The primary objective of this secondary analysis is to assess the extent of PCANC received by women who participated in a randomized control trial in Rwanda and to explore factors associated with receiving high PCANC. To our knowledge this is the first study in Rwanda to quantitatively examine factors associated with PCANC. We find that PCANC is sub-optimal with 30% of women leaving ANC either with questions or confused and 24% feeling disrespected. In bivariate analysis, factors that significantly predict high PCANC are better levels of cognitive maternal empowerment, greater parity, being in the traditional care (control group), and being from Burera district. However, only the study group to which women were assigned is significantly associated with low PCANC in the multivariate analysis. Our findings are consistent with prior studies on quality of ANC and person-centered care during childbirth, but differ in some ways.
That 30% of women left ANC with questions or confused adds to the evidence on critical gaps in communication during ANC and childbirth (Afulani PA, Buback L, et. al, 2019; Afulani, P. A., & Moyer, C. A., 2019). In a study in Kenya on PCANC, about one-third of women did not often understand the purposes of tests and medicines received and did not feel able to ask questions to the health care provider (Afulani PA, Buback L, et. al, 2019). The rate of disrespect during antenatal care found in our study is also similar to rates of self-reported disrespect during facility-based childbirth in Rwanda, (J. Mukamurigo, Dencker, Ntaganira, & Berg, 2017; Rosen et al., 2015). A cross-sectional household study in Rwanda found that 22.5% of women felt disrespected during childbirth (J. Mukamurigo, Dencker, Ntaganira, & Berg, 2017; Rosen et al., 2015). The low levels of person-centered care during pregnancy in our study as well as during childbirth reported in other studies in Rwanda might be because the staffing and resource constraints are the same for both ANC and birthing facilities (J. U. Mukamurigo et al., 2017). Additionally, our findings may be overestimating the extent of high PCANC, given evidence that women tend to underreport disrespect and abuse because they have not been exposed to medical systems that are sensitive to their humanity and may normalize disrespectful care (Ishola, Owolabi, & Filippi, 2017). Disrespect may be invisible due to long standing patterns of poor quality care in the context of resource scarcity (Bowser & Hill, 2010; Kruk et al., 2018).
Our finding in the bivariate analysis that being cognitively empowered—the ability to discuss the health of one’s pregnancies with one’s partner—was associated with high PCANC is also consistent with prior studies. Multiple studies demonstrate that empowerment broadly promotes the use of recommended health services (Afulani, Altman, 2017; Diamond-Smith, 2017). Studies on person-centered care during childbirth also report high person-centered care among more empowered women (Afulani, 2015; Joshi, 2014). Notably, however, these studies also find economic empowerment to be a significant factor, which was not significant in our analysis. This might be because of the nearly universal health insurance scheme in Rwanda or because our sample was more representative of economically disadvantaged women, (Saksena, 2010; Saskena, 2011), which will make a woman’s ability to advocate for herself a more important determinant of the extent of PCANC she receives when compared to others in our study. This highlights the potential benefit of a greater understanding of the complexity of empowerment measures and of evaluating multiple axes of empowerment (Kabeer, 1999) when describing quality of care.
Additionally, we found that greater parity contributed to higher quality of care in our bivariate model. This differed from other studies in Nepal and Kenya on service provision, which demonstrate that greater parity results in low quality of care (Joshi, 2014; Tran, 2012). In both of these studies, the authors suggest that women who had already had successful deliveries experienced complacency around receiving all the necessary services for their current pregnancies. However, in our study, quality is focused exclusively on the experience of care and not service provision, as was the focus of these studies, and, by comparison, qualitative studies on women’s experiences during childbirth support our finding that first time mothers tend to experience more disrespect and abuse (Bohren et al., 2015).
Notably, women in Burera and Rubavu received high PCANC when compared to other districts. Some of the variability might reflect ongoing development projects by partners as well as unaccounted for variation in site. Additionally, there should not have been a significant difference between those who would receive group care and those who would receive traditional care, given that the first visit was individual, standardized, and did not follow the group care format. Thus, we might attribute this difference in PCANC to multiple factors including baseline differences at facilities unaccounted for. For example, providers for this first visit would have included a mix of those who received intensive training and mentorship on the group model of care and those who had not. Additionally, women allocated to the group care study arm might have had high expectations of their care after being oriented to the group care model. The additional information to orient them to when, where, and how their subsequent visits would be conducted in the context of limited personnel, which might have resulted in a less person centered encounter (Sayingoza 2018) and less time available to illicit questions or concerns from women. As there was no one PCANC question that drove this result, our findings may suggest that the introduction of group care, a complete reconfiguration of how ANC is provided, has the potential to disrupt the provision of core care components, specifically those related to person-centeredness (Sharma et al., 2018). Further studies are required to better understand this finding.