{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T17:11:52Z","timestamp":1768410712065,"version":"3.49.0"},"reference-count":20,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,1,28]],"date-time":"2021-01-28T00:00:00Z","timestamp":1611792000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2021,1,28]],"date-time":"2021-01-28T00:00:00Z","timestamp":1611792000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17\/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80\/1000 births. There was a reduction in newborns with birth weight less than 2500\u2009g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in\u00a0newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12913-021-06107-x","type":"journal-article","created":{"date-parts":[[2021,1,28]],"date-time":"2021-01-28T13:06:26Z","timestamp":1611839186000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7542-6346","authenticated-orcid":false,"given":"Corinna","family":"Vossius","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Estomih","family":"Mduma","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Moshiro","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paschal","family":"Mdoe","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jan Terje","family":"Kval\u00f8y","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hussein","family":"Kidanto","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sara","family":"Lyanga","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hege","family":"Ersdal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2021,1,28]]},"reference":[{"key":"6107_CR1","unstructured":"Transforming our World: The 2030 Agenda for Sustainable Development United Nations, 2015. https:\/\/sustainabledevelopment.un.org\/index.php?page=view&type=400&nr=2125&menu=1515. Accessed 24 March 2020."},{"key":"6107_CR2","first-page":"97","volume":"17","author":"WJ Graham","year":"2001","unstructured":"Graham WJ, Bell JS, Bullough CH. Can skilled attendance at delivery reduce maternal mortality in developing countries. Safe Motherhood Strategies. 2001;17:97\u2013130.","journal-title":"Safe Motherhood Strategies"},{"issue":"Issue suppl_4","key":"6107_CR3","doi-asserted-by":"publisher","first-page":"S325","DOI":"10.1093\/cid\/ciu439","volume":"59","author":"ER Mduma","year":"2014","unstructured":"Mduma ER, Gratz J, Patil C, Matson K, Dakay M, Liu S, et al. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Study (MAL-ED): Description 5 of the Tanzanian Site. 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NIMR\/HQ\/R.8a\/Vol.IX\/1247 and the Safer Births project Ref. NIMR\/HQ\/R8a\/Vol. IX\/1434) and by the Regional Committee for Medical and Health Research Ethics, Western Norway (Ref. 2009\/302 and Ref number 2013\/110\/REK). Data is not openly available, and we received permission by NIMR to access the raw data for this study and to publish the findings. All relevant health care providers were informed about the different HBB CQI and Safer Births quality assessment studies and gave oral consent. Patients were also informed about ongoing studies, but consent was not required for this descriptive study.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Consent to access the raw data and to publish our finings was granted by the National Institute for Medical Research (NIMR), Ministry of Health in Tanzania.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"99"}}