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

In Tanzania, despite the fact that majority of population lives within 5 kilometers of a primary health facility, utilization of these facilities is limited owing to poor quality of services. This study tests the hypothesis that women bypass nearest primary health facility in order to receive better antenatal care (ANC) elsewhere and assesses covariates of this behavior. We combine original data on mothers with recent pregnancies from cross-sectional household survey (n=912) with health facility information collected in 2011 in Rufiji, Kilombero and Ulanga Districts. Bypassers are defined as mothers who opt to seek ANC at facilities other than the facility nearest to her home village. Multivariate logistic regression is used to examine maternal and contextual factors associated with odds of bypassing proximate facilities. Results show more than half of women are categorized as 'bypassers'. Bypassers were 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) than dispensary. Women whose nearest facility was over 1 km away from home village were more likely to bypass than those who had a facility within village (OR 3.96, p<0.00). 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. The strong patterns of bypassing reveal mothers' preferences for better ANC services, despite additional costs and time involved. This suggests crucial need to improve the quality of community-based ANC services to achieve health equity.