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Background: Although quality postnatal care (PNC) is a known significant intervention for curbing maternal and newborn morbidity and mortality, it is underutilized in most developing countries including Rwanda. Thus, it is crucial to identify factors that facilitate or occlude receipt of adequate PNC. This study aimed at assessing the prevalence of adequate PNC content and the associated factors in Rwanda. Methods: We used weighted data from the Rwanda Demographic and Health Survey (RDHS) of 2020, comprising of 4456 women aged 15–49 years, who were selected using multistage sampling. Adequate PNC was considered if a woman had received all of the five components; having the cord examined, temperature of the baby measured, counselling on newborn danger signs, counselling on breastfeeding and having an observed breastfeeding session. We, then, conducted multivariable logistic regression to explore the associated factors, using SPSS version 25. Results: Out of the 4456 women, 1974 (44.3, 95% confidence interval (CI): 43.0–45.9) had received all the PNC components. Having no radio exposure (adjusted odds ratio (AOR) =1.41, 95% CI: 1.18–1.68), visited by a fieldworker (AOR = 1.35, 95% CI: 1.16–1.57), no big problem with distance to a health facility (AOR = 1.50, 95% CI:1.24–1.81), and residing in the Southern region (AOR = 1.75, 95% CI: 1.42–2.15) were associated with higher odds of adequate PNC compared to their respective counterparts. However, having no exposure to newspapers/magazines (AOR = 0.74, 95% CI: 0.61–0.89), parity of less than 2 (AOR = 0.67, 95% CI: 0.51–0.86), being a working mother (AOR = 0.73, 95% CI: 0.62–0.85), no big problem with permission to seek healthcare (AOR = 0.54, 95% CI: 0.36–0.82), antenatal care (ANC) frequency of less than 4 times (AOR = 0.79, 95% CI: 0.62–0.85), inadequate ANC quality (AOR = 0.56, 95% CI: 0.46–0.68), and getting ANC in a public facility (AOR = 0.57, 95% CI: 0.38–0.85) were associated with lower odds of adequate PNC. Conclusions: Less than half of the mothers in Rwanda had received adequate PNC, and this was associated with various factors. The results, thus, suggested context-specific evidence for consideration when rethinking policies to improve adequate PNC, including a need for intensified PNC education and counselling during ANC visits, continued medical education and training of PNC providers, and strengthening of maternal leave policies for working mothers.
The 2019–20 Rwanda Demographic Survey (RDHS) was used for this analysis and employed a two-stage sample design with the first stage involving sample points (clusters) selection consisting of enumeration areas (EAs) [20]. The second stage involved systematic sampling of households in all the selected EAs leading to a total of 13,005 households [20]. The data used in this analysis were from the household and the woman’s questionnaires. Data collection started in November 2019 and ended in July 2020 taking longer than expected due to the COVID-19 pandemic restrictions [20]. 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 a 99.9% response rate [20]. This study included women who had given birth within 5 years preceding the survey and had at least one postnatal check whether before discharge from health facility after birth or after home delivery/discharge from the health facility. 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 [20]. Out of the 14,634 successfully interviewed women, a weighted sample of 6302 women had given birth within the last 5 years preceding the survey and 4456 had had at least one postnatal check. The outcome variable was the content of postnatal care (PNC). Based on the WHO recommendations [24] and availability of data in the 2020 RDHS dataset, adequate content of PNC was considered when a woman was able to have received all the five PNC components that included: having the cord examined, temperature of the baby measured, counselling on newborn danger signs, counselling on breastfeeding and having had an observed breastfeeding session [25]. This information was self-reported by the women. Andersen’s behavioral model of health service use was adapted considering data availability and evidence from available literature [13, 20, 25, 26] to examine the factors associated with utilization of adequate PNC, as shown in Table 1. As per Andersen’s behavioral model, utilization of healthcare is a function of three major elements: predisposing factors, enabling factors and healthcare needs [29]. The predisposing factors in the model were: age, level of education, region of residence, place of residence, religion, marital status, household size, and parity. Wealth index, working status, having health insurance, exposure to mass media, being visited by a field health worker, seeking permission and distance to the nearest health facility as an indicator of access were considered as enabling factors, while place of childbirth and ANC, ANC frequency and quality were included in the model as a proxy for the need factor [28], as illustrated in Supplementary file 1. Categorization of independent variables as obtained from the 2020 Rwanda Demographic Health Survey dataset In order to account for the unequal probability sampling in different strata [30] and to ensure representativeness of the study results [31], DHS sample weights were applied. We used SPSS (version 25.0) statistical software complex samples package incorporating the following variables in the analysis plan to account for the multistage sample design inherent in the DHS dataset: individual sample weight, sample strata for sampling errors/design, and cluster number [32–34]. Initially, we did descriptive statistics for both dependent and independent variables. Frequencies and proportions/percentages for categorical dependent and independent variables have been presented. Afterwards, bivariable logistic regression was done to assess the association of each independent variable with adequate content of postnatal care 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. Hosmer and Lemeshow test was finally done to test the goodness of the multivariable regression model. Adjusted odds ratios (AOR), 95% Confidence Intervals (CI) and p-values were calculated at significance level of 0.05 [35]. All variables in the model were assessed for multi-collinearity, which was considered present if the variables had a variance inflation factor (VIF) greater than 2.5 [36].
