Antenatal Care: Predictors of Delays and Effectiveness of Targeted Mentorship and Quality Improvement Intervention at Rural Health Centers in Rwanda

Abstract

Background Although 98% of women receive antenatal care (ANC) from a skilled provider in Rwanda, only 38% of them have an ANC visit in their first three months of pregnancy. Further, inadequate ANC delivery leads to missed diagnosis of danger signs which often results in poor pregnancy outcomes. This thesis provides evidence on predictors of delayed ANC in Rwanda. We also measured the effect and cost-effectiveness of the Mentorship, Enhanced Supervision and Quality Improvement (MESH-QI), an intervention to improve the quality of ANC at health centers in rural Rwanda. Methods We used a multivariate logistic regression model to assess factors associated with delayed ANC. This study included 6,325 women age 15-49. The second study used mixed-effects linear regression model to measure the effect of the MESH-QI on the danger sign assessment score. This study included 330 observation checklists completed at baseline and 292 completed during the MESH-QI intervention. An economic evaluation estimated the cost-effectiveness of the MESHQI intervention. Results Having many children, feeling that distance to health facility is a problem, and unwanted pregnancy were significantly associated with delayed ANC. The second study found that MESHQI led to significant improvements in danger sign assessments. The incremental cost per ANC visit attributable to MESH-QI with all assessment items completed was 0.70 USD for danger signs and 1.10 USD for vital signs. Conclusions Long distance to health facility, unwanted pregnancies, and having many children constitute the major predictors of delayed ANC. This reflects the need to decentralize ANC and birth control services. In the efforts to improve access to essential health services, the government of Rwanda launched a campaign to build community health posts. Future studies should to assess the impact of decentralized services on access and quality of ANC in Rwanda.