Are perceived barriers to accessing health care associated with inadequate antenatal care visits among women of reproductive age in Rwanda?

Maternal and neonatal mortality remain a global health concern despite different interventions that have been implemented to address this issue [1]. Sub-Saharan Africa (SSA) is by far among the regions with the highest ratios of maternal mortality with 351 per 100 000 live births and high neonatal mortality rates with 20 per 1000 live births [2]. Several studies have shown that 15% of maternal and newborn deaths in SSA are attributed to pregnancy complications that are a result of inadequate pregnancy follow-up [2‐4].

Timely and frequency of ANC are crucial in reducing delivery complications, maternal and neonatal mortality [5, 6]. A study conducted in Zimbabwe found a 42 and 29% decrease in neonatal and under-five mortality respectively as a result of utilization and quality improvement of ANC services [7]. Before 2016, the World Health Organization (WHO) ANC guidelines—also known as Focused Antenatal Care (FANC)—recommended at least four ANC visits during the time of the pregnancy. The guidelines recommended the first ANC visit to take place within 3 months of pregnancy (timely ANC) and subsequent visits in 24–26 weeks, 32 weeks and 36–38 weeks [5, 8]. The new WHO ANC guidelines recommend at least eight ANC visits including one visit in the first trimester, two visits in the second trimester and five visits in the third trimester [9]. This study used the former guidelines since DHS was conducted before the development of the new guidelines. WHO developed these guidelines to improve ANC in developing countries; however, the available evidence shows poor utilization of ANC in low-and-middle income countries [8, 10‐12].

Rwanda is among the few countries that achieved maternal and child millennium development goals (MDGs) with a child mortality decrease of more than 70% comparing 2002 to 2015 [13, 14] and a maternal mortality ratio decreased from 1020 deaths per 100,000 live births in 2000 to 290 deaths per 100,000 live births in 2015 [15]. However, the country’ maternal and neonatal death rates remains high and had slower decline compared to the post-neonatal mortality in the MDGs era. Therefore, there is a need for combined efforts towards the progress to achieving sustainable development goals on maternal and neonatal health [13]. Among these efforts, there is a call to promoting the use of ANC services among women in Rwanda as research shows that there is still suboptimal utilization of ANC services. Based on recent findings, 64% of women did not complete at least four ANC visits, and only 56% of these women had a timely first ANC visit [11]. Further, 59% of women reported at least one barrier to accessing health care [11, 16]. Limited access to health care leads to an increased risk of poor health outcomes [17]. A study conducted in rural Tanzania found a strong association between distance to the health facility and maternal mortality [18], hence speaking to physical access barriers. Other studies have reported treatment cost and demand at work to be potential barriers of health services utilization [19], the former being related to financial access and the latter being availability and accommodation of women’s needs while seeking maternal health services [20].

To date, there is a paucity of studies that assessed the relationship between perceived barriers to health care and inadequate ANC visits in Rwanda. A study conducted in Rwanda assessed the determinants of timing of first ANC visit [21]. This study considered only distance to a health facility as a barrier to health care; the authors did not consider other substantial barriers to care such as treatment cost, time and ability to go alone to a health facility [16, 22]. Further, the study did not investigate subsequent ANC visits [5] and recommended future research in this area [21]. Another study that assessed these barriers and frequency of ANC visits in Rwanda was conducted only in two out of five provinces of Rwanda and included only women who had a child in the past 13 months [23] which limits the generalizability of the findings. The recent 2015 DHS data gives an opportunity to assess whether there is an underlying relationship between perceived barriers to health care and ANC services utilization using a country representative sample. Therefore, this study aims to investigate the relationship between perceived barriers to health care and inadequate ANC visits among women of reproductive health in Rwanda after adjusting for potential confounders.

We hypothesized that women who perceived to have barriers to health care are more likely to have inadequate ANC visits. This study will contribute to future interventions that are essential in improving ANC utilization and access to health care in Rwanda.

In this study, we found that almost two-thirds of women with perceived barriers to accessing health care had inadequate ANC visits. Women who reported having barriers to care were more likely to have inadequate ANC visits, however, the association was not statistically significant. The results were consistent in the sensitivity analysis using propensity score methods and when we investigated the relationship between each perceived barrier and the outcome separately. Although we cannot draw causal conclusions, our results are similar to other studies that assessed barriers to ANC services utilization in SSA. A survey conducted in Nigeria found that non-users of ANC services were women who had problems of getting money for treatment, and those who lived far from the health facility and had issues of transport facilities [37]. Similarly, to these studies, the current study showed that women who had reported distance to health facility and money for treatment to be barriers were more likely to have inadequate ANC visits.

Several studies conducted in SSA found that women who could not get permission to go to a health facility were less likely to use ANC services [19, 37, 38]. We noted that women who reported permission to go to a health facility as a perceived barrier to health care were less likely to have inadequate ANC visits. This finding is not consistent with what we anticipated and found for other barrier factors because of the small sample size. Only very few women reported permission to be a barrier to health care which might have led to unstable estimates and change of direction in the relationship.

The study showed that women who perceived to have barriers to accessing care were more likely to have a delayed first ANC visit and not complete at least four recommended visits; however, the association was borderline statistically significant. We observed other behavior, socio-economic and demographic factors also significantly to contribute to inadequate ANC visits. Implementation of programs improving access to health care such as decentralization of ANC services to health post level could improve ANC services utilization. Health posts are health facilities that are closest to patients’ home. Decentralizing ANC services to this level of care would reduce the distance that women have to travel to the health centers. These findings also suggest that achieving adequate ANC visits requires sustained, coordinated effort across many sectors. Rwanda Ministry of Health should prioritize programs aiming at improving health care-seeking behavior, pregnancy planning, and interventions that will enhance women’s knowledge about ANC. Timely and more frequent ANC visit will contribute to reducing maternal and neonatal mortality and morbidity.