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

Quality of intrapartum care in Rwanda: management and women's experiences

The overall aim of this PhD project was to assess the quality of intrapartum care at healthcare facilities offering maternity services in Rwanda by investigating healthcare pro- viders’ management of labour and birth and women’s childbirth experiences. Study I, was a cross-sectional household study investigating how women’s perceptions of care received during labour and birth were related to their overall childbirth experience. Of 921 women, 77.5% reported a good childbirth experience. Predictors of a good experience were trusting healthcare professionals, receiving enough information, being respected, receiving profes- sional support during childbirth and having the baby skin to skin early after birth. Study II, a qualitative study using a phenomenological lifeworld approach to interview 17 women, identified the essential meaning of a poor childbirth experience as being exposed to disre- spectful care, which was constituted by neglect, verbal or physical abuse, insufficient infor- mation and refusal for the husband to be a present companion. Study III, investigated the quality of healthcare facilities’ intrapartum care for 435 healthy women with a spontaneous onset of labour at gestational term. More than 90.0% of the women gave birth spontane- ously vaginally, but a large proportion of women were transferred from a lower health facility level to a district or a referral hospital. A partograph was used in 84.8% of the labours, the majority (88.0%) of the women did not receive any oxytocin for the augmen- tation of labour, 6.2% gave birth in a non-supine position, only one woman was accompa- nied by her husband in the birthing room and 12.5% had early skin-to-skin contact with the newborn within one hour after birth. Study IV, measured childbirth experience, focus- ing on women’s own capacity and perceived safety when giving birth at health facilities. Of 817 women, 83% reported a positive experience. Internal consistency measured with Cronbach’s alpha was 0.76 and 0.72 respectively for the own capacity and perceived safety subscales. Married women vs unmarried and multiparous vs primiparous scored higher for own capacity and perceived safety during childbirth. To conclude, the findings show that women rated their overall childbirth experiences positively, with a significant relationship to perceptions of care. The best intrapartum practices of healthy women with a spontane- ous labour onset included the high non-use of labour augmentation with oxytocin and the use of the partogram. However, several areas of childbirth care need to be improved, not least to ensure respectful, women-centred care. This includes allowing women to have a companion present during labour and birth, being encouraged to give birth in a non-supine position and placing the newborn and mother skin to skin early after birth

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

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.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.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.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

Abstract 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

Characteristics of study participants, n = 17.

<p>Characteristics of study participants, n = 17.</p