Background: Over the last decade, progress in reducing maternal mortality in Rwanda has been slow, from 210 deaths per 100,000 live births in 2015 to 203 deaths per 100,000 live births in 2020. Access to quality antenatal care (ANC) can substantially reduce maternal and newborn mortality. Several studies have investigated factors that influence the use of ANC, but information on its quality is limited. Therefore, this study aimed to identify the determinants of quality antenatal care among pregnant women in Rwanda using a nationally representative sample. Methods: We analyzed secondary data of 6,302 women aged 15–49 years who had given birth five years prior the survey from the Rwanda Demographic and Health Survey (RDHS) of 2020 data. Multistage sampling was used to select RDHS participants. Good quality was considered as having utilized all the ANC components. Multivariable logistic regression was conducted to explore the associated factors using SPSS version 25. Results: Out of the 6,302 women, 825 (13.1%, 95% CI: 12.4–14.1) utilized all the ANC indicators of good quality ANC); 3,696 (60%, 95% CI: 58.6–61.1) initiated ANC within the first trimester, 2,975 (47.2%, 95% CI: 46.1–48.6) had 4 or more ANC contacts, 16 (0.3%, 95% CI: 0.1–0.4) had 8 or more ANC contacts. Exposure to newspapers/magazines at least once a week (aOR 1.48, 95% CI: 1.09–2.02), lower parity (para1: aOR 6.04, 95% CI: 3.82–9.57) and having been visited by a field worker (aOR 1.47, 95% CI: 1.23–1.76) were associated with more odds of receiving all ANC components. In addition, belonging to smaller households (aOR 1.34, 95% CI: 1.10–1.63), initiating ANC in the first trimester (aOR 1.45, 95% CI: 1.18–1.79) and having had 4 or more ANC contacts (aOR 1.52, 95% CI: 1.25–1.85) were associated with more odds of receiving all ANC components. Working women had lower odds of receiving all ANC components (aOR 0.79, 95% CI: 0.66–0.95). Conclusion: The utilization of ANC components (13.1%) is low with components such as having at least two tetanus injections (33.6%) and receiving drugs for intestinal parasites (43%) being highly underutilized. Therefore, programs aimed at increasing utilization of ANC components need to prioritize high parity and working women residing in larger households. Promoting use of field health workers, timely initiation and increased frequency of ANC might enhance the quality of care.
Rwanda located in central-eastern part of Africa is a low-income country with a population of about 12 million people [16, 19]. Rwanda’s public health system comprises of national referral hospitals as the highest level of care followed by provincial hospitals, district hospitals, health centers, and health posts [20, 21]. Community health workers (CHWs) who are over 45,000 provide health services at the village level [20, 22]. These CHWs provide the first line of basic health services with each village having a male–female CHW pair [20]. Rwanda has a universal, community-based health insurance program that has a household subscription and co-payments at the time of care and all citizens are eligible to enroll into it [20, 23]. Community-Based Health Insurance (CBHI) is purchased by about 86% of households [24]. Cross sectional study to analyze secondary data. The 2019–20 Rwanda Demographic Survey (RDHS) was used for this analysis. Data collection started in November 2019 and ended in July 2020 taking longer than expected due to the COVID-19 pandemic restrictions [16]. The Rwanda National Ethics Committee (RNEC) and the ICF Institutional Review Board reviewed and approved the survey protocol [16]. The2019-20 RDHS employed a two-stage sample design with the first stage involving sample points (clusters) selection consisting of enumeration areas (EAs) leading to 500 clusters being selected (112 in urban areas and 388 in rural areas) [16]. The second stage involved systematic sampling of households in all the selected EAs leading to a total of 13,005 households [16]. The RDHS used five questionnaires that included: the household, the woman’s, the man’s, the biomarker, and the fieldworker questionnaires. The data used in this analysis were from the household and the woman’s questionnaires. Women aged 15–49 years who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed. Out of the total 13,005 households that were selected for the survey, 12,951 were occupied and 12,949 were successfully interviewed leading to 100% response rate of 100.0% [16]. This study included women aged 15–49 years who were in need of ANC having had childbirth within five years preceding the survey. For those with more than one birth, the latest birth was considered. Among the interviewed households,14,675 women aged 15–49 were eligible to be interviewed and 14,634 women were successfully interviewed leading to a 99.7% response rate [16]. Out of the 14,634 successfully interviewed women, a weighted sample of 6,302 women had given birth within the last five years preceding the survey as shown in the supplementary file 1. The primary outcome variable was complete utilization of ANC components available in the RDHS women dataset that included: having blood pressure measurement, urine and blood samples being taken, being given iron tablets/syrups and intestinal parasite drugs and having had at least two tetanus injections [25–27]. Complete utilization of all the six ANC components was considered a proxy for having received good quality ANC and was coded 1 while inadequate quality was coded zero [25, 28]. The secondary outcomes were timing of ANC initiation and frequency of ANC visits. As recommended by the latest WHO guidelines, early ANC initiation was considered as initiation within the first trimester coded as one and initiation after first trimester coded as zero [27]. Adequate ANC frequency was considered as 4 and more contacts and coded as one and less than 4 contacts coded as zero [2, 6]. However, sensitivity analysis was done using 8 or more contacts as a measure of adequate ANC frequency recommended by the latest WHO guidelines [27]. This study included determinants of ANC initiation timing, frequency and quality based on evidence from available literature and data [6, 16, 25, 28]. Twenty explanatory variables were used in this study as shown in Table Table11. Categorization of independent variables Not at all Less than once a week’ At least once a week Not at all Less than once a week’ At least once a week Not at all Less than once a week’ At least once a week RDHS sample weights were used through the analysis to account for the unequal probability sampling in different strata [29] and to ensure representativeness of the findings [30]. In order to account for the multistage sample design inherent in the DHS dataset and to avoid any effect of the study design on the results hence ensuring accurate and reliable results, SPSS version 25.0 statistical software complex samples package was used. The complex samples’ package the analysis plan incorporated the sample individual weight, strata for sampling errors/design, and cluster number used in the RDHS which accounted for the multistage sample design inherent in the RDHS dataset [31–33]. Furthermore, use of weights enables making statistical inference at the population level while incorporating strata and cluster ensures getting correct standard error. Bivariable logistic regression was done to assess the association of each independent variable with each outcome and crude odds ratio (COR), 95% confidence interval (CI) and p-values are presented. Independent variables found significant at bivariable level with p-values less than 0.25 were added in the multivariable logistic regression model. Adjusted odds ratios (AOR), 95% Confidence Intervals (CI) and p-values were calculated with statistical significance level set at p-value < 0.05 [34]. All variables in the model were assessed for collinearity, which was considered present if the variables had a variance inflation factor (VIF) greater than 3. Sensitivity analysis was done with 8 or more ANC contacts as the outcome.