BACKGROUND: Estimates of population-level coverage with prevention of mother-to-child transmission (PMTCT) services are vital for monitoring programmes but are rarely undertaken. This study describes uptake of PMTCT services among HIV-positive pregnant women in a community cohort in rural Tanzania. METHODS: Kisesa cohort incorporates demographic and HIV sero-surveillance rounds since 1994. Cohort data were linked retrospectively to records from four Kisesa clinics with PMTCT services from 2009 (HIV care and treatment clinic (CTC) available in one facility from 2008; referrals to city hospitals for PMTCT and antiretroviral treatment (ART) from 2005). The proportion of HIV-positive pregnant women residing in Kisesa in 2005-2012 who accessed PMTCT service components (based on linkage to facility records) was calculated per HIV-positive pregnancy and by year, with adjustments made to account for the sensitivity of the linkage algorithm. RESULTS: Out of 1497 HIV-positive pregnancies overall (to 849 women), 26% (n = 387/1497) were not linked to any facility records, 35% (n = 519/1497) registered for ANC but not HIV services (29% (n = 434/1497) were not tested at ANC or diagnosed previously), 8% (n = 119/1497) enrolled in PMTCT but not CTC services (6 % (n = 95/1497) received antiretroviral prophylaxis), and 32% (n = 472/1497) registered for CTC (14% (n = 204/1497) received ART or prophylaxis) (raw estimates). Adjusted estimates for coverage with ANC were 92%, 57% with HIV care, and 29 % with antiretroviral drugs in 2005-2012, trending upwards over time. CONCLUSIONS: Population-level coverage with PMTCT services was low overall, with weaknesses throughout the service continuum, but increased over time. Option B+ should improve coverage with antiretrovirals for PMTCT through simplified decisions for initiating ART, but will rely on strengthening access to CTC services.