Following the difficult economic situation various countries introduced health sector reforms, including user charges to finance the system. The assessment of user costs for maternity services in Tanzania was part of a larger study, which covered inputs, outputs and efficiency of services. The study was carried out from October 1997 to January 1998 in Mtwara urban and rural district in South Tanzania. One hundred and seven women attending a quarter of government health facilities were randomly selected and interviewed. Twenty one key informants were also interviewed and service procedures observed. Users of maternity services pay mainly for admission, drugs, other supplies and travel costs. Travel costs represent about half of these financial costs. The average total costs vary between US$11.60 for antenatal consultation and US$135.40 for caesarean section at the hospital. Unofficial payments are not included in the calculation. The amounts vary and payment is irregular. We therefore conclude that time costs are constantly higher than financial costs. High direct payments and the fear of unofficial costs are acute barriers to the use of maternity services. User costs can substantially be reduced by the re-organisation of service delivery especially at antenatal consultation.
In southern Tanzania, few high-risk pregnancies are channeled through antenatal care to the referral level. We studied the influences that make pregnant women heed or reject referral advice. Semi-structured interviews with sixty mothers-to-be, twenty-six health workers and six key-informants to identify barriers to use of referral level were conducted. Expert-defined risk-status was found to have little influence on a woman's decision to seek hospital care. Besides well known geographical and financial barriers, we found that pregnant women have different perceptions and interpretations of danger signs. Furthermore, rural women avoid the hospital because they fear discrimination. We conclude that a more individualised antenatal consultation could be provided by taking into account women's perception of risk and their explanatory models. Hospital services should be reorganised to address rural women's feelings of fear and insecurity.
Summaryobjective To assess whether antenatal care achieves identification and timely referral of high-risk pregnancies in southern Tanzania.methods We compared the risk profiles of pregnant women in general with those attending obstetric care and investigated the reasons for seeking care. The risk profile of inpatients was drawn up through interviews with maternity cases and analysis of their antenatal records at the regional referral hospital (n ϭ 415); population-based data on the prevalence of specific risk factors were obtained from entries in antenatal care registers (n ϭ 1630) and from literature.results A significant risk selection towards obstetric referral level care was observed only for previous caesarean section (prevalence hospital 6.7%, all pregnancies 1.5%, P Ͻ 0.005) and for nulliparity (hospital 42.8%, all pregnancies 25.0%, P Ͻ 0.005). No significant differences were observed for other risk factors such as previous perinatal death, height Ͻ 150 cm, multiple gestation and breech presentation. Prevalence of the risk factors age Ͼ 34 years and grand multiparity was significantly lower among hospital users. Coverage of obstetric care was below 50% for all risk factors except previous caesarean section (91.5%).conclusion Despite pursuing the risk approach and very good coverage, antenatal care in Tanzania has only limited effect on extending obstetric care to high-risk mothers. A critical review of the present screening and counselling practices, including a more focused and client-centred application of risk assessment, is warranted.keywords Safe motherhood, antenatal care, referral system, risk approach, Tanzania correspondence Dr Albrecht Jahn,
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