Prevalence and risk factors for delayed antenatal care visits in Rwanda: an analysis of secondary data from Rwanda demographic health survey 2019-2020.

Introduction: antenatal care (ANC) delivers services to prevent pregnancy complications and provides counseling for birth, and emergency preparedness. Having ANC on time has life-saving potential for the child and mother. Despite improvements in health infrastructure, human resources, and health insurance, hindrances to early ANC visits still exist in Rwanda. This study aimed to investigate the burden and factors associated with delayed ANC visits in Rwanda so that policymakers can develop strategies to promote early ANC visits. Methods: this is a cross-sectional study using Rwanda demographic health survey (RDHS) 2019-2020 that included 6,039 women that had had a pregnancy in the 5 years preceding the survey. Descriptive analysis was used to determine the prevalence and a multivariable logistic regression model using manual backward stepwise regression was used to identify risk factors for delayed ANC in Rwanda. STATA 16 statistical software was used for all the analyses. Results: the prevalence of delayed ANC in Rwanda was 41% and the risk factors include: the number of children 4-6 (AOR = 1.4, 95% CI: 1.2-1.6) and 7 or more children (AOR = 1.5, 95% CI: 1.5-2.1) versus less than 3 children, unwanted pregnancy (AOR = 1.7, 95% CI: 1.5-2.0), not covered by health insurance (AOR = 14, 95% CI: 1.2-1.6), woman´s education level: no education (AOR 2.6, 95% CI: 1.6-4.1), primary education (AOR 2.5, 95% CI: 1.6-3.7), secondary education (AOR 2.2, 95% CI: 1.5-3.2), woman´s occupation: informal (AOR 2.3 95% CI: 1.5-3.7) and unemployment (AOR 2.3. 95% CI: 1.4-3.7). Conclusion: based on the findings from our study, family planning services should be made available to all women of childbearing age to prevent unwanted pregnancies; female education should be considered a priority, promotion of health insurance coverage and community-based education about reproductive health to encourage the early seeking of care among women of childbearing age.

Women's childbirth experience emphasizing own capacity and safety: A cross-sectional Rwandan study.

PROBLEM AND AIM: Women's childbirth experience is central when assessing intrapartum care quality. This study accordingly measures women's childbirth experience in Rwandan health facilities, focusing on own capacity and perceived safety. METHODS: A cross-sectional health facility-based study was conducted December 2014 to January 2015 in Kigali City and the Northern Province. Childbirth experience was assessed before discharge using an overall assessment and two subscales, Own capacity and Perceived safety, of the Childbirth Experience Questionnaire, with high scores reflecting a good experience. The questionnaire was translated from English into Kinyarwanda. Reliability was tested using Cronbach's alpha; and mean scores between groups were compared using Mann-Whitney U test. FINDINGS: All invited women (n = 817) agreed to participate after informed consent. Mean age was 27.8 years and 63.6% were multiparous. A majority of women (82.3%) reported an overall positive childbirth experience (≥8 out of 10). Cronbach's alpha indicated good reliability for Own capacity (0.78) and Perceived safety (0.76). In both subscales multiparous women had higher mean scores than primiparous, married women scored higher than unmarried, older women (>35) scored higher than younger (<35), and women with higher level of education scored higher than those with lower level. Women with HIV scored lower on perceived safety. CONCLUSION: A majority of the women reported a positive overall childbirth experience. Own capacity and perceived safety are important dimensions of childbirth experience and should be addressed in building high-quality intrapartum care. Further research is needed and should include exploration of specific groups.

Quality of intrapartum care for healthy women with spontaneous onset of labour in Rwanda: A health facility-based, cross-sectional study.

OBJECTIVE: To investigate the quality of intrapartum care provided at Rwandan healthcare facilities to women undergoing normal pregnancy and spontaneous full-term labour. METHODS: A cross-sectional study was conducted over eight weeks during 2014-2015 in 18 healthcare facilities in Kigali City and the Northern Province: eight health centres, seven district hospitals, one provincial hospital, one private hospital, and one referral hospital. Data were collected from medical records and a questionnaire including the Bologna score with its five variables: presence of a companion, use of partograph, no augmentation of labour, birth in a non-supine position, and skin-to skin contact. RESULTS: Among the 435 women who fulfilled the inclusion criteria during the study period, mean age was 27.4 years and 41.8% were primiparous. The assisting healthcare professionals were midwives (49.4%), nurses (28.8%), and physicians (22%), and birth occurred at health centres (29%), district hospitals (40%), and the referral hospital (31%). Mean Bologna score was 2.03 of the maximum 5 (range: 0-4). Only one woman (0.2%) had a companion present (her husband). A partograph was used for the majority (84.8%), and 88.0% had no augmentation of labour with oxytocin. Few (6.2%) gave birth in a non-supine position, and few (12.4%) had early skin-to-skin contact with their newborn. CONCLUSION: There are several areas for improving childbirth care according to the Bologna score. Healthy newborns should be placed skin-to-skin with their mothers shortly after birth, non-supine birthing positions should be encouraged, and the importance of a companion during labour and birth should be considered.

The meaning of a poor childbirth experience - A qualitative phenomenological study with women in Rwanda.

OBJECTIVE: Being pregnant and giving birth is a pivotal life event and one that a woman ordinarily remembers for most of her life. A negative childbirth experience can affect a woman's health well beyond the episode of the labour and birth itself. This study explored the meaning of a poor childbirth experience, as expressed by women who had given birth in Rwanda. METHODS: In a cross-sectional household study conducted in Northern Province and in Kigali City, the capital of Rwanda, a structured questionnaire was answered by women who had given birth one to 13 months earlier. One question, answered by 898 women, asked them to rate their overall experience of childbirth from 0 (very bad) to 10 (very good). Of these, 28 women (3.1%) who had rated their childbirth experience as bad (≤ 4) were contacted for individual interviews. Seventeen of these women agreed to participate in individual in-depth interviews. The texts were analysed with a reflective lifeworld approach. RESULTS: The essential meaning of a "poor" childbirth experience was that the women had been exposed to disrespectful care, constituted by neglect, verbal or physical abuse, insufficient information, and denial of their husband as a companion. The actions of carers included abandonment, humiliation, shaming and insult, creating feelings of insecurity, fear and distrust in the women. Two of the women did not report any experience of poor care; their low rating was related to having suffered from medical complications. CONCLUSION: It is challenging that the main finding is that women are exposed to disrespectful care. In an effort to provide an equitable and high quality maternal health care system in Rwanda, there is a need to focus on activities to implement respectful, evidence-based care for all. One such activity is to develop and provide education programmes for midwives and nurses about professional behaviour when caring for and working with women during labour and birth.

Associations between perceptions of care and women's childbirth experience: a population-based cross-sectional study in Rwanda.

BACKGROUND: In recent years Rwanda has achieved remarkable improvement in quality of maternity care services but there is evidence of deficiencies in care quality in terms of disrespectful care. Women's overall childbirth experience is an important outcome of childbirth and a factor in assessing quality of care. The aim of this study was to investigate how women's overall childbirth experience in Rwanda was related to their perceptions of childbirth care. METHODS: A cross-sectional household study of women who had given birth 1-13 months earlier (n = 921) was performed in the Northern Province and in the capital city. Data was collected via structured interviews following a questionnaire. Significant variables measuring perceptions of care were included in a stepwise forward selection logistic regression model with overall childbirth experience as a dichotomised target variable to find independent predictors of a good childbirth experience. RESULTS: The majority of women (77.5%) reported a good overall childbirth experience. In a logistic regression model five factors of perceived care were significant independent predictors of a good experience: confidence in staff (Adjusted OR 1.73, 95% CI 1.20-2.49), receiving enough information (AOR 1.44, 95% CI 1.03-2.00), being treated with respect (AOR 1.69, 95% CI 1.18-2.43), getting support from staff (AOR 1.75, 95% CI 1.20-2.56), and having the baby skin-to-skin after birth (AOR 2.21, 95% CI 1.52-3.19). CONCLUSIONS: To further improve childbirth care in Rwanda and care for women according to their preferences, it is important to make sure that the childbirth care includes the following quality aspects in national and clinical guidelines: build confidence, provide good information, treat women and families with respect, provide good professional support during childbirth and put the newborn baby skin-to-skin with its mother early after birth.

Factors associated with postnatal care utilisation in Rwanda: A secondary analysis of 2010 Demographic and Health Survey data.

BACKGROUND: Postnatal care (PNC) in the first seven days is important for preventing morbidity and mortality in mothers and new-borns. Sub-Saharan African countries, which account for 62 % of maternal deaths globally, have made major efforts to increase PNC utilisation, but utilisation rates remains low even in countries like Rwanda where PNC services are universally available for free. This study identifies key socio-economic and demographic factors associated with PNC utilisation in Rwanda to inform improved PNC policies and programs. METHODS: This is a secondary analysis of the 2010 Demographic and Health Survey, a national multi-stage, cross-sectional survey. In bivariate analysis, we used chi-square tests to identify demographic and socio-economic factors associated with PNC utilisation at α = 0.1. Pearson's R statistic (r > 0.5) was used to identify collinear covariates, and to choose which covariate was more strongly associated with PNC utilisation. Manual backward stepwise logistic regression was performed on the remaining covariates to identify key factors associated with PNC utilisation at α = 0.05. All analyses were performed in Stata 13 adjusting for sampling weights, clustering, and stratification. RESULTS: Of the 2,748 women with a live birth in the last two years who answered question about PNC utilisation, 353 (12.8 %) returned for PNC services within seven days after birth. Three factors were positively associated with PNC use: delivering at a health facility (OR: 2.97; 95 % CI: 2.28-3.87), being married but not involved with one's own health care decision-making (OR: 1.69; 95 % CI: 1.17, 2.44) compared to being married and involved; and being in the second (OR: 1.46; 95 % CI: 1.01-2.09) or richest wealth quintile (OR: 2.04; 95 % CI: 1.27-3.29) compared to the poorest. Mother's older age at delivery was negatively associated with PNC use (20-29 - OR: 0.51, 95 % CI: 0.29-0.87; 30-39 - OR: 0.47, 95 % CI: 0.27-0.83; 40-49 - OR: 0.32, 95 % CI: 0.16-0.64). CONCLUSIONS: Low PNC utilisation in Rwanda appears to be a universal problem though older age and poverty are further barriers to PNC utilisation. A recent change in the provision of BCG vaccination to new-borns might promote widespread PNC utilisation. We further recommend targeted campaigns to older mothers and poorest mothers, focusing on perceptions of health system quality, cultural beliefs, and pregnancy risks.