ON MY MIND : More questions than answers in understanding health inequalities

Infant and child mortality rates have fallen considerably during the last 15 years or so, based on statistics provided in the Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-2016. However, significant differences remain in risk of dying among new born babies (neonates), infants before the age of one year, and children before the age of five years.

There has not been a corresponding improvement unfortunately in maternal mortality rates. The maternal mortality ratio has remained at 556 maternal deaths per 100,000 live births for the 10-year period before the survey, in line with estimates reported in the 2004-05 TDHS and 2010 TDHS and is consistent with the estimate from the 2012 Population and Housing Census.

Inequalities in mortality rates are not necessarily in the direction expected.

For example, infant mortality was higher in urban areas than in rural areas (63 and 47 deaths per 1000 live births, respectively) reportedly because of the higher neonatal mortality rates in urban areas. This provokes us to ask questions about underlying causes, given our assumption that urban areas usually have better health services, education, and living conditions than rural areas.

What are the factors in life and health in urban areas that make life more risky for both pregnant mothers and their new born infants than in rural areas? Then again, there are enormous class differences among urban women, which may help explain these findings, in terms of unequal access to safe and clean water and sanitation, dignified employment and income, and quality health care.

There is also major rural differentiation however, as found in comparative measures of zonal and regional mortality rates – such that gross urban/rural comparisons may not be meaningful.

For example, newborn babies’ risk of dying ranged between 23 deaths per 1,000 live births in the Northern zone and 47 deaths per 1,000 live births in the Southern zone.

Similar differences were found among infants below the age of one year, with least risk found again for the Northern zone (38 deaths per 1,000) and most in the South West Highlands and Southern zones (70 and 69 deaths per 1,000 live births respectively).

The growing impoverishment of rural peasant communities, and women among them, in part due to land grabbing and steady marginalization, also needs to be taken into consideration, along with urban migration.

What proportion of ‘urban’ women are in fact recent rural migrants?

The THDS-MIS report does not provide analysis of geographical, educational and income differences in maternal mortality rates, in contrast to that provided for children, with no explanation for this gap in information. However, structural differences in access to quality health care within and outside of the health care system are documented, which are suggestive of different risks of dying due to childbirth issues, and also provide one level of explanation for the differentials found in neonate, infant and underfive mortality rates.

Inequalities within the health system

Consistent differences are found among different socioeconomic groups of women in access to health facilities for child delivery, depending on geographic location, education and income level.

These differences should correspond to differentials in women’s chances of surviving childbirth, as well as their neonate children.

For example, urban women are more likely to deliver in a health facility than rural women (86 per cent and 54 per cent, respectively), and women in certain zones are more advantaged than others: 88 percent in Southern Highlands Zone and 87 per cent in Eastern Zone [with 94 per cent in Dar es Salaam] compared to 50 per cent in Western and Lake Zones [and 40 percent in Simiyu region]. In Zanzibar, Mjini Magharibi (85 per cent) has the highest rate of facility deliveries and the lowest is in Kaskazini Pemba (50 per cent).

Women with secondary education or more are more than twice as likely to be assisted during delivery by a skilled provider as women with no education (91 per cent and 42 per cent respectively). Similarly, 95 per cent of women in the highest wealth quintile receive such assistance as compared to 42 per cent in the lowest quintile.

Much more analysis is needed however to examine the basic causes of maternal and child health differences.

This underscores the need to triangulate data provided by massive surveys like this one with more detailed micro and qualitative studies, in order better understand the basic causes of inequalities in health.

Prof Marjorie Mbilinyi is Gender and Development analyst and member of TGNP Mtandao