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Background: With an aim to prevent adverse pregnancy outcomes, ‘birth preparedness and complication readiness’ (BP/CR) promotes timely access to skilled maternal and neonatal services. Objective of this study was to assess implementation of BP/CR among pregnant women admitted with obstetric emergencies in rural Rwanda. Methods: A cross-sectional study among pregnant women who were referred to Ruhengeri hospital between July and November 2015. The ‘Safe Motherhood questionnaire’ as developed by Jhpiego’s Maternal and Neonatal Health Program was used to collect data. Women were asked to mention key danger signs and respond as to whether they had identified: (A) skilled birth attendant, (B) location to give birth, (C) mode of transport, (D) money to cover health care expenditure. Women who answered ‘yes’ to three or four items were labeled ‘well prepared’. Multivariate logistic regression analysis was conducted to compare the ‘well prepared’ and ‘less prepared’. Results: With regard to complication readiness, out of 350 women, 296 (84.6%), 271 (77.4%) and 288 (82.3%) could mention at least one key danger sign during pregnancy, labor and postpartum respectively, but only 23 (6.6%) could mention three or more key danger signs during all three periods. With regard to birth preparedness, 46 (13.1%) women had identified a skilled birth attendant, 68 (19.4%) birth location, 76 (21.7%) mode of transport, and 306 (87.4%) had saved money for health care costs. Seventy-eight women (22.3%) were ‘well prepared’, associated factors being first time pregnancy (adjusted Odds Ratio (aOR) = 3.2; 95% CI; 1.2-5.8), knowledge of at least two danger signs (aOR = 2.8; 95% CI; 1.7-3.9) and having been assisted by a community health worker at the antenatal clinic (aOR = 2.2, 95% CI; 1.3-3.7). Conclusion: Knowledge of obstetric danger signs was suboptimal and birth preparedness low. We recommend review of practices regarding health promotion in antenatal care, taking care not to exclude multiparous women from messages related to birth preparedness, and do promote use of community health workers to enhance effectiveness of BP/CR.
This was a cross-sectional study among pregnant women who were referred for obstetric emergencies to Ruhengeri hospital, Musanze district, Rwanda, between July and November 2015. According to the Population Census, Musanze district had a population of 368,267 inhabitants with a total fertility rate of 4.6 births per woman in 2012. Health insurance coverage was 85.1%, and 65.3% of women who gave birth with assistance from a skilled birth attendant. Uptake of postnatal care by skilled personnel was 4.5% [24]. Health promotion and counseling as part of BP/CR are provided by community health workers in addition to other facility-based professionals. Community health workers sometimes escort laboring women to health facilities. Ruhengeri hospital acts as a provincial referral hospital for women with high-risk pregnancies and referrals from health centers and other district hospitals in the northern province. Medical services offered are covered by community-based health insurance (‘Mutuelle de Santé’) at contribution of an annual fee of RWF 3000 (US$4.5), with a 10% surcharge for each episode of illness. In case of shortages of supplies, patients are requested to procure missing items from private pharmacies. During the study period, medical staff consisted of one specialist obstetrician, four medical officers, two intern doctors and 18 midwives. The study included all pregnant women who were referred to the maternity ward who consented to participation, using the consent form given in Additional file 1. Participants were followed up to discharge or death. Two trained research assistants identified possible participants while the principal investigator verified suitability for study inclusion. The ‘Safe Motherhood questionnaire’ developed by the Maternal Neonatal Program of JHPIEGO, an affiliate of John Hopkins University [5] was used, and adapted to the local context to include a question regarding purchase of birth materials as a common birth preparedness practice (Additional file 1). The expert translator translated it from the English version to the local language (Kinyarwanda), and then another translator translated this text back into English to check whether the original meaning was still present. The questionnaire pertained to socio-demographic variables such as age, residence, religion, education level, marital and employment status, and other variables with regard to antenatal care (including type of advice received and type of health worker seen), obstetric history, reasons for referral. With regard to knowledge of obstetric danger signs, we assessed whether a woman, when prompted, could mention danger signs and symptoms such as vaginal bleeding, fits, swelling of face or limbs, fever, loss of consciousness, headache, abdominal pain, prolonged labor and retained placenta. Lastly, four ‘BP/CR questions’ verified whether the woman had taken one of the following four steps: A) identification of a skilled birth attendant, B) identification of the location of the closest appropriate care facility, C) identification of a means of transport to that facility, D) saving money for hospital costs/birth materials. Women answering ‘yes’ to at least three of these four BP/CR questions were labeled ‘well prepared’. Remaining women were labeled ‘less prepared’. We also assessed whether mentioning of at least two danger signs during pregnancy, childbirth or postpartum was associated with being well prepared. Data were entered, coded, cleaned and analyzed using SPSS for Windows Version 18.0. After the initial descriptive analysis, bivariate analysis was done to test for associations between the dependent variable BP/CR and independent variables using Pearson’s chi square or Fischer’s exact test. Factors that were found to have p-values below 0.2 in the bivariate analysis were entered into multivariable logistic regression model to compare women who were well prepared with those who were less prepared.
