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Background: In Rwanda, maternal community health workers (M-CHWs) are involved in the country’s overall health system. In maternal health, their role includes the provision of preventive and promotional health services at the community level. They provide services such as health education on maternal health wellbeing, advice and information on access and timely utilization of health facilities for prenatal, delivery and postpartum care. The contribution of M-CHWs in the health sector combined with other government initiatives led the country to achieving the fifth Millennium Development Goal (MDG) – target 5A- that aimed to improve maternal health through the reduction of maternal mortality ratio by 75% between 1990 and 2015). The objective of this study was to explore M-CHWs’ perceptions and experiences on access and provision of maternal health services. Methods: We used a case study methodology, a qualitative research approach to explore M-CHWs’ experiences and perceptions on access and provision of maternal health services at the community level in Rwanda. For the period of June–August 2014, in-depth interviews were conducted with sixteen M-CHWs who had been providing maternal health services in the Eastern Province of Rwanda. Participants shared their experiences and perceptions on access and provision of maternal health service in their communities. Results: The results of this research highlight the role of M-CHWs in promoting the use of health facilities for prenatal care and delivery and the ways they use to reach out to women. Several challenges prohibit M-CHWs to deliver adequate maternal health services and these are related to the poor resources settings in which they operate. Conclusion: The results of this study highlight the experiences and perceptions of M-CHWs on the provision and access to maternal health services in their communities. The fact that M-CHWs are volunteers operating in limited resources settings with no formal training in maternal health and with considerable workloads translates into challenges regarding the quality and quantity of services they provide in their communities. Such challenges create an impact on M-CHWs service provision, satisfaction and retention. The voices of M-CHWs and the communities they serve are needed to explore areas that are specific to each community context that would contribute to making the M-CHW program sustainable to achieve equitable access to maternal health services.
We used a case study research design to explore M-CHWs’ perceptions and experiences on access and provision of maternal health services. The case study approach was deemed appropriate for this research in order to explore the complex aspects of M-CHWs’ roles in the context of providing maternal health services [17, 18] . Through this approach, we conducted in-depth interviews with M-CHWs where they provided a deeper understanding of their experiences on access and provision of maternal health at the community level. We used a semi-structured interview guide that included open ended questions to elicit views from M-CHWs about: 1) their understanding of maternal health; 2) the types of maternal health services provided at the community level by M-CHWs; 3) the factors that contribute to the use of maternal health services; 4) gaps and barriers in the provision of maternal health services in the community; and 5) suggestions to improve service provision. All the sampled participants accepted to fully participate in the study. Body languages and non-verbal communication were observed, and field notes were taken. These were used during the analysis to better interpret the interviews. The current study reports on data collected as part of a master’s research conducted in the Eastern and Western provinces of Rwanda [19]. For this study, we used data from semi-structured interviews with M-CHWs [19] in the Eastern Province, where the MNCH project operated. The project interventions included in-service training of health professionals (nurses, midwives and physicians) on maternal, newborn and child health care. The trained health professionals, especially nurses, work closely with M-CHWs. The lead author (GT) conducted interviews in Kinyarwanda, the official language in Rwanda, which is also her mother tongue. GT is familiar with the Rwandan culture as well as the Rwandan health system, which helped her to navigate the communities where the study was conducted. The Eastern Province is the largest and most populated province with the lowest population density in the country [20]. Data were collected in eight district hospitals across the province: Nyamata, Rwamagana, Kibungo, Kirehe, Gahini, Kiziguro, Ngarama and Nyagatare. Each of these hospitals serves as a second level of health care for about 11–20 health centers. Health centers provide primary health services, and they oversee M-CHWs activities in different communities. For every health center, there are about 20–38 M-CHWs, each one of them operating in their own village of approximately 100 households and all together serving the population in the catchment area of a health center. All the M-CHWs included in this study operate in equally remote settings from the health centers. The sample size was determined by the qualitative nature of this study. In total, sixteen semi-structured interviews were conducted with M-CHWs on their perceptions and experiences on access and provision of maternal health services in their communities. There was at least one interview per hospital selected for this particular analysis. Eligible participants were identified and were given written and verbal information about the study by the coordinators of M-CHWs’ activities at the health center and district hospital levels. The letter of information stated the objective of the study and that there was no impact whatsoever on M-CHW following their (non) participation in the study. Those who were interested in participating in the study contacted the researcher, who in return, scheduled a meeting with each of them to further explain the study, answer questions, and schedule interviews. Following participants’ choice, most interviews took place at the health center (n = 12), very few took place at the M-CHW’s home (n = 4). The semi-structured interviews were about 30–45 min and proceeded in an open dialogue form and were audio recorded with participants’ permission. All the interviews were conducted in the Kinyarwanda language and were audio-recorded with participants’ permission. The audio recordings were transcribed verbatim, translated from Kinyarwanda into English prior to analysis. Three members of the research team (GT, CH & SR) are fluent in both English and Kinyarwanda which helped for translation validity. The transcripts were stored and organized with NVIVO™ software, a qualitative data management program. Selected transcripts that corresponded to research objectives were independently reviewed by each team member. Initially, inductive coding was done by GT using NVivo and simultaneously, by each research team member manually. A first analysis team meeting involved the discussion on codes and categorizing them into emerging themes [21]. Team members separately went back through the transcripts prior to a second meeting that was aimed to discuss on additional inductive and deductive codes for the application of thematic analysis. Thematic analysis was conducted involving the grouping of themes that emerged from the interviews in comparison to existing literature on CHWs’ involvement in promoting maternal health [4, 22–25] . Through thematic analysis, we developed different concepts and categories from the data: promoting access to maternal health services in communities, reaching out to women, and empowering M-CHWs. In order to verify the accuracy of our analysis, we returned the findings to study participants to gain their feedback and ensure that the final result and clustering were faithful and true to the data. This process helped to validate the data while offering gratitude and paying respect to acknowledge participants’ contributions. Prior to commencement of the study, ethical approvals to conduct this study were granted by Western University’s Research Ethics Board (File No: 103945) and Ministry of Education of Rwanda (MINEDUC/ S&T/251/2014). Before conducting interviews, letters of information were given to participants and written informed consent were obtained from them. Participants were assured of voluntary participation, confidentiality, anonymity and freedom to withdraw from the study at any time. Participants were given a token of appreciation for their time and contribution to the study. The token consisted of a food item (a bag of rice or sugar) as per the cultural protocols and participants’ socio-economic positions.
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