1. UNDERSTANDING MATERNAL SERVICE UTILIZATION IN TANZANIA USING A POPULATION BASED NATIONAL SURVEY DATA FIRST ANNUAL INTERNATIONAL CONFERENCE ON PUBLIC AND GLOBAL HEALTH MARCH 16-17 th 2016 DR. STEPHEN M. KIBUSI BScN MA PhD COLLEGE OF HEALTH SCIENCES UNIVERSITY OF DODOMA

2. The 2011-12 THMIS was commission by the Tanzania Commission for AIDS (TACAIDS) and the Zanzibar AIDS Commission (ZAC). The survey was implemented by the National Bureau of Statistics (NBS) and the Office of the Chief Government Statistician Zanzibar (OCGS) in collaboration with the Ministry of Health and Social Welfare (MOHSW). Funding for the 2011-12 THMIS was provided by the Government of Tanzania through the Ministry of Health and Social Welfare (MOHSW). The United States Agency for International Development (USAID) provided funds for the implementation of the survey and technical assistance through ICF International. Additional support was provided by the National AIDS Control Programme (NACP), the National Malaria Control Programme (NMCP), the Zanzibar AIDS Control Programme (ZAC), the Zanzibar Malaria Control Programme (NMCP), the Muhimbili University of Health and Allied Sciences(MUHAS), and the Ifakara Health Institute(IHI)-Bagamoyo Site.

3. Which data files are available? CodeRecode Type HRHousehold PRPeople (all household members) IRWomen and men with completed interviews KRChildren < 5 of interviewed women BRBirths to interviewed women in past 6 years ARHIV test results

4. How DHS data are collected

5. Stata/SPSS can’t handle hierarchical files, so we make different files for different units of analysis

6. For analyzing data at the household level, we have a Household Recode (HR) file.

7. For analyzing data at the men’s and women’s level, we have an Individual Recode (IR) file.

8. For analyzing data on children ages 0-59 months of INTERVIEWED women, we have a Kids Recode (KR) file.

9. Children of non-interviewed mothers are NOT included in the KR and Birth Recode (BR) files

10. To look at data on ALL household members (including children whose mothers weren’t interviewed), use the Person Recode (PR) file. Note: children who do not live in the household, but are children of interviewed women will be included in KR and BR files, but not the PR file

11.  MATERNAL SERVICE UTILIZATION - THMIS 2011/2012

12. OBJECTIVES  TO ASSESS HIDDEN COSTS IN ACCESSING MATERNAL HEALTH SERVICES IN TANZANIA  TO ASSESS FACTORS ASSOCIATED WITH ACCESS TO MATERNAL HEALTH SERVICES IN TANZANIA  MISSED OPPORTUNITIES IN PMTCT (came to ANC, Not offered HIV test, Offered test but not received results, received results but not offered post-test counseling) ---- ONGOING STUDY

13. DEFINING MATERNAL SERVICE UTILIZATION  UPTAKE OF IPTp DURING PREGNANCY  TIMING OF THE FIRST ANTENATAL CARE VISIT  COMPLETING THE RECOMMENDED NUMBER OF ANTENATAL VISITS DURING PREGNANCY  DELIVERY AT A HEALTHCARE FACILITY

14. Predictors for Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) in Tanzania. Published in BMC Public Health Journal

15. Background  An estimated 3.4 billion people are at risk for malaria.  In 2012, there were an estimated 207 million cases of malaria and an estimated 627,000 deaths.  90% of all malaria deaths occur in sub-Saharan Africa.  Between 2000 and 2012, the increase in malaria interventions helped to reduce global malaria mortality rate by 42% and by 49% in the WHO African Region.

16. Background…  In Tanzania, reported cases of malaria in 2010, 2011, and 2012 were 1,278,998; 2,150,761; and 1,986,955, respectively.  The number of reported deaths from malaria in 2010, 2011, and 2012 were 15,867; 11,806; and 7,820 respectively

17. Background…  Infection with P. falciparum can lead to chronic anemia, placental malaria infection, and low birth weight, and premature delivery all of which increase the risk of neonatal death  IPTp is a regimen of sulfadoxine-pyrimethamine (SP) given at least twice during antenatal care (ANC) visits  IPTp in 2 doses during pregnancy reduces prevalence of anemia and placental malaria infections at time of delivery

18. Trends in Intermittent Preventive Treatment during Pregnancy Intermittent Preventive Treatment Percent of women age 15-49 with a live birth in the two years before the survey, who:

19. Intermittent Preventive Treatment during Pregnancy (IPTp), THMIS 2011-12 Percent of women age 15-49 with a live birth in the two years before the survey, who:

20. Question, Objective  Question: What are the predictors for uptake of IPTp among pregnant women aged 15-49 years attending ANC in Tanzania?  Objective: To investigate the predictors for uptake of IPTp among pregnant women in Tanzania.

21. Method  Design:  Cross-sectional survey of nationally representative sample of individuals aged 15-49 years living in Tanzania in the period between December 2011 and May 2012.  Data sources: THMIS 2011/12  Questionnaire: 2011-12 THMIS Individual Questionnaire.  Outcome: Uptake of IPTp, 2+ doses among women aged15-49yrs who attended ANC

22. Unit of analysis Unit of Analysis: Pregnant woman, aged 15-49, gave live birth 2 years prior to the survey and attended ANC Numerator: Women with live births 2 years prior to survey who took two or more does of IPTp during pregnancy Denominator: Women who had live births in the past two years before the survey who attended ANC during pregnancy..

23. A CONCEPTUAL FRAMEWORK DEMOGRAPHIC FACTORS: Age Residence(rural/ urban) Education level Marital status Occupation Wealth index Parity Zones MODIFIABLE FACTORS: Access to Information: Ever heard about malaria Access to services: Number of ANC visits Timing of the 1 st Antenatal check-ups Number of antenatal visits during pregnancy. Uptake of IPTp

24. Sample selection: All women N=10,967 (Weighted) Women with a live birth 2 years prior to the survey N=3,555 (Weighted) Women with live birth 2yrs prior to the survey and attended ANC N= 1,615 (Weighted)

25. Key Findings: Descriptive Analysis – IPTp Uptake by wealth.

26. Key Findings: Descriptive – IPTp Uptake by Timing of the First ANC Visit.

27. Intermittent Preventive Treatment during Pregnancy by Region Tanzania 32% Kagera 32% Mjini Magharibi 53% Kaskazini Unguja 59% Kusini Unguja 58% Kaskazini Pemba 36% Kusini Pemba 34% Njombe 39% Mtwara 40% Lindi 48% Pwani 43% Dar es Salaam 48% Tanga 35% Morogoro 45% Ruvuma 37% Iringa 49% Mbeya 37% Rukwa 19% Katavi 24% Kigoma 23% Tabora 26% Singida 31% Dodoma 50% Manyara 30% Kilimanjaro 32% Arusha 36% Mara 10% Simiyu 16% Mwanza 27% Geita 14% Shinyanga 31% Percent of women age 15-49 with a live birth in the two years before the survey, who took 2+ doses of SP/Fansidar and received at least one during ANC

28. Summary of Descriptive Findings: Significant Association VariableLabelP-value EducationNo education, Primary Inc., Com, Secondary+ Age15-19, 20-24, 25-29, 30-43, 34-39, 40-44, 45-49 <0.01 ** OccupationUnemployed, Self employed, Employed Marital statusNever married, Separated/ Widowed, Married Wealth IndexPoorest, Poorer, Middle, Richer, Richest <0.001 *** ParityNo child, 1 child, 2 Children, 3+ Children <0.001 *** Timing of trimester 1 st trimester, 2 nd trimester, 3 rd trimester <0.001 *** Malaria Prevention Yes, No <0.001 *** ZonesEastern, Western, Southern, Southern High, SW Highlands, Central, Northern, Lake, Zanzibar <0.001 *** Source of anti-malaria Antenatal visit, Other source <0.001 ***

30. Factors associated with uptake of IPTp…

32. Discussion  There are regional variations in uptake of IPTp with more uptake high in the Eastern zone  IPTp use among pregnant women was very low and there was poor adherence despite utilization of Directly Observed Therapy (DOT).  Confusion about appropriate timing and poor implementation of direct observation of IPTp.

33. Discussion…  There are concerns about the safety of the drug during pregnancy.  Poor compliance with taking SP especially when women are allowed to take the drug at home.  Compliance of DOT in administering SP for IPTp at ANC clinics is complicated due to shortage of clean water and cups

34. Recommendations  Efforts to encourage earlier attendance at ANC alone are unlikely to improve uptake of IPTp.  Need for a concerted effort to increase awareness of IPTp among the public especially women of child bearing age  Need to train health workers on how to monitor IPTp adherence and also to communicate the importance of uptake of IPTp using simplified messages.  Need to ensure clinics do not run out of stock of IPTp medications  Need for proper planning of, support of, and training of health care workers and sustained sensitization of pregnant women

35. DEFINING MATERNAL SERVICE UTILIZATION  UPTAKE OF IPTp DURING PREGNANCY  TIMING OF THE FIRST ANTENATAL CARE VISIT  COMPLETING THE RECOMMENDED NUMBER OF ANTENATAL VISITS DURING PREGNANCY  DELIVERY AT A HEALTHCARE FACILITY HEALTH INSURANCE COVERAGE ….. HIDDEN COSTS

36. Health Insurance is a cornerstone to Improving Maternal Health Services Utilization in Tanzania: Analysis of the 2011/2012 Tanzania HIV/AIDS and Malaria Indicator Survey Published in BMC Health Service Research Journal

37. Background  Globally, the rate of annual decline of maternal deaths increased from 0.3% from 1990-2003 to 2.7% between 2003-2013.  In Africa South of Sahara MMR have been increasing.  Tanzania, MMR per 100,000 live births was 498 in 1990, increased to 622 in 2003, and slightly decreased to 324.9 in 2013

38. Background…  Early and planned ANC attendance and facility delivery with skilled health workers can potentially reduce the risks of immediate causes of MMR: pregnancy induced hypertension, malaria infection during pregnancy, vaccine-preventable diseases such as rubella and tetanus, high risk pregnancies such as multipara and multiple gestation, and prenatal, natal, and post natal hemorrhage  However, Tanzania faces poor health systems with inequality in health facilities distribution & high out-of- pocket health expenditures.  High proportion of mothers choose to deliver at home, unassisted by skilled health workers, even if they attend antenatal clinics

39. Background…  In Tanzania as high as 96.5% of women attend ANC at least once; however, a fraction of them attend the four required ANC visits and only 42.6% of births are attended by skilled personnel  The government subsidizes maternal health services including user-fee exemption.  The question is; why maternal health services utilization is low? HIDDEN COSTS??? INFRASTRUCTURAL BARRIERS???? SOCIO- CULTURAL FACTORS?????

40. OBJECTIVES  TO ASSESS HIDDEN COSTS IN ACCESSING MATERNAL HEALTH SERVICES IN TANZANIA  TO ASSESS FACTORS ASSOCIATED WITH ACCESS TO MATERNAL HEALTH SERVICES IN TANZANIA  MISSED OPPORTUNITIES IN PMTCT (came to ANC, Not offered HIV test, Offered test but not received results, received results but not offered post-test counseling) ---- ONGOING STUDY

41. DEFINING MATERNAL SERVICE UTILIZATION  UPTAKE OF IPTp DURING PREGNANCY  TIMING OF THE FIRST ANTENATAL CARE VISIT  COMPLETING THE RECOMMENDED NUMBER OF ANTENATAL VISITS DURING PREGNANCY  DELIVERY AT A HEALTHCARE FACILITY HEALTH INSURANCE COVERAGE ….. HIDDEN COSTS??

42. Study design  This cross-sectional study was designed to utilize secondary data originated from the nationally representative sample of men and women aged 15-49 years in the 2011/12 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS).  Two stage sampling: selection of clusters (EAs) & systematic sampling of households = 10,496 households

43. Before data analysis  19,319 men and women. Out of them, a total of 8,352 men were excluded to get the study population of women who had a live birth within three years prior to the survey. Out of the 10,967 women remained, only 4,627 women had one or more live births in the past three years before the survey were selected. A total of 114 women were excluded for missing data on important variables.  Finally, 4,513 women who had one or more live births within three years before the survey were included for analysis.

44. Variables and Measurements  Outcome variable: Maternal health services utilization  Main exposure variable: health insurance coverage  Covariates:

45. Data analysis  Both descriptive and inferential analysis

46. RESULTS

52. Join me to Discuss these findings

53. Discussion  Only 6.2% of women had health insurance.  Only 16.9% of all women had a timing of first ANC initiation as recommended.  Only 7.1% completed four recommended ANC visits  Up to 43.5% did not deliver their last baby in a health care facility  Having a health insurance was associated with proper timing of ANC initiation and giving birth under a skilled attendant 73.3% of women with facility delivery reported having made out-of-pocket payments for delivery-related costs

54.  Parity, age, education level, wealth index, place of residence influences timing of ANC initiation.  Women who were older had adhered to the recommendation of at least four ANC visits compared to the youngest age group (15-19).  Women of urban areas were less likely to deliver under skilled health workers compared to their rural counterparts

55. Conclusion  Having health insurance was associated with recommended timing the first ANC visit and increases the chances for health facility delivery under skilled health worker.  Results highlight the potential role of health insurance in improving maternal health and therefore address areas of improvement in the newly introduced Sustainable Development Goals number three and five.

56. THANK YOU FOR YOUR ATTENTION