Abstract #: L09

BYPASSING FIRST LEVEL CLINICS FOR CHILDBIRTH IN RURAL TANZANIA: A CENSUS OF 3000 RECENT DELIVERIES. Sabrina Hermosilla*, Margaret Kruk, Elysia Larson, Godfrey M. Mbaruku, (Columbia University, New York NY United States)

Background: National maternal mortality reduction strategies in low-income countries rely on primary care expansion. We assessed delivery care utilization patterns among women in rural Tanzania to measure the extent, determinants, and results of bypassing local clinics for secondary care (health center or hospital). Methods: We conducted a census of all deliveries between 6 weeks - 12 months in 24 rural clusters in Pwani Region, Tanzania. We assessed women’s demographic and obstetric characteristics, quality of their birth experience, and local clinic functioning through structured assessments. We analyzed characteristics associated with bypassing primary care clinics using logistic regression (robust standard errors). We examined differences between bypassers’ and non-bypassers’ birth experiences in bivariate analyses. Findings: We interviewed 3,019 eligible women (93% response rate). The population was 25.7% first time mothers and 75.1% literate. 71.0% delivered in a health facility, of which 41.8% bypassed primary care to deliver in a health center or hospital. The bypassing likelihood increased with primiparity (OR (odds ratio) 2.5, p<0.001), perceived poor quality at the local clinic (OR 1.3, p=0.046), and decreased with recent clinic renovations (OR 0.39, p=0.017) and clinic performance of 4 or more obstetric signal functions (OR 0.19, p<0.001). Bypassers reported greater receipt of mother and newborn exams and better quality of care. Interpretation: Bypassing first level clinics for obstetric care is common among women in eastern Tanzania. First birth and poor quality of care at the local clinic appear to be major determinants of bypassing. Women who delivered at hospitals and health centers reported better quality of care. Primary care is not meeting the expectations of women in this rural low-income setting, problematizing its role as a strategy for reducing maternal mortality in Africa.