Factors affecting home delivery in rural Tanzania

Women with lower education, higher parity, and those living in rural areas are the least likely to access facility delivery services.

“Women with lower education, higher parity, and those living in rural areas are the least likely to access facility delivery services [9, 32, 33].”

Lack of privacy in a facility acts as a barrier to facility-based delivery.

“Barrier: Lack of privacy in a facility”

Lack of supportive attendance during facility delivery acts as a barrier to facility-based delivery.

“Barrier: Lack of supportive attendance during facility delivery”

Lack of access to funds in an emergency acts as a barrier to facility-based delivery.

“Barrier: Lack of access to funds in an emergency”

Indirect and hidden costs associated with facility delivery act as a barrier to facility-based delivery.

“Barrier: Indirect and hidden costs associated with facility delivery”

Inaccessibility of transportation and facilities during off-hours acts as a barrier to facility-based delivery.

“Barrier: Inaccessibility of transportation and facilities during off-hours”

Lack of accessible and reliable transportation acts as a barrier to facility-based delivery.

“Barrier: Lack of accessible and reliable transportation”

Inadequate health facility staffing and infrastructure act as a barrier to facility-based delivery.

“Barrier: Inadequate health facility staffing and infrastructure”

Neglect and delays in receiving care at the facility act as a barrier to facility-based delivery.

“Barrier: Neglect and delays in receiving care at the facility”

Stigmatization of unwed, pregnant women acts as a barrier to facility-based delivery.

“Barrier: Stigmatization of unwed, pregnant women”

Even if women are able to arrange transportation during the off-hours, health facilities may be closed or lack the staffing to manage her delivery.

“Even if women are able to arrange transportation during the off-hours, health facilities may be closed or lack the staffing to manage her delivery.”

In the absence of a reliable private car, women were faced with arduous modes of transportation including bicycle, rickshaw, motorcycle, boat, walking, or public transportation, which was often intermittent in rural areas.

“In the absence of a reliable private car, women were faced with arduous modes of transportation including bicycle, rickshaw, motorcycle, boat, walking, or public transportation, which was often intermittent in rural areas.”

Poor availability of transportation played a crucial role in the decision to deliver at a facility and whether or not it could be reached in a timely manner.

“Poor availability of transportation played a crucial role in the decision to deliver at a facility and whether or not it could be reached in a timely manner.”

Travel at night or on weekends was considered particularly difficult as there are fewer public transportation options, women may be afraid of thieves and wild animals, and the price is higher.

“Travel at night or on weekends was considered particularly difficult as there are fewer public transportation options, women may be afraid of thieves and wild animals, and the price is higher.”

Instead, family members were often sent around the community to collect money from their neighbors or try to sell property or livestock.

“Instead, family members were often sent around the community to collect money from their neighbors or try to sell property or livestock”

Even in settings where direct delivery costs were subsidized, families were expected to pay for transportation to the facility, drugs, medical supplies (i.e.: gloves, needles, gauze), blood for transfusions, laboratory services, food during the hospital stay, bribes to health providers, and laundry services.

“Even in settings where direct delivery costs were subsidized, families were expected to pay for transportation to the facility, drugs, medical supplies (i.e.: gloves, needles, gauze), blood for transfusions, laboratory services, food during the hospital stay, bribes to health providers, and laundry services.”

Collecting the necessary money was a difficult task as few banks or moneylenders would lend money to the poor, and if they did, exorbitant interest rates could make the principle escalate rapidly in just a few months.

“Collecting the necessary money was a difficult task as few banks or moneylenders would lend money to the poor, and if they did, exorbitant interest rates could make the principle escalate rapidly in just a few months.”

Low-SES families often did not plan in advance for costs associated with child birth and few families had assets or savings to devote to health expenses, thus causing a scramble to raise funds during obstetric complications.

“Low-SES families often did not plan in advance for costs associated with child birth and few families had assets or savings to devote to health expenses, thus causing a scramble to raise funds during obstetric complications.”

In addition to the extra point-of-care costs associated with facility birth, families experienced opportunity costs due to absence from work and domestic responsibilities.

“In addition to the extra point-of-care costs associated with facility birth, families experienced opportunity costs due to absence from work and domestic responsibilities.”

These additional costs often came as a surprise to women after they attended the facility, which may impact their future choice of delivery location.

“These additional costs often came as a surprise to women after they attended the facility, which may impact their future choice of delivery location.”

Upon arrival to a facility, women often experienced delays in care provision and health workers were often slow to respond to patient needs.

“Upon arrival to a facility, women often experienced delays in care provision and health workers were often slow to respond to patient needs.”

Delivering at home was a desirable choice for unwed women or adolescents to avoid embarrassment or discrimination at a facility, particularly because these women were often lacking emotional and financial support from their partner or parents.

“Delivering at home was a desirable choice for unwed women or adolescents to avoid embarrassment or discrimination at a facility, particularly because these women were often lacking emotional and financial support from their partner or parents.”

Health workers often did not communicate with the woman or her family on the progress of labor.

“Health workers often did not communicate with the woman or her family on the progress of labor.”

Most societies view pregnancy and childbirth as the outcome of a marital relationship, thereby potentially stigmatizing and disempowering unwed women seeking facility delivery.

“Most societies view pregnancy and childbirth as the outcome of a marital relationship, thereby potentially stigmatizing and disempowering unwed women seeking facility delivery.”

The lack of adequate staffing led to overburdened lower-level providers and often prompted women to visit untrained traditional providers to respond to the gaps in service.

“The lack of adequate staffing led to overburdened lower-level providers and often prompted women to visit untrained traditional providers to respond to the gaps in service.”

Traditional influences including local understandings of disease etiology and externally-focused loci of control play complex but important roles in understanding decision-making on location of delivery.

“Traditional influences including local understandings of disease etiology and externally-focused loci of control play complex but important roles in understanding decision-making on location of delivery [16–22, 41].”

Inadequate staffing and infrastructure in the facilities contributed to the perceived low quality of care.

“Inadequate staffing and infrastructure in the facilities contributed to the perceived low quality of care.”

The lack of supportive attendance during facility-based delivery was a major concern.

“The lack of supportive attendance during facility-based delivery was a major concern [23, 24, 29, 34, 36, 39, 41, 43].”

Many women felt more in control of maintaining their privacy when delivering at home.

“Many women felt more in control of maintaining their privacy when delivering at home [24, 26, 27, 31, 39, 41, 42].”

Women commonly referred to their families and TBAs as providing supportive care during home births.

“Women commonly referred to their families and TBAs as providing supportive care during home births.”

Travel at night or on weekends is especially difficult as there are fewer options and higher costs.

“Travel at night or on weekends is especially difficult as there are fewer options and higher costs [33, 39, 41, 43, 45, 46].”

Limited availability of transportation options played a crucial role in whether or not a facility could be reached in a timely manner.

“Likewise, limited availability of transportation options played a crucial role in whether or not a facility could be reached in a timely manner [25–27, 32, 36, 39, 41, 45, 47].”

Women viewed costs outside of the direct cost for a delivery as "hidden" and said they were difficult to prepare for.

“Women viewed costs outside of the direct cost for a delivery as “hidden” and said they were difficult to prepare for [16, 19, 20, 24, 25, 30, 31, 34, 41, 43–45, 47–49].”

Even in settings where direct delivery costs were subsidized, families were expected to pay for transportation to the facility and other costs related to treatment at the facility.

“Even in settings where direct delivery costs were subsidized, families were expected to pay for transportation to the facility, and other costs related to treatment at the facility [25, 30, 31, 34, 41, 43, 48, 49].”

Low-resource households may have trouble acquiring funds to pay for facility-based care at the time-of-service, particularly those families who rely on seasonal labor.

“Low-resource households may have trouble acquiring funds to pay for facility-based care at the time-of-service, particularly those families who rely on seasonal labor [28, 32–34, 37, 41, 48, 49].”

Women also experienced neglect and long delays in receiving facility-based care.

“Women also experienced neglect and long delays in receiving facility-based care [17, 24, 31, 36, 39, 41, 45, 46, 48].”

Inadequate facility infrastructure and staffing contributed to an overall perception of low quality of care.

“Inadequate facility infrastructure and staffing contributed to an overall perception of low quality of care and many women complained of overcrowded wards without dedicated labor and delivery areas [17, 18, 24, 34, 35, 37, 39, 41, 45–47].”

Many women complained of overcrowded wards without dedicated labor and delivery areas.

“Inadequate facility infrastructure and staffing contributed to an overall perception of low quality of care and many women complained of overcrowded wards without dedicated labor and delivery areas [17, 18, 24, 34, 35, 37, 39, 41, 45–47].”