DOI: https://doi.org/10.21203/rs.3.rs-103136/v1
Background: Research suggests that person centered antenatal care (PCANC) provides an effective tool for addressing maternal deaths in Sub-Saharan Africa through the delivery of health care which is both respectful of, and responsive to, the preferences, needs, and values of women. Yet little is known in Rwanda about either the extent to which PCANC is practiced or the factors that might determine its use. This is the first study to quantitatively examine the extent of and the factors associated with PCANC in Rwanda.
Methods: We used quantitative data from a pair-matched cluster randomized control trial (CRCT) in Rwanda. A total of 2,150 surveys were used from 36 health centers across five districts. Eligible women were 16 – 49 years old and were not referred to higher levels of care or had incomplete survey responses.
Results: PCANC was found to be sub-optimal with 30% of women leaving antenatal care (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. The study group to which women were assigned and the district in which women received care were significantly associated with PCANC in the multivariate analysis.
Conclusions: Given the benefits of PCANC, improvements in PCANC through provider training in Rwanda might promote an institutional culture shift towards a more person-centered model of care. We also found that better measurement tools are needed to more comprehensively measure PCANC and recommend wider use of these validated tools in national surveys to get a systematic understanding of PCANC in Rwanda. Additionally, we recommend thoughtful measures of empowerment during antenatal care to capture the social experiences of women in Rwanda.
Trial registration: Not applicable
Despite global progress in reducing maternal mortality, Sub-Saharan Africa accounts for the majority of pregnancy and childbirth related deaths (WHO, 2019). In 2017, approximately 300,000 women around the world died from pregnancy and childbirth complications; 200,000 of these deaths occurred in Sub-Saharan Africa. Antenatal care (ANC) provides an opportunity for health care providers to positively impact maternal health (Carroli, 2001). ANC ensures early detection, monitoring and treatment of conditions such as hypertension, gestational diabetes, preeclampsia and fetal congenital abnormalities, which may result in the prevention of morbidity and mortality amongst pregnant women (Bauserman, M., Lokangaka, A., Thorsten, V., 2015; Bergsjø, P., 2001). High quality ANC includes not only the provision of these necessary services but also a positive experience of care (Van den Broek NR, 2009). According to the World Health Organization (WHO), high quality ANC should be “safe, effective, timely, efficient, equitable and people-centered” (WHO, 2016).
Person centered antenatal care (PCANC) provides an effective tool for addressing maternal deaths in Sub-Saharan Africa through the delivery of health care which is both respectful of, and responsive to, the preferences, needs, and values of women (Afulani PA, Buback L, et. al, 2019). PCANC extends the work on person centered maternity care during childbirth (PCMC) to the pregnancy period, and thus focuses on dignity, respect, support and autonomy with regards to each woman’s health related decision making (Afulani, Diamond-Smith, 2017). The concept and benefits of PCMC apply with equal force to PCANC (Downe, 2018; Afulani, 2019). PCANC has been shown to positively influence the decisions of pregnant women in Sub-Saharan Africa to pursue a facility-based delivery and to obtain care from a skilled birth attendant (Chukwuma, 2017; Adjiwanou, 2013; Afulani, Moyer, 2016).
Despite the benefits of PCANC and PCMC, disrespect and abuse of women during pregnancy and childbirth are common. In a landmark 2010 review, Bowser and Hill demonstrated the high prevalence of abuse and disrespect of pregnant women by health care providers during facility-based deliveries (Bowser & Hill, 2010). Most of the research subsequently focused on disrespect and abuse during childbirth (Bohren et al., 2015; Downe, 2018; Freedman et al., 2014; Miller, 2016; Sen et al., 2018; Rosen et al. 2015; Solnes Miltenberg et al., 2018). Very few studies have examined PCANC, although one study in Kenya demonstrated key gaps in PCANC (Afulani, 2019). Additionally, the majority of studies on quality of ANC focused on the service provision dimensions of quality care (Afulani, 2015; Joshi, 2014; Manzi, 2018; Sharma, 2017; Rurangirwa, 2018). In Rwanda, studies have focused generally on provider knowledge and service provision without describing the extent to which PCANC is delivered or the factors associated with PCANC (Manzi, 2018; Rurangirwa, 2018)
The primary aim of this paper is to assess the extent of PCANC received by women that participated in a Group Antenatal Care randomized control trial in Rwanda and to examine the factors associated with high and low levels of PCANC. Based on prior studies, we hypothesized that women’s age, socioeconomic status and empowerment would be associated with PCANC (Afulani, 2019). With this analysis, we hope to further inform and revitalize a focus on accountability to the provision of PCANC in Rwanda.
We conducted a secondary analysis using data from a pair-matched cluster randomized control trial (CRCT) in Rwanda (Sayinzoga et al., 2018). In the parent study, health centers were pair-matched and one facility was randomized to Group Antenatal Care (GANC) and the other randomized to continue delivering the standard models of focused antenatal care (ANC) and postnatal care (PNC). No allocation concealment was used. Baseline data of all arms was collected in collaboration with the East Africa Preterm Birth Initiative-Rwanda, the Rwanda Ministry of Health, the Rwanda Biomedical Center, the University of Rwanda School of Public Health, and the University of California, San Francisco, Institute of Global Health Sciences. Data collection occurred between May 2017 and December 2018 at 36 different health centers across five districts in Rwanda: Burera, Bugesera, Nyamasheke, Nyarugenge and Rubavu. A total of 25,334 women were enrolled in the parent study. A convenience sample of the first five women to present for ANC per month were invited to participate in a baseline survey at the completion of their first ANC visit. A total of 2,744 women completed the survey. Women were excluded from the survey if they were less than 16 years old, were referred to higher levels of care or had incomplete survey responses. After exclusion, our analytical sample included a total of 2,150 women (Fig. 1).
We report according to STROBE guidelines (Gallo, 2011).
Three questions were included in the survey to measure the extent of PCANC delivered to these women based on reported themes of mistreatment during facility-based deliveries and determinants of women’s satisfaction during maternal healthcare (Sheferaw, Mengesha, & Wase, 2016; Srivastava, Avan, Rajbangshi, & Bhattacharyya, 2015; Sudhinaraset et al., 2017; Afulani et al., 2017): (1) I left the antenatal care visit with questions or confused about some things, (2) The provider did not show me respect or act in respectful ways, and (3) I had enough time with my provider. The complete surveys are published in Musange et al. 2019. Initially responses to these three questions were coded as strongly agree (code = 1), agree (code = 2), neither (code = 3), disagree (code = 4) or strongly disagree (code = 5). Questions were recoded so that code = 1 corresponded with the lowest level of PCANC and code = 5 corresponded with the highest level. We created a summative PCANC score ranging from 3 to 15 by combining responses to the three questions. We then recoded this as a binary variable using the median. Responses 3–11 were coded as low PCANC (code = 0) and 12–15 were coded as having high PCANC (code = 1).
Past research demonstrates that age, socioeconomic background and empowerment are associated with person centered care during childbirth (Bohren et al, 2019, Afulani, Sayi, 2018, Afulani, Phillips, 2019). We therefore included the following socio-demographic characteristics as has been done in previous research and based on data availability: age, gravidity, parity, education level, health insurance, food security, trimester upon presentation, and, ubudehe category at the first ANC visit. Ubudehe are economic categories designed by the government and designated by communities where category one represents the poorest household and category four the richest (Nizeyimana, 2018). Whether or not women were able to discuss the health of their pregnancy with their partner was used as a potential measure of cognitive empowerment and whether or not women brought income to their households was used as a potential measure of economic empowerment. Having food insecurity was measured as responding yes to any of three questions: have you ever had no food, run out of food, not had enough food.
The analytical sample is 2,105. This includes women who had at least one ANC visit during their pregnancy and who completed the survey. Our primary analysis was to examine the extent of PCANC and to determine the factors associated with high PCANC. Frequency distributions were used to describe the background characteristics of the women. Cross-tabulations were used to investigate associations between both the women’s experience with their first ANC visit and factors associated with high PCANC. Pearson’s chi-squared (χ2 ) tests were used to examine the significant differences between level of PCANC and the explanatory variables. Both bivariate and multivariate logistic regression analyses were used to test the hypothesis that certain participant characteristics would predict high PCANC. Given that data collection happened with the context of a CRCT, within the multivariate analysis, we controlled for the trial group and district. Results are presented in the form of Odds Ratios (OR) reporting 95% confidence intervals. The level of statistical significance using p -values was set at p < 0.05. All analyses were performed using Stata/SE for Mac (updated March 2018).
This study was exempt by the UCSF Review Board (#16-21177, 2017). The parent study protocol was reviewed and approved by the Rwanda National Ethics Committee (No 0034/RNEC/2017) and the UCSF Institutional Review Board (No 16-21177). A waiver of parental consent for any adolescent 15 years of age or older was granted by the Rwanda National Ethics Committee, allowing adolescents over 15 to consent to participation in primary and secondary interventions and data collection and analysis.
All members of the research team were trained in ethical practices in human research. Research staff will emphasize that participation in the study is voluntary and that refusal to participate in the study will not results in negative repercussions. If any modifications to the study protocol are made, these modifications will be submitted to both ethical review boards for approval. This study was registered on ClinicalTrials.gov, ID NCT03154177 on May 16, 2017. All data from the parent study was de-identified.
Table 1 presents the sociodemographic characteristic of the sample. The average age of women was 28 years. One fourth of the women were primigravida (27%). The majority (75%) had only a primary education or less. A minority (8%) of women reported having no health insurance and most (63%) of those insured had Mutuelle (a form of community-based health insurance). The majority of women sampled were unable to contribute financially to their households (77%) but most were able to discuss the health of their pregnancy with their partners (88%). The majority reported food insecurity (62%). The sample was distributed between the five districts (Burera, Bugesera, Nyamasheke, Nyarugenge and Rubavu) with the majority of participants in Bugesera (31%) and the minority in Nyarugenge (11%).
Table 2 presents the frequency of PCANC. Thirty-percent of women left the ANC visit with questions or confused about some things, 23% reported disrespect from their provider, and 3% reported not having enough time with their provider. The average PCANC score based on the three questions was 11.33 (SD: 2.44, Range: 5–15, Median: 12). Forty-five percent of responses were between 3 and 11. Based on the recoded variable, 45% of participants had low PCANC.
PCANC Measure |
High PCANC |
Low PCANC |
|
N(%) |
N(%) |
Experienced Respect |
1,639 (76.3) |
509 (23.7) |
Left with Questions |
1,493 (69.4) |
657 (30.6) |
Not Enough Time |
2,082 (96.9) |
67 (3.1) |
Combined Score |
1,185 (55.1) |
965 (44.9) |
Table 3 presents the results of bivariate associations with chi-square tests with respect to whether PCANC at the first ANC visit was low and selected factors. Factors that were significantly associated with high PCANC in the bivariate analysis were multiparity and being able to discuss the health of one’s pregnancy with one’s partner. The factors that were associated with low PCANC were study group and receiving care in any district other than Burera. Women who were multiparous (56%) were more likely to have high PCANC than were those who were nulliparous (51%). Women who were able to discuss the health of their pregnancies with their partners were more likely to have high PCANC (56%) than were women who did not discuss pregnancies with partners (47%). The districts where women were most likely to receive high PCANC were Burera (72%) and Rubavu (59%) compared to 45% in Nyamasheke district which had the lowest PCANC. Those who were allocated to receive exclusively traditional care after their first visit were more likely to receive high PCANC (69%) during their first visit than were those who would receive exclusively group care after their first visit (39%).
Characteristics |
High PCANCA |
P ValueB |
|
N(%) |
|
Total |
1,185 (55.1) |
|
Age |
|
0.546 |
16-19 |
32 (53.3) |
|
20-24 |
321 (55.2) |
|
25-29 |
306 (52.4) |
|
30-34 |
295 (56.4) |
|
35+ |
231 (57.5) |
|
Gravidity |
|
0.083 |
Primigravida |
294 (52.1) |
|
Multigravida |
891 (56.4) |
|
Parity |
|
0.020 |
Nulliparous |
313 (51.2) |
|
Multiparous |
871 (56.7) |
|
Trimester |
|
0.046 |
First |
242 (58.6) |
|
Second |
851 (53.6) |
|
Third |
92 (61.7) |
|
Education |
|
0.749 |
None |
92 (57.5) |
|
Primary or less |
809 (55.4) |
|
Secondary or more |
279 (54.2) |
|
Health InsuranceC |
|
0.486 |
No Insurance |
104 (59.4) |
|
CBHI |
820 (60.7) |
|
RSSB |
33 (71.7) |
|
MMI |
8 (53.3) |
|
Other |
1 (100.0) |
|
Ubudehe Category |
|
0.376 |
1 (Lowest) |
187 (60.7) |
|
2 |
358 (59.1) |
|
3 |
343 (63.0) |
|
4 (Highest) |
0 (0.0) |
|
Unknown |
49 (55.1) |
|
Discusses Pregnancy with Partner |
0.013 |
|
Yes |
1,070 (56.3) |
|
No |
105 (47.5) |
|
Contributor to Household Finances |
0.519 |
|
Yes |
248 (56.7) |
|
No |
914 (55.0) |
|
Food Secure |
|
0.985 |
Yes |
740 (55.1) |
|
No |
445 (55.1) |
|
Study Group |
|
0.000 |
Group Care |
377 (38.6) |
|
Traditional Care |
808 (68.8) |
|
HC District |
|
0.000 |
Burera |
261 (71.7) |
|
Bugesera |
358 (53.9) |
|
Nyamasheke |
232 (44.8) |
|
Nyarugenge |
116 (50.4) |
|
Rubavu |
216 (59.2) |
|
Note: All percentages are row percentages A High PCANC defined as summative scores between 11 and 15 B P Values are from bivariable Pearson chi-square tests C CBHI is Mutuelle (Community-Based Health Insurance); RSSB is the Rwanda Social Security Board; MMI is military medical insurance |
Table 4 shows results from both bivariate and multivariate regression models. In the bivariate model multiparity was significantly correlated with having high PCANC (OR 1.24 [1.03–1.51]). Ability to discuss one’s pregnancy with one’s partner was also correlated with having high PCANC in the bivariate model (OR 1.42 [1.07–1.88]). Receiving care at a facility trained for group care was significantly associated with low PCANC in the bivariate model (OR 0.28 [0.24–0.33]). The multivariate regression was also adjusted for district: receiving care in Bugesera (OR 0.55 [0.39–0.78]), Nyamasheke (OR 0.411 [0.28–0.59]), Nyarugenge (OR 0.55 [0.36–0.85]) or Rubavu (OR 0.47 [0.32–0.70]) were associated with low PCANC when compared to Burera. Group care also remained significantly associated with low PCANC (OR 0.32 [0.25–0.40]) in the multivariate regression.
Characteristics |
Bivariate PCANC |
Multivariate PCANC |
---|---|---|
OR [95% CI] |
OR [95% CI] |
|
Age |
||
16–19 |
Ref. |
Ref. |
20–24 |
1.08 [0.63–1.84] |
1.34 [0.71–2.52] |
25–29 |
0.96 [0.56–1.64] |
1.13 [0.59–2.19] |
30–34 |
1.13 [0.66–1.93] |
1.47 [0.74–2.91] |
35+ |
1.18 [0.68–2.03] |
1.32 [0.66–2.67] |
Parity |
||
Nulliparous |
Ref. |
Ref. |
Multiparous |
1.24 [1.03–1.51] ** |
1.23 [0.90–1.68] |
Gestational Age |
||
First |
Ref. |
Ref. |
Second |
0.81 [0.65–1.01]* |
0.82 [0.63–1.67] |
Third |
1.14 [0.78–1.67] |
0.82 [0.50–1.32] |
Education Level |
||
None |
Ref. |
Ref. |
Primary |
0.92 [0.66–1.27] |
1.15 [0.75–1.76] |
Secondary or more |
0.87 [0.61–1.25] |
1.37 [0.86–2.24] |
Ubudehe Category |
||
1 (Lowest) |
Ref. |
Ref. |
2 |
0.93 [0.70–1.24] |
0.93 [0.68–1.26] |
3 |
1.10 [0.83–1.47] |
0.99 [0.72–1.36] |
4 (Highest) |
-- |
-- |
Unknown |
0.79 [0.49–1.27] |
0.84 [0.51–1.41] |
Partner discussion |
||
No |
Ref. |
Ref. |
Yes |
1.42 [1.07–1.88]** |
1.12 [0.76–1.66] |
Contributes to household finances |
||
No |
Ref. |
Ref. |
Yes |
1.08 [0.87–1.33] |
1.23 [0.85–1.77] |
Study Group |
||
Traditional Care |
Ref. |
Ref. |
Group Care |
0.28 [0.24–0.34]** |
0.32 [0.25–0.40]** |
HC District |
||
Burera |
Ref. |
Ref. |
Bugesera |
0.46 [0.35–0.61]** |
0.55 [0.39–0.78]** |
Nyamasheke |
0.32 [0.24–0.43]** |
0.411 [0.28–0.59]** |
Nyarugenge |
0.40 [0.28–0.57]** |
0.55 [0.36–0.85]** |
Rubavu |
0.57 [0.42–0.78]** |
0.47 [0.32–0.70]** |
Notes **p<0.05 *p<0.1 |
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.
The study is a secondary analysis of survey data collected within a CRCT designed to evaluate group antenatal care and preterm birth in Rwandan facilities with a model of group care that began after the first individual visit at all facilities. As such, the study was not designed specifically to measure PCANC. We were limited by the available variables relevant to PCANC. For example, other aspects of PCANC such as privacy, confidentiality, autonomy, social support, timeliness, cleanliness (Afulani et al., 2017), or the availability of specific amenities (Sheferaw et al., 2016) could not be examined because data were not available. Additionally, responses were self-reported, which may have resulted in under-reporting of disrespect (Bowser & Hill, 2010; Kruk et al., 2018). In the future, perhaps visits could be observed or the self-report survey can ask about more specific elements of respect (Did you feel the doctors, nurses, or other health providers shouted at you, scolded, insulted, threatened, or talked to you rudely?) or of the facility upkeep (were there clean sheets, drinking water, electricity etc..) (Afulani, Diamond-Smith, Phillips, et al., 2018).
Overall, based on limited measures, we find an indication of sub-optimal levels of PCANC amongst our study population in Rwanda. Improvements in PCANC would positively impact the perception of care and would likely improve outcome. Efforts are thus needed to sensitize providers to these findings and implement provider training in Rwanda to promote an institutional culture shift towards a more person-centered model of care. Furthermore, in order to better understand all dimensions of quality ANC—including measures not assessed in this study such as patient privacy and supplies—better measurement tools are needed to more comprehensively measure PCANC. The tools that have been validated for person-centered care during childbirth (Afulani, Diamond-Smith, 2017), could be adapted for ANC (Afulani PA, Buback L, et. al, 2019). We also recommend wider use of these validated tools in national surveys to get a systematic understanding of PCANC in Rwanda and globally. Additionally, we recommend thoughtful measures of empowerment during antenatal care to capture the social experiences of women in Rwanda.
Antenatal Care (ANC), Cluster Randomized Control Trial (CRCT), Person Centered Care (PCC), Person Centered Maternity Care (PCMC), Person Centered Antenatal Care (PCANC)
Ethics approval and consent to participate: This study was exempt by the UCSF Review Board (#16-21177, 2017). The parent study was approved by the UCSF IRB and the RBC IRB (#NCT03154177).
Not applicable.
All data generated or analyzed during this study are included in this published article [and its supplementary information files].
The authors declare that they have no competing interests
This work was generously funded by the Bill and Melinda Gates Foundation (grant OPP1107312), The University of California San Francisco SOM Summer Explore Research, and University of Berkeley Joint Medical Program Thesis Grant. The funders had no role in the research design, data collection, analysis or synthesis of the data.
All authors have read and approved this manuscript. PM analyzed, interpreted, and wrote the manuscript. DW and PA were major contributors to the analysis, interpretation and writing of the manuscript. SM and SF contributed to both the interpretation and writing of the manuscript.
Not applicable
Due to technical limitations, table 1 is only available as a download in the Supplemental Files section.