*Corresponding author. 1 Mailman School of Public Health, Columbia University, New York, USA 2 Ifakara Health Institute, Dar es Salaam, Tanzania

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1 Do women bypass village services for better maternal health care in clinics? A case study of antenatal care seeking in three rural Districts of Tanzania Christine E. Chung 1*, Almamy M. Kante, 1,2, Amon Exavery 2, Colin Baynes 1,2, Kate Ramsey 1,2, Ahmed Hingora 2, Stephane Helleringer 1, James F. Phillips 1 Background In Tanzania, the provision of community-based healthcare has been significantly hindered by the lack of a trained healthcare workforce. Despite the fact that majority of Tanzanians live within five kilometers of a primary health facility, utilization of these facilities is limited owing to the poor quality of primary healthcare. Research suggests that individuals often choose to seek care at more distant higher level facilities, with the likelihood of bypassing dependent on individual factors, severity of disease or condition, and travel time (Kahabuka et al., 2011; Klemick, Leonard, & Masatu, 2009; Kruk et al., 2009; Akin & Hutchinson, 1999). In rural Kenya, at least half of mothers bypassed nearest facility (often lowest level government facilities) for antenatal care, immunization and other child health services (Audo et al., 2005). This research tests the hypothesis that women bypass the nearest primary health facility in order to receive better care for antenatal care (ANC) and delivery services elsewhere and assesses covariates of this behavioral phenomenon. The objective of this study is to explore the extent to which mothers bypass the nearest primary care facilities to seek antenatal care at more distant health facilities and to identify individual characteristics and contextual factors associated with the decision to bypass. A secondary objective is to examine the characteristics of bypassed facilities in comparison to the chosen facility in order to elucidate a possible explanation for bypassing among pregnant mothers seeking antenatal care in rural Tanzania. Data and Methods We combine original data from a cross-sectional household survey and a health facility survey collected in 2011 in Rufiji, Kilombero and Ulanga Districts. The household survey includes information gathered from women of reproductive age (15 to 49 years) on their health seeking behaviors during pregnancy and antenatal care, intrapartum care and immediate newborn care, on health service accessibility and utilization of health care. The health facility survey includes information on quality and services available at the facilities located within the three districts. Using information on only the most recently completed pregnancies in the previous two years, we categorize our sample (n=912) into bypassers and non-bypassers; we exclude a tiny fraction of mothers who did not visit a facility at all for antenatal care (n=5). A bypasser is defined as a woman who opts to seek care at a facility other than the one nearest to her home village. We link the household and facility survey data to geotagged village and facility locations in ArcGIS in order to identify the nearest facility to each respondent based on her home village and to measure the straight-line distance from the centroid of the village to the point location of the facility. 1 Mailman School of Public Health, Columbia University, New York, USA 2 Ifakara Health Institute, Dar es Salaam, Tanzania *Corresponding author

2 Bypassing for better maternal health care in rural Tanzania 2 Bivariate and multivariate logistic regressions are used to examine the maternal characteristics and the contextual factors associated with the odds of bypassing proximate facilities to seek antenatal care at a relatively distant health facility. We control the effects of only significant variables in the bivariate regressions to determine individual-level, facility-level and contextual factors contributing to the likelihood of bypassing. Maternal characteristics are examined to identify direct and interaction effects to assess the role of educational attainment, socioeconomic status, and parity as correlates of bypassing behavior. Data from health facility survey is analyzed to determine the type of maternal services available in each facility and to validate our hypothesis that bypassing for better services represents a significant factor in health seeking behavior. Multi-level models: Further analysis will test whether observed outcome (bypass or not) depend on characteristics of health facility. We note y r,i a categorical variable coded 1 if woman i of village r was bypasser during the survey and 0 otherwise. We estimate the following logistic model: where X is a vector of woman s characteristics, Z is a dummy variable taking value 1 if the health facility visited by the woman is within the village and 0 otherwise, T is a dummy variable taking value 1 if the health facility visited by the woman provided ANC services and 0 otherwise, and measures the interaction between woman and health facility visited. is a vector of random effects representing unobserved characteristics of woman that may affect health facility visited for ANC services. Preliminary Results and Discussion The health facility data cleaning is ongoing. Multilevel analysis will begin in January Preliminary analyses will take about a month; multi-level models will require another month of analysis. We expect the proposed manuscript to be ready in April To-date, preliminary results show that more than half of women interviewed sought these services at a health facility outside of the home village rather than at the dispensary closest to home. No significant differences between bypassers and non-bypassers on the factors of age, wealth quintile, number of ANC visits or the timing of ANC initiation. On the other hand, mothers who chose to travel further for antenatal care were more likely to use other forms of transport than walking and spend longer times traveling. Bypassers were almost 5 to 6 times more likely to visit a health center (OR 4.95, p<0.00) or hospital (OR 6.09, p<0.00) for care than a primary dispensary. Women whose nearest facility was over 1 kilometer away from her home village were more likely to bypass than those who had a facility within their village (OR 3.96, p<0.00). Almost three-quarters of the women who visited a hospital for antenatal care were categorized as bypassers. Results attest to the need to improve the quality of primary health care if Tanzania is to accelerate progress toward MDG5. Evidence that bypassing behavior covaries inversely with educational attainment and directly with relative prosperity suggests that the poor and least educated are less likely to selectively bypass the most convenient dispensary-based ANC than the least poor and most educated.

3 Bypassing for better maternal health care in rural Tanzania 3 The strong patterns of bypassing reveal pregnant mothers preferences for better maternal and child health services, despite the additional costs and time involved with traveling further. The high bypassing rate of government dispensaries suggests the current primary health care system is not meeting the needs of mothers in rural Tanzania. Reasons given for bypassing dispensaries in favor of visiting higher level health centers and hospitals have included lack of diagnostic facilities, shortage of drugs, lack of skilled staff and trust in staff, and overall poor services (Kahabuka et al., 2011). This suggests a crucial need for the government to improve not only access to healthcare but also the quality of services available especially at the community level. Improving the quality of dispensary and community-based ANC outreach services and information is therefore essential to improving health service equity more generally. Limitations and Further Research This research is premised on two assumptions, that individuals are more likely to seek care at the closest facility according to the principle of distance decay, and that individuals bypass for the purpose of receiving better or higher quality services. Further research will extend the current study to provide an examination of the actual services rendered by the chosen facilities in comparison to the potential services offered at the bypassed or nearest facility. We are also interested in comparing the package of antenatal care services received by mothers who bypass and by mothers who do not bypass the nearest facility. Do mothers who bypass actually receive better, if not similar, quality of services when compared to the mothers who seek care at their home facility? Our definition of bypassing is limited by the data available and methods of measuring bypassing. Using village-level data to calculate straight-line distances and to determine bypasser status may result in an underestimation of the proportion of mothers who bypass proximate facilities. Further research will utilize GIS-linked individual-level household survey data, which allows us to link each mother to the nearest facility based on road networks and foot paths as well as to calculate real distances from each household to the nearest facility and to the chosen facility. References Akin, J.S., & Hutchinson, P. (1999). Health-care facility choice and the phenomenon of bypassing. Health Policy and Planning, 14: Audo, M.O., Ferguson, A., & Njoroge, P.K. (2005). Quality of health care and its effects in the utilisation of maternal and child health services in Kenya. East African Medical Journal, 82: Kahabuka, C., Kvale, G., Moland, K.M., & Hinderaker S.G. (2011). Why caretakers bypass primary health care facilities for child care a case from rural Tanzania. BMC Health Services Research, 11: 315. Klemick, H., Leonard, K.L., & Masatu, M.C. (2009). Defining access to health care: Evidence on the importance of quality and distance in rural Tanzania. American Journal of Agricultural Economics, 91(2): Kruk, M.E., Mbaruku, G., McCord, C.W., Moran, M., Rockers, P.C., & Galea, S. (2009). Bypassing primary care facilities for childbirth: A population-based study in rural Tanzania. Health Policy and Planning, 24: Leonard, K.L., Mliga, G.R., & Mariam, D.H. (2003). Bypassing health centres in Tanzania: Revealed preferences for quality. Journal of African Economics, 11(4):

4 Bypassing for better maternal health care in rural Tanzania 4 Table 1. Bivariate associations between maternal and facility characteristics and bypasser status for a sample of mothers with recently completed pregnancies in Rufiji, Kilombero and Ulanga districts, Tanzania (n=907) Variables OR p-value [95% CI] Risk Factors Age <25 years ref 25 years (0.703, 1.198) Number of children under 5yrs 0 1 children ref 2 3 children (0.764, 1.312) Number of antenatal visits 1 2 visits ref 3 visits (0.634, 1.404) 4+ visits (0.567, 1.247) Antenatal care initiation/timing 0 3 months ref 4 6 months (0.960, 1.905) 7 9 months (0.791, 2.187) Mode of transport Foot ref Other *** (1.634, 2.830) Time spent traveling 0 30 mins ref mins ** (1.156, 2.230) >60 mins ** (1.242, 2.321) Demographic Factors District Rufiji ref Kilombero ** (0.417, 0.798) Ulanga *** (0.258, 0.601) Wealth quintile Poor ref Middle (0.725, 1.366) High (0.783, 1.577) Education level None ref Primary education and higher (0.551, 1.019) Marital status Other ref Married or living with a man as if married ** (0.454, 0.886) Religion Christian ref Muslim * (1.036, 1.786) Other (0.503, 1.507) Ethnic group Ndengereko ref Ngindo * (0.349, 0.945) Pogoro ** (0.277, 0.749) Sukuma * (0.313, 0.898) Other ** (0.327, 0.738) Facility Characteristics Visited: Facility type Dispensary ref Health centre *** (3.533, 6.941)

5 Bypassing for better maternal health care in rural Tanzania 5 Variables OR p-value [95% CI] Hospital *** (3.976, 9.342) Facility ownership Government ref Private *** (1.335, 2.380) Nearest: Facility type Dispensary ref Health centre *** (0.265, 0.596) Hospital *** (0.026, 0.213) Facility ownership Government ref Private *** (4.051, 7.176) Distance to nearest facility In village ref km ** (1.203, 2.406) km ** (1.135, 2.873) >1km *** (2.616, 5.939) *p<0.05, **p<0.01, ***p<0.00