Abstract
BackgroundThe proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda.MethodsUsing census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18–50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities.ResultsAnalysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery.ConclusionsThe strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.
Highlights
Few countries are on track to meet Millennium Development Goal 5 (MDG 5), which aims for a 75% reduction in maternal mortality by 2015 [1,2]
More than 86% of respondents were subscribers of a national community-funded health insurance program known as Mutuelle de Santé, while 10.9% did not have any form of health insurance
A number of interventions likely played a role, including the commitment of a dedicated political leadership to improved donor aid coordination; the refurbishment of most health facilities and many roads in the country; the implementation of a nation-wide performance-based payment initiative for healthcare providers; the national rollout of a community-financed health insurance program known as Mutuelle de Santé; the steady rise in overall health insurance subscription rates, from 68% household coverage in the 2007–8 Interim Demographic and Health Survey (DHS) to 78% household coverage in the 2010 DHS; and the inauguration of an aggressive sensitization campaign linked to performance contracts at the district level that aims to educate women on the dangers of delivering at home while strongly encouraging health facility delivery [9,10,20,26,27,28]
Summary
The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births. Few countries are on track to meet Millennium Development Goal 5 (MDG 5), which aims for a 75% reduction in maternal mortality by 2015 [1,2]. A densely populated country of 11 million people located in central Africa, has made impressive strides in improving its health indicators since the 1994 genocide, but still has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births [1]. Widespread reliance on this indicator has contributed to a major shift in global policies aimed at reducing rates of maternal mortality: rather than training and equipping traditional birth attendants, efforts have increasingly been directed at improving access to and utilization of formal healthcare services during the antenatal period and at the time of delivery [5,7]
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