Assessing predictors of delayed antenatal care visits in Rwanda: A secondary analysis of Rwanda demographic and health survey 2010

  • BMC Pregnancy and Childbirth, Volume 14, No. 1, Year 2014

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Study Justification:
– Early initiation of antenatal care (ANC) can reduce maternal complications and mortality.
– Rwanda has made progress in reducing maternal mortality, but only 38% of women have an ANC visit in their first three months of pregnancy.
– This study aims to identify factors associated with delayed ANC in Rwanda.
Study Highlights:
– The study used data from the 2010 Rwanda Demographic and Health Survey (RDHS) and included 6,325 women aged 15-49 who had a pregnancy in the last five years.
– Factors associated with delayed ANC were identified using a multivariable logistic regression model.
– Several factors were found to be significantly associated with delayed ANC, including having many children, perceiving distance to health facilities as a problem, and unwanted pregnancy.
– Protective factors against delayed ANC included having ANC at a private hospital or clinic, being married, and having health insurance.
Study Recommendations:
– Infrastructure improvement and decentralization of maternal ANC to health posts and dispensaries to address the barrier of distance to health facilities.
– Continued implementation of interventions such as universal health insurance coverage, family planning, and community maternal health systems to address delays in ANC.
Key Role Players:
– Ministry of Health in Rwanda
– Health facility administrators and staff
– Community health workers
– Non-governmental organizations working in maternal health
Cost Items for Planning Recommendations:
– Infrastructure development and maintenance
– Training and capacity building for health workers
– Health education and awareness campaigns
– Procurement of medical equipment and supplies
– Monitoring and evaluation activities
– Research and data collection

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a nationally representative two-stage cluster sample and includes a large number of households. The study also uses a multivariable logistic regression model to identify factors associated with delayed ANC. However, to improve the evidence, the abstract could provide more information on the statistical significance of the associations and the magnitude of the effect sizes. Additionally, it would be helpful to include information on the response rate and any potential limitations of the study.

Background: Early initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda. Methods: This is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15-49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design. Results: Several factors were significantly associated with delayed ANC including having many children (4-6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46). Conclusion: This analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.

The 2010 RDHS is a nationally representative two-stage cluster sample that included 492 primary sampling units (PSUs) and 12,540 households. Data collection occurred between September 26, 2010 and March 10, 2011. Respondents answered detailed questions about their reproductive health histories, reproductive health practices, recent pregnancy experiences, household assets, and access to health services [17]. This study only includes the 6,325 women ages 15–49 years who had a pregnancy in the last five years [14]. If there was more than one pregnancy in the last five years, the outcomes and predictors were based on their last pregnancy. The primary outcome for this study is delayed ANC, defined as having no ANC visit or having the first ANC visit during the second or third trimester of pregnancy. Based on a conceptual framework (Figure 1), 16 potential predictors of delayed ANC collected in the 2010 DHS were identified: number of children, place of residence, place of ANC, marital status, having health insurance, problem with distance to clinic, unwanted pregnancy, woman’s age, wealth status, woman’s education, partner’s education, woman’s employment status, partner’s employment status, knowledge of ovulatory cycle, and access to TV or radio at least once a week. Due to collinearity, partner’s education and working status were combined into a single variable. Conceptual framework. Variables that were differentially distributed among women who did and did not have delayed ANC (p  =0.8, using Pearson’s correlation test) the variable more strongly correlated with delayed ANC was retained. Manual backward stepwise regression was used to develop a multivariable logistic regression model of predictors of delayed ANC in Rwanda. Only factors significant at the α = 0.05 level were retained in the final model except age and place of residence which were considered by the study team as potential confounders. Analysis was completed in Stata v12, with svyset commands to apply inverse probability weights that account for oversampling of urban PSUs, and to adjust for clustering of observations within PSUs and stratification by district. Odds ratios (ORs) and 95% confidence intervals are reported.

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The study “Assessing predictors of delayed antenatal care visits in Rwanda: A secondary analysis of Rwanda demographic and health survey 2010” identified several factors associated with delayed antenatal care (ANC) visits in Rwanda. These factors include:

1. Having many children: Women with 4-6 children or more than six children were more likely to have delayed ANC visits.
2. Distance to health facility: Women who felt that distance to the health facility was a problem were more likely to have delayed ANC visits.
3. Unwanted pregnancy: Women with unwanted pregnancies were more likely to have delayed ANC visits.
4. Type of ANC facility: Women who had ANC visits at private hospitals or clinics were less likely to have delayed ANC visits.
5. Marital status: Being married was protective against delayed ANC visits.
6. Health insurance: Having public mutuelle health insurance or another type of insurance was protective against delayed ANC visits.

Based on these findings, potential recommendations to improve access to maternal health and reduce delayed ANC visits in Rwanda could include:

1. Infrastructure improvement: Addressing the issue of distance to health facilities by improving infrastructure and decentralizing maternal ANC services to health posts and dispensaries.
2. Universal health insurance coverage: Expanding and promoting universal health insurance coverage to ensure that all women have access to affordable maternal health services.
3. Family planning: Strengthening family planning programs to reduce the number of unwanted pregnancies and promote timely ANC visits.
4. Community maternal health system: Implementing community-based maternal health programs that provide education, support, and resources to pregnant women, including information on the importance of early ANC visits.

These recommendations, along with ongoing interventions such as universal health insurance coverage and community maternal health systems, can contribute to addressing delays in ANC and improving access to maternal health services in Rwanda.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study is as follows:

1. Infrastructure improvement: The study identified distance to health facilities as a major barrier to accessing antenatal care (ANC). To address this, an innovation could focus on improving infrastructure by establishing health posts and dispensaries in closer proximity to communities. This would reduce the travel distance for pregnant women and make ANC services more accessible.

2. Decentralization of ANC services: Building on the infrastructure improvement, the innovation could involve decentralizing ANC services to the newly established health posts and dispensaries. This would ensure that pregnant women have access to ANC services within their communities, reducing the need for long-distance travel.

3. Universal health insurance coverage: The study found that having public mutuelle health insurance or another type of insurance was protective against delayed ANC. To improve access to maternal health, an innovation could involve implementing universal health insurance coverage for pregnant women. This would remove financial barriers and ensure that all women have access to necessary ANC services.

4. Family planning interventions: Unwanted pregnancy was identified as a factor associated with delayed ANC. An innovation could focus on implementing comprehensive family planning interventions to reduce unintended pregnancies. This could include increasing awareness and access to contraception methods, as well as providing counseling and support for family planning.

5. Community maternal health system: The study highlighted the importance of community-based interventions. An innovation could involve developing a community maternal health system that engages and empowers local communities to support pregnant women. This could include training community health workers to provide basic ANC services, conducting awareness campaigns, and establishing support groups for pregnant women.

By implementing these recommendations as innovative solutions, access to maternal health can be improved, leading to better maternal and perinatal outcomes.
AI Innovations Methodology
The study titled “Assessing predictors of delayed antenatal care visits in Rwanda: A secondary analysis of Rwanda demographic and health survey 2010” aims to identify factors associated with delayed antenatal care (ANC) visits in Rwanda. The study used data collected during the 2010 Rwanda DHS from 6,325 women aged 15-49 who had at least one birth in the last five years.

The methodology used in the study involved a cross-sectional design and a multivariable logistic regression model. The analysis was conducted in Stata v12, applying survey commands to account for the complex sample design.

Here is a brief description of the methodology:

1. Sample: The study used data from the 2010 Rwanda DHS, which included 492 primary sampling units (PSUs) and 12,540 households. The sample included 6,325 women aged 15-49 who had a pregnancy in the last five years.

2. Outcome variable: The primary outcome for this study was delayed ANC, defined as having no ANC visit or having the first ANC visit during the second or third trimester of pregnancy.

3. Predictor variables: Sixteen potential predictors of delayed ANC were identified based on a conceptual framework. These predictors included number of children, place of residence, place of ANC, marital status, having health insurance, problem with distance to clinic, unwanted pregnancy, woman’s age, wealth status, woman’s education, partner’s education and employment status, knowledge of ovulatory cycle, and access to TV or radio at least once a week.

4. Model building: Variables that were differentially distributed among women who did and did not have delayed ANC were retained for model building. Collinearity was assessed, and for strongly collinear variables, the variable more strongly correlated with delayed ANC was retained. Manual backward stepwise regression was used to develop a multivariable logistic regression model.

5. Analysis: The analysis was conducted in Stata v12, using svyset commands to apply inverse probability weights that account for oversampling of urban PSUs and to adjust for clustering of observations within PSUs and stratification by district. Odds ratios (ORs) and 95% confidence intervals were reported.

The study identified several factors significantly associated with delayed ANC, including the number of children, distance to health facility, and unwanted pregnancy. Protective factors against delayed ANC included having ANC at a private hospital or clinic, being married, and having public or other types of health insurance.

Based on the findings, the study suggests the need for interventions such as infrastructure improvement, decentralization of maternal ANC to health posts and dispensaries, and the implementation of universal health insurance coverage, family planning, and community maternal health systems to address delays in ANC.

Overall, the study provides valuable insights into the factors influencing delayed ANC visits in Rwanda and offers recommendations for improving access to maternal health services.

Statistics:
Citations: 54
Authors: 8
Identifiers:
DOI: 10.1186/1471-2393-14-290
Research Areas:
Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Rwanda
Study Design:
Cross Sectional Study, Grounded Theory
Study Approach:
Quantitative
Participants Gender:
Female
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