Factors associated with utilization of quality antenatal care: a secondary data analysis of Rwandan Demographic Health Survey 2020

BMC Health Services Research, Volume 22, No. 1, Year 2022

Interpretation

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.

AI Digest

Study Justification:

– Maternal mortality in Rwanda has been slow to decrease, indicating a need for further investigation into factors that can improve maternal and newborn health outcomes.
– Access to quality antenatal care (ANC) is crucial in reducing maternal and newborn mortality.
– While previous studies have examined factors influencing ANC utilization, there is limited information on the quality of ANC in Rwanda.
– This study aims to identify the determinants of quality ANC among pregnant women in Rwanda using a nationally representative sample.

Study Highlights:

– The study analyzed secondary data from the Rwanda Demographic and Health Survey (RDHS) of 2020, including 6,302 women aged 15-49 who had given birth within the previous five years.
– The study found that only 13.1% of women utilized all the indicators of good quality ANC.
– Factors associated with higher odds of receiving all ANC components included exposure to newspapers/magazines at least once a week, lower parity, and being visited by a field worker.
– Belonging to smaller households, initiating ANC in the first trimester, and having 4 or more ANC contacts were also associated with higher odds of receiving all ANC components.
– Working women had lower odds of receiving all ANC components.

Recommendations for Lay Readers and Policy Makers:

– Programs aimed at increasing the utilization of ANC components should prioritize high parity and working women residing in larger households.
– Promoting the use of field health workers, timely initiation of ANC, and increased frequency of ANC visits may enhance the quality of care.
– Efforts should be made to improve access to information through newspapers/magazines to increase awareness and utilization of ANC services.

Key Role Players Needed to Address Recommendations:

– Ministry of Health: Responsible for developing and implementing policies and programs related to maternal and child health, including ANC.
– Community Health Workers (CHWs): Provide basic health services at the village level and can play a crucial role in promoting ANC utilization.
– Health Facilities: Responsible for providing quality ANC services and ensuring timely initiation and adequate frequency of ANC visits.
– Media Organizations: Collaborate with the Ministry of Health to disseminate information about ANC through newspapers, magazines, and other media channels.

Cost Items to Include in Planning the Recommendations:

– Training and Capacity Building: Costs associated with training CHWs and health facility staff on ANC guidelines and best practices.
– Outreach and Awareness Campaigns: Costs for developing and implementing campaigns to promote ANC utilization, including printing materials, organizing community events, and media advertisements.
– Infrastructure and Equipment: Costs for improving health facilities and ensuring they have the necessary equipment and supplies to provide quality ANC services.
– Monitoring and Evaluation: Costs for monitoring and evaluating the implementation and impact of ANC programs, including data collection and analysis.
– Coordination and Collaboration: Costs for coordinating efforts between different stakeholders, including the Ministry of Health, CHWs, health facilities, and media organizations.
Please note that the cost items provided are general categories and may vary depending on the specific context and implementation strategies.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study utilized a nationally representative sample and conducted multivariable logistic regression analysis, which adds to the strength of the evidence. However, the study is based on secondary data analysis, which may have limitations in terms of data quality and availability of certain variables. Additionally, the study relies on self-reported data, which may introduce bias. To improve the strength of the evidence, future studies could consider using primary data collection methods and include objective measures of ANC quality. Furthermore, conducting qualitative research to explore the reasons behind the low utilization of certain ANC components would provide valuable insights for program development and improvement.

Abstract

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.

Materials

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health in Rwanda:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies such as SMS reminders for ANC appointments, educational messages about maternal health, and access to teleconsultations with healthcare providers can help improve access to maternal health services, especially in remote areas.

2. Community-Based Health Workers (CHWs): Strengthening the role of CHWs in providing maternal health services at the village level can improve access to care. This can include training CHWs to provide basic ANC services, conducting home visits to pregnant women, and facilitating referrals to higher-level healthcare facilities when necessary.

3. Improving Health Insurance Coverage: Enhancing the coverage and affordability of the Community-Based Health Insurance (CBHI) program can ensure that more women have access to quality maternal health services without financial barriers.

4. Targeted Health Education Campaigns: Designing and implementing targeted health education campaigns to raise awareness about the importance of ANC, early initiation, and regular visits can help increase utilization of these services.

5. Strengthening Health Facility Infrastructure: Investing in the improvement of health facility infrastructure, including the availability of essential equipment, supplies, and trained healthcare providers, can enhance the quality of ANC services and encourage more women to seek care.

6. Public-Private Partnerships: Collaborating with private healthcare providers and organizations can help expand the availability of ANC services, particularly in underserved areas, and improve access for women.

7. Integrating ANC with Other Health Services: Integrating ANC services with other healthcare services, such as family planning, HIV testing, and immunizations, can improve efficiency and convenience for women, leading to increased utilization.

These are just a few potential innovations that could be considered to improve access to maternal health in Rwanda. It is important to assess the feasibility, acceptability, and effectiveness of these innovations in the local context before implementation.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health in Rwanda is as follows:

1. Increase awareness and education: Implement programs to increase awareness among pregnant women about the importance of quality antenatal care (ANC) and its components. This can be done through community health workers, media campaigns, and educational materials.

2. Improve healthcare infrastructure: Strengthen the healthcare system by increasing the availability and accessibility of ANC services. This includes ensuring that health facilities have the necessary equipment, supplies, and trained healthcare providers to deliver quality ANC.

3. Address barriers to ANC utilization: Identify and address barriers that prevent pregnant women from accessing ANC services. This may include addressing financial barriers by expanding health insurance coverage and reducing out-of-pocket expenses for ANC. Other barriers such as distance to health facilities and cultural beliefs should also be considered and addressed.

4. Promote early initiation of ANC: Emphasize the importance of early initiation of ANC within the first trimester of pregnancy. This can be achieved through community education and outreach programs, as well as by training healthcare providers to prioritize early ANC initiation.

5. Increase ANC frequency: Encourage pregnant women to attend ANC visits regularly and promote the recommended minimum of four or more ANC contacts. This can be achieved through community education, reminders, and incentives for attending ANC visits.

6. Target high-risk groups: Develop targeted interventions for high-risk groups such as women with higher parity and working women residing in larger households. These interventions should address specific barriers and challenges faced by these groups in accessing and utilizing ANC services.

7. Strengthen the role of field health workers: Promote the use of field health workers in delivering ANC services, as they have been found to be associated with higher odds of receiving all ANC components. This may involve training and capacity-building for field health workers, as well as ensuring their regular and effective engagement in ANC service delivery.

By implementing these recommendations, it is expected that access to quality maternal health services, specifically ANC, will be improved in Rwanda, leading to a reduction in maternal and newborn mortality rates.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen community-based health services: Building on the existing network of community health workers (CHWs) in Rwanda, further investment and training can be provided to enhance their capacity to provide quality antenatal care (ANC) services at the village level. This can include regular supervision and support from higher-level health facilities, as well as ensuring that CHWs have the necessary resources and supplies to deliver comprehensive ANC.

2. Improve health education and awareness: Increasing access to information about the importance of ANC and its components can help raise awareness among pregnant women and their families. This can be done through various channels such as community outreach programs, radio broadcasts, and educational materials. Emphasizing the benefits of early initiation of ANC and the importance of regular ANC visits can help improve utilization of these services.

3. Address barriers to ANC utilization: Identifying and addressing barriers that prevent pregnant women from accessing ANC is crucial. This can include addressing financial barriers by expanding the coverage and affordability of health insurance programs, such as the Community-Based Health Insurance (CBHI) in Rwanda. Additionally, efforts can be made to improve transportation infrastructure and ensure that ANC services are geographically accessible to all women, especially those in rural areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Collect data on key indicators related to access to maternal health, such as ANC utilization rates, timing of ANC initiation, and frequency of ANC visits. This data can be obtained from national surveys, health facility records, and other relevant sources.

2. Baseline assessment: Analyze the collected data to establish a baseline for the current state of access to maternal health. This will provide a benchmark against which the impact of the recommendations can be measured.

3. Modeling the impact: Use statistical modeling techniques, such as regression analysis, to simulate the potential impact of the recommendations on access to maternal health. This can involve estimating the changes in ANC utilization rates, timing of ANC initiation, and frequency of ANC visits that could be achieved by implementing the recommendations.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the results and explore different scenarios. This can involve varying key parameters, such as the coverage of community-based health services or the effectiveness of health education campaigns, to understand their potential influence on the outcomes.

5. Evaluation and interpretation: Evaluate the results of the simulation and interpret the findings in terms of the potential improvements in access to maternal health. This can include quantifying the expected changes in key indicators and assessing the feasibility and cost-effectiveness of implementing the recommendations.

6. Policy recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders and decision-makers. These recommendations should highlight the potential benefits of the proposed interventions and outline the necessary steps for their implementation.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and data availability in Rwanda.

Authors & Co-Authors

Statistics:

Citations: 6

Authors: 5

Identifiers:

DOI: 10.1186/s12913-022-08169-x

Research Areas:

Community Interventions, COVID, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Workforce

Study Countries:

Rwanda

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female