Quality of antenatal care services in Rwanda: assessing practices of health care providers.

BACKGROUND: Although most pregnant women in Rwanda visit antenatal care (ANC) clinics, little has been studied about the quality of services being provided. We investigated the ANC providers' (HCPs) current practices in relation to prevention, management and referral of maternal conditions as well as the information provided to pregnant women attending ANC services in Rwanda. METHODS: This facility-based, cross-sectional study included 312 ANC providers as participants and a review of 605 ANC medical records from 121 health centers. Data collection was performed using an interviewer-administered questionnaire and a structured observation checklist. For the analyses, descriptive statistics and bi-and multivariable logistic regression were used. RESULTS: Nurses and midwives in ANC services failed to report a number of pregnancy-related conditions that would need urgent referral to a higher level of health care. Midwives did somewhat better than nurses in reporting these conditions. There was no statistically significant difference in how nurses and midwives informed pregnant women about pregnancy-related issues. Ever been trained in how to manage a pregnant woman exposed to violence was reported by 14% of the participants. In 12, 13 and 15% of the medical records there was no report on tetanus immunization, anthelmintic treatment and syphilis testing, respectively. CONCLUSION: The providers in ANC clinics reported suboptimal practices on conditions of pregnancy that needed urgent referral for adequate management. Information to pregnant women on danger signs of pregnancy, recommended medicines and tests do not seem to be consistently provided. Midwifery training in Rwanda should be expanded so that most of staff at ANC clinics are trained as midwives to help lower maternal and child mortality and morbidity.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study.

OBJECTIVES: To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs. DESIGN: Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city. PARTICIPANTS AND SETTINGS: Totally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling RESULTS: The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2. CONCLUSION: IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

Determinants of poor utilization of antenatal care services among recently delivered women in Rwanda; a population based study.

BACKGROUND: In Rwanda, a majority of pregnant women visit antenatal care (ANC) services, however not to the extent that is recommended. Association between socio-demographic or psychosocial factors and poor utilization of antenatal care services (≤2 visits during the course of pregnancy irrespective of the timing) among recently pregnant women in Rwanda were investigated. METHODS: This population-based, cross sectional study included 921 women who gave birth within the past 13 months. Data was obtained using an interviewer-administered questionnaire. For the analyses, bi-and multivariable logistic regression was used and odds ratios were presented with their 95% confidence intervals. RESULTS: About 54% of pregnant women did not make the recommended four visits to ANC during pregnancy. The risk of poor utilization of ANC services was higher among women aged 31 years or older (AOR, 1.78; 95% CI: 1.14, 2.78), among single women (AOR, 2.99; 95% CI: 1.83, 4.75) and women with poor social support (AOR, 1.71; 95% CI: 1.09, 2.67). No significant associations were found for school attendance or household assets (proxy for socio-economic status) with poor utilization of ANC services. CONCLUSION: Older age, being single, divorced or widowed and poor social support were associated with poor utilization of ANC services. General awareness in communities should be raised on the importance of the number and timing of ANC visits. ANC clinics should further be easier to access, transport should be available, costs minimized and opening hours may be extended to facilitate visits for pregnant women.

Intimate partner violence among pregnant women in Rwanda, its associated risk factors and relationship to ANC services attendance: a population-based study.

OBJECTIVES: To investigate the prevalence of four forms of intimate partner violence during pregnancy in Rwandan women, associated sociodemographic and psychosocial factors and relationship to antenatal care service usage. DESIGN: This was a cross-sectional population-based study conducted in the Northern province of Rwanda and in Kigali city. PARTICIPANTS AND SETTINGS: A total of 921 women who gave birth within the past 13 months were included. Villages in the study area were selected using a multistage random sampling technique and community health workers helped in identifying eligible participants. Clinical psychologists, nurses or midwives carried out face-to-face interviews using a structured questionnaire. Bivariable and multivariable logistic regression were used to assess associations. RESULTS: The prevalence rates of physical, sexual, psychological violence and controlling behaviour during pregnancy were 10.2% (95% CI 8.3 to 12.2), 9.7% (95% CI 7.8 to 11.6), 17.0% (95% CI 14.6 to 19.4) and 20.0% (95% CI 17.4 to 22.6), respectively. Usage of antenatal care services was less common among women who reported controlling behaviour (OR) 1.93 (95% CI 1.34 to 2.79). No statistically significant associations between physical, psychological and sexual violence and antenatal care usage were found. Low socioeconomic status was associated with physical violence exposure (OR) 2.27 (95% CI 1.29 to 3.98). Also, young age, living in urban areas and poor social support were statistically significant in their associations with violence exposure during pregnancy. CONCLUSIONS: Intimate partner violence inquiry should be included in the standard antenatal care services package and professionals should be trained in giving support, advice and care to those exposed. Gender-based violence is criminalised behaviour in Rwanda; existing policies and laws must be followed and awareness raised in society for preventive purposes.

Hemodynamic adaptations in different trimesters among nulliparous and multiparous pregnant women; the Generation R study.

BACKGROUND: It has been suggested that maternal vascular adaptations during pregnancy differ between nulliparous and multiparous women. Therefore, we examined the associations of parity with blood pressure and hemodynamic placental function during pregnancy and risks of gestational hypertensive disorders. METHODS: The study was embedded in a population-based prospective cohort study among 8,377 pregnant women. Information about parity and gravidity was obtained at enrollment. Blood pressure was repeatedly measured in each trimester and mean pulsatility and resistance indexes of uterine artery were measured in second and third trimesters. Information on gestational hypertension and preeclampsia was available from medical records. RESULTS: As compared with nulliparous women, multiparous women had a lower systolic and diastolic blood pressure in each trimester of pregnancy and a slightly higher second and third trimester uterine artery resistance and pulsatility indexes (all P values < 0.05), but a lower risk of third trimester uterine artery notching (odds ratio (OR) 0.67 (95% confidence interval (CI):0.53, 0.84)). The risks of gestational hypertension and preeclampsia were lower among multiparous women as compared with nulliparous women (OR 0.32 (95% CI: 0.24, 0.43) and OR 0.24 (95% CI: 0.16, 0.37), respectively). Among multiparous women only, we did not observe associations of parity with hemodynamic parameters. CONCLUSIONS: Nulliparous pregnant women have higher blood pressure levels throughout pregnancy and higher risks of notching and gestational hypertensive disorders. The first pregnancy might be a major risk factor for maternal hemodynamic maladaptations and vascular complications. Further studies are needed to explore the underlying mechanisms and consequences for fetal growth and development.