from the three most recent rounds (2004, 2010, and 2016) of the Tanzania Demographic Health Survey (TDHS). Maternal healthcare utilization was assessed based on six services (outcomes) which are i) booking during the first trimester (bANC), ii) at least four antenatal visits (ANC4+), iii) adequate antenatal care (aANC), iv) facility-based delivery (FBD), v) skilled birth attendance (SBA), vi) cesarean section delivery (CSD). The concentration curve and the concentration index were used to measure socioeconomic inequality in maternal healthcare utilization outcomes. The interaction coefficients suggest that each unit increase in the wealth status is significantly associated with higher odds of utilizing all maternal healthcare services for women with primary and secondary or higher education compared to those with no education (booking during the first trimester [AOR = 1.30; 95% CI: 1.08-1.57], at least four antenatal visits [AOR = 1.16; 95% CI: 1.01-1.33], facility-based delivery [AOR = 1.29; 95% CI: 1.12-1.48], skilled birth attendance [AOR = 1.31; 95% CI: 1.15-1.49]). The highest wealth-related inequality in bANC (EI: 0.166), at least four antenatal visits (EI: 0.259), FBD (EI: 0.323) and skilled birth attendance (EI: 0.328) (P < 0.05) was observed among women with primary and secondary or higher education. These findings provide strong evidence that there is an interaction effect between education attainment and wealth status in socioeconomic inequalities of maternal health services utilization. Therefore, any approach which will address both women's education and wealth status might be the first step to reducing socioeconomic inequalities in maternal health services utilization in Tanzania.

Dependency Theory: An Evaluation of the Period-Based Changes in the Utilization of Maternal Health Care and Neonatal Mortality in Tanzania Between 1991 and 2016

While efforts have been made to increase maternal health care (MHC) utilization and decrease neonatal mortality in Tanzania, much remains to be known about the effect of dependency (particularly on reproductive policy changes) on the use of MHC and neonatal health over time among varying socioeconomic groups. This study applied dependency theory to cross-sectional secondary data (collected by the Tanzania Demographic Health Surveys between 1991 and 2016) to investigate period-based changes in MHC and neonatal mortalities in Tanzania. Results from the data analysis found that while neonatal mortalities were decreasing in Tanzania (from 1991 to 2016), the odds of neonatal mortality were still greater in 2016. Also, a decline in the recommended skilled delivery assistance and 4 + antenatal care visits occurred in the data period. A significant increase in socioeconomic inequality around MHC use and neonatal mortality occurred during the study period as well. Policy recommendations to reduce these inequalities and move toward meeting Sustainability Development Goals for maternal and neonatal health in Tanzania are discussed.

HIV Testing among sexually active Ghanaians: an examination of the rural-urban correlates

HIV testing is critical in reducing the risk of HIV transmission. We investigated the rural-urban correlates of HIV testing amongst sexually active Ghanaians using data from the 2017/2018 Ghana Multiple Indicator Cluster Survey Six (GMICS 6). Robust Poisson models (reporting Adjusted Prevalence Ratios (APR) and 95% Confidence Intervals (CIs)) were used to achieve this aim. About 46% of the participants had ever tested for HIV. According to the results, approximately 52% and 39% of urban and rural dwellers, respectively, have undergone HIV testing. HIV knowledge, HIV stigma, gender, age, education, marital status, childbirth history, sexual history, health insurance coverage, media exposure, household wealth, and region of residence were significantly related to HIV testing with observed variations across rural-urban areas. The findings call for the expansion of advocacy efforts towards encouraging HIV testing, targeting sexually active Ghanaians particularly in rural areas.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

BACKGROUND

Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition.

METHODS AND FINDINGS

Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability.

CONCLUSIONS

In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Equity in public health spending in Ethiopia: a benefit incidence analysis

Inequality in access and utilization of health services because of socioeconomic status is unfair, and it should be monitored and corrected with appropriate remedial action. Therefore, this study aimed to estimate the distribution of benefits from public spending on health care across socioeconomic groups in Ethiopia using a benefit incidence analysis. We employed health service utilization data from the Living Standard Measurement Survey, recurrent government expenditure data from the Ministry of Finance and health services delivery data from the Ministry of Health's Health Management Information System. We calculated unit subsidy as the ratio of recurrent government health expenditure on a particular service type to the corresponding number of health services visits. The concentration index (CI) was applied to measure inequality in health care utilization and the distribution of the subsidy across socioeconomic groups. We conducted a disaggregated analysis comparing health delivery levels and service types. Furthermore, we used decomposition analysis to measure the percentage contribution of various factors to the overall inequalities. We found that 61% of recurrent government spending on health goes to health centres (HCs), and 74% was spent on outpatient services. Besides, we found a slightly pro-poor public spending on health, with a CI of -0.039, yet the picture was more nuanced when disaggregated by health delivery levels and service types. The subsidy at the hospital level and for inpatient services benefited the wealthier quintiles most. However, at the HC level and for outpatient services, the subsidies were slightly pro-poor. Therefore, an effort is needed in making inpatient and hospital services more equitable by improving the health service utilization of those in the lower quintiles and those in rural areas. Besides, policymakers in Ethiopia should use this evidence to monitor inequity in government spending on health, thereby improving government resources allocation to target the disadvantaged better.

Decomposing the urban-rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in Sub-Saharan Africa

Background

There has been a substantial improvement in reducing maternal mortality in the Sub-Saharan African region. The vast rural-urban gap in maternal health outcomes, however, is obscured by this average achievement. This study attempts to measure the contribution of identified risk factors to describe the average rural-urban difference in the use of antenatal care, health facilities for delivery, and health professional assistance at delivery.

Method

To achieve this objective, we used descriptive analysis and Fairlie non-linear decomposition method to quantify covariates’ contribution in explaining the urban–rural difference in maternal healthcare services utilisation.

Result

The study’s finding shows much difference between urban and rural areas in the use of maternal healthcare services. Socio-economic factors such as household wealth index, exposure to media, and educational level of women and their husbands/partners contributed the most in explaining the gap between urban and rural areas in healthcare services utilisation.

Conclusions

Interventions to bridge the gap between urban and rural areas in maternal healthcare services utilisation in Sub-Saharan Africa should be centred towards socio-economic empowerment. Government can enforce targeted awareness campaigns to encourage women in rural communities in Sub-Sharan Africa to take the opportunity and use the available maternal health care services to be at par with their counterparts in urban areas.

Maternal health refers to the health of women throughout pregnancy, delivery, and the postnatal period. Each step should be a good experience that ensures mothers, and their infants realize their maximum health and well-being potential. In this study, we used individual, demographic, and socio-economic characteristics to measure the urban–rural discrepancies in maternal health care services in Sub-Saharan Africa. We used Information of 220 164 women of child-bearing age (15–49) gathered from National Demographic Health Surveys from 27 countries in the Sub-Sahara African region. We found 46.1% of women in rural areas had no education, 39.7% of the women in rural areas have husbands/partners with no education, and 60.1% of the women in rural areas are from households with poor wealth indexes. The use of maternal health care services found to be predominant in the urban areas than rural areas, and the measure of this difference can inform policymakers on the level of effort that needed to be put in place to balance the discrepancies and improve maternal health in general.

Birth preparedness and related factors: a cross-sectional study in Tanzania City area

Background

Birth preparedness could be the key factor that influences the choice of birthplace with skilled birth attendants. To reduce the high maternal mortality of Tanzania, a large study was planned to develop a smartphone app to promote birth preparedness in a city area of Tanzania. This study aimed to identify factors that influence birth preparedness in the city area of Tanzania.

Methods

Pregnant women were asked to complete the Birth Preparedness Questionnaire during antenatal visits using tablets. Multiple linear regression analyses were performed to determine the sociodemographic and obstetric characteristics that influenced the factors.

Results

A total of 211 participants were included in the analysis. Distance from the nearest health facility negatively influenced the total score of the Birth Preparedness Assessment (β= 0.7, p = 0.02). Education higher than college positively influenced the total score (β = 4.76, p = 0.01). Decision-making of birthplace by other people (not women) negatively influenced Family Support (β=1.18, p = 0.03). Having jobs negatively influenced Preparation of Money and Food (β=-1.02, p < 0.01) and positively influenced the knowledge (β = 0.75, p = 0.03). Being single positively influenced Preparation of Money and Food (β = 0.35, p = 0.19) and Preference of Skilled Birth Attendants (β = 0.42, p = 0.04). Experience of losing a baby negatively influenced the knowledge (β=0.80, p < 0.01) and Preference of Skilled Birth Attendants (β=0.38, p = 0.02).

Conclusions

The findings showed an updated information on pregnant Tanzanian women living in an urban area where rapid environmental development was observed. Birth preparedness was negatively affected when women reside far from the health facilities, the birthplace decision-making was taken by others beside the women, women have jobs, and when women have experienced the loss of a baby. We hope to use the information from this study as content in our future study, in which we will be applying a smartphone app intervention for healthy pregnancy and birth preparedness. This information will also help in guiding the analysis of this future study. Although generalization of the study needs careful consideration, it is important to reconsider issues surrounding birth preparedness as women’s roles both in the family and society, are more, especially in urban settings.

Urban-rural disparities of antenatal care in South East Asia: a case study in the Philippines and Indonesia

Background

The government is obliged to guarantee equal access to antenatal care (ANC) between urban and rural areas. This study aimed to analyze urban-rural disparities in ≥4 ANC visits during pregnancy in the Philippines and Indonesia.

Methods

The study processed data from the 2017 PDHS and the 2017 IDHS. The analysis unit was women aged 15–49 years old who had given birth in the last 5 years. The weighted sample size was 7992 respondents in the Philippines and 14,568 respondents in Indonesia. Apart from ANC as the dependent variable, other variables analyzed were residence, age, husband/partner, education, parity, and wealth. Determination of urban-rural disparities using binary logistic regression.

Results

The results show that women in the urban Philippines are 0.932 times more likely than women in the rural Philippines to make ≥4 ANC visits. On the other side, women in urban Indonesia are more likely 1.255 times than women in rural Indonesia to make ≥4 ANC visits. Apart from the type of residence place (urban-rural), five other tested multivariate variables also proved significant contributions to ANC’s use in both countries, i.e., age, have a husband/partner, education, parity, and wealth status.

Conclusions

The study concluded that disparities exist between urban and rural areas utilizing ANC in the Philippines and Indonesia. Pregnant women in the rural Philippines have a better chance of making ≥4 ANC visits. Meanwhile, pregnant women in urban Indonesia have a better chance of making ≥4 ANC visits.

Hukou-based rural-urban disparities in maternal health service utilization and delivery modes in two Chinese cities in Guangdong Province

BACKGROUND

Most existing research on rural-urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural-urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China.

METHODS

Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015-2019) and 25,849 live births in City B (2018-2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable.

RESULTS

While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively.

CONCLUSIONS

Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services.