Quality of intrapartum care in Rwanda: management and women's experiences

Abstract

The overall aim of this PhD project was to assess the quality of intrapartum care at healthcare facilities offering maternity services in Rwanda by investigating healthcare pro- viders’ management of labour and birth and women’s childbirth experiences. Study I, was a cross-sectional household study investigating how women’s perceptions of care received during labour and birth were related to their overall childbirth experience. Of 921 women, 77.5% reported a good childbirth experience. Predictors of a good experience were trusting healthcare professionals, receiving enough information, being respected, receiving profes- sional support during childbirth and having the baby skin to skin early after birth. Study II, a qualitative study using a phenomenological lifeworld approach to interview 17 women, identified the essential meaning of a poor childbirth experience as being exposed to disre- spectful care, which was constituted by neglect, verbal or physical abuse, insufficient infor- mation and refusal for the husband to be a present companion. Study III, investigated the quality of healthcare facilities’ intrapartum care for 435 healthy women with a spontaneous onset of labour at gestational term. More than 90.0% of the women gave birth spontane- ously vaginally, but a large proportion of women were transferred from a lower health facility level to a district or a referral hospital. A partograph was used in 84.8% of the labours, the majority (88.0%) of the women did not receive any oxytocin for the augmen- tation of labour, 6.2% gave birth in a non-supine position, only one woman was accompa- nied by her husband in the birthing room and 12.5% had early skin-to-skin contact with the newborn within one hour after birth. Study IV, measured childbirth experience, focus- ing on women’s own capacity and perceived safety when giving birth at health facilities. Of 817 women, 83% reported a positive experience. Internal consistency measured with Cronbach’s alpha was 0.76 and 0.72 respectively for the own capacity and perceived safety subscales. Married women vs unmarried and multiparous vs primiparous scored higher for own capacity and perceived safety during childbirth. To conclude, the findings show that women rated their overall childbirth experiences positively, with a significant relationship to perceptions of care. The best intrapartum practices of healthy women with a spontane- ous labour onset included the high non-use of labour augmentation with oxytocin and the use of the partogram. However, several areas of childbirth care need to be improved, not least to ensure respectful, women-centred care. This includes allowing women to have a companion present during labour and birth, being encouraged to give birth in a non-supine position and placing the newborn and mother skin to skin early after birth.