Birth preparedness and complication readiness among pregnant women admitted in a rural hospital in Rwanda

Maternal mortality remains a major global concern, especially in sub-Saharan Africa where the maternal mortality ratio, although declining, is still high [1‐3]. One of the reasons is lack of Birth Preparedness and Complication Readiness (BP/CR), which is recognized as a key component of safe motherhood programs around the world [4, 5].

BP/CR is a comprehensive package to promote timely access to skilled maternal and neonatal health services. It also promotes active preparation and decision making for birth among pregnant women and their families [5‐7]. A birth plan includes identifying a skilled birth attendant and location of the closest appropriate care facility, saving funds for birth-related and emergency expenses, arranging transport to a health facility for birth and obstetric emergencies and identification of compatible blood donors in case of need [5]. The latter criterion does not apply in Rwanda, where centralized blood banks taking blood from voluntary donors are in place [8].

Whilst BP/CR has been associated with reduced maternal and neonatal mortality [9], improved preventive behaviors [10‐12], increased knowledge of danger signs [13‐15] and more frequent seeking of professional care during emergencies [11, 16, 17], previous studies have shown low rates of BP/CR among women in Uganda [18], Ethiopia [4, 14, 15] and Burkina Faso [19]. The rate of BP/CR among women in Rwanda is unknown.

In 2003, Rwanda adopted BP/CR as part of ‘focused antenatal care’ to increase access to skilled birth attendance [20, 21]. Part of this strategy is that health workers explain women the obstetric danger signs that may occur during pregnancy, childbirth and the postpartum period as well as methods to prevent mother-to-child transmission of HIV [20]. The introduction of focused antenatal care may have contributed to the reduction of the maternal mortality ratio by roughly two-thirds from 750 in 2005 to 210 per 100,000 live births in 2015 and to the increased skilled birth attendance rate from 28 to 91% [22, 23].

This study aimed to assess practices around and factors associated with BP/CR among pregnant women admitted with obstetric emergencies in a rural Rwandan hospital.

Of all 350 women who were interviewed, mean age was 27.7 years. Characteristics are shown in Table 1.

All respondents had attended ANC at least once during this pregnancy; 131 women (37.4%) had completed the recommended four or more antenatal visits. Mean antenatal visits were 2.9 ± 0.9. Almost two out of three women (59.4%) had received education on the importance of knowing danger signs, knowing where to go in case of complications (73.1%) and where to give birth (76.3%), identifying transport (67.1%), identifying a skilled birth attendant (17.7%) and saving money (76.9%) (Table 2).

Regarding knowledge of key danger signs, vaginal bleeding was the most frequently mentioned complication by women during pregnancy (61.1%), labor/birth (73.1%) and postpartum (58%) (Table 3). Prolonged labor, which is one of the leading causes of maternal morbidity, was reported by only 13.7%. Most women knew at least one key danger sign during pregnancy (n = 296; 84.6%), labor/birth (n = 271; 77.4%) and postpartum (n = 288; 82.3%). Only 23 women (6.6%) had knowledge of three or more key danger signs during the three periods.

In practice, 46 women (13.1%) had identified a skilled birth attendant, 68 (19.4%) a facility to give birth, and 76 (21.7%) a means of transportation. Most women (n = 306; 87.4%) had saved money for hospital costs/birth materials (Table 4). About one in five women (n = 78; 22.3%) were considered ‘well prepared’ in terms of BP/CR.

The adjusted multivariate model showed that significant predictors for being well prepared were first time pregnancy (adjusted odds ratio (aOR) = 3.2; 95% CI 1.2–5.8), knowledge of at least two danger signs during pregnancy (aOR = 2.8; 95% CI 1.7–3.9) and having seen a community health worker (aOR = 2.2, 95% CI 1.3–3.7) (Table 5).

Our findings show that involving community health workers in antenatal care, as well as counseling on danger signs during pregnancy may be two effective strategies to promote birth preparedness. Although factors such as advanced maternal age, higher education, better antenatal care attendance and occupation of a woman or her partner were previously found to be associated with increased BP/CR in other studies [12, 15, 25], this was not the case in our population.

Similar to other settings, a high proportion of women reported to have received advice on BP/CR [13, 18, 19]. This may be explained by the wide availability of community health workers throughout Rwanda. Community health workers engage women and their families into formulating birth plans on a one-to-one basis prior to childbirth [26]. Still, a number of women do miss out on BP/CR advice, even if they attend antenatal care. Moreover, a considerable number of women had not followed the advice they were given, perhaps due to poor understanding of what the components of BP/CR actually entail, or to poor delivery of the messages. This finding stresses the importance of improved training for health providers on how to better communicate BP/CR-related messages and the need to address additional barriers to the uptake of BP/CR.

There were marked differences with regard to how frequent various danger signs were mentioned. In line with previous reports by others, vaginal bleeding during pregnancy, childbirth and postpartum was the most commonly reported key danger sign [16, 18]. On the contrary, prolonged labor, which is another leading cause of maternal deaths in Rwanda [22, 23] was mentioned by only few women in this study.

Our findings indicated low levels of knowledge of danger signs and birth preparedness respectively, lower than in other low-income countries [14, 18]. This may be due to our facility-based rather than community-based study setting. In addition, we applied the criterion of three out of four BP/CR components for being ‘well prepared’, where another study applied three out of five [14]. Nevertheless, the underlying principles and methods used to study BP/CR are the same.

Nulliparous women were better prepared than multiparous women, perhaps due to the misconception that after the first pregnancy BP/CR may not be required anymore. This is an indication that the frequency or quality of BP/CR messages given to multiparous women may be reduced, although these should clearly aim to also target multiparous women.

Women who knew at least two key danger signs were found more likely to be well prepared, which is similar to previous studies [12, 16, 18]. This illustrates that knowing danger signs may be an essential step towards behavioral change. This opens up possibilities for a number of potential interventions, such as the need for community-based health promotion programs and health promotion efforts at the facility in all stages of a woman’s reproductive life [27]. In addition, BP/CR requires that health services are equipped to meet the increased demand for care [28, 29].

Women who had seen community health workers had better outcomes with regard to BP/CR [26, 30]. This may be explained by the high level of community recognition for community health workers in Rwanda [26]. Therefore, in general, and particularly in settings where other health workers are scarce, community health workers should receive appropriate recognition and support [26, 31, 32].

The strength of this study is that the interview took place shortly after birth, minimizing recall bias. The fact that these women were referred for complications makes for a selected study population and it is difficult to infer our results to the general pregnant population. Moreover, some women may recall or provide information about BP/CR selectively, depending on their experience during birth or pregnancy outcome.

Nevertheless, we believe our study provides relevant information on possible opportunities to improve BP/CR. The fact that Rwanda is a densely-populated country with relatively widespread availability of health facilities (most women live less than an hour’s travel away from a facility), combined with increasing government investment in community-based health programs, performance-based financing, innovative community health insurance and SMS-based alert systems are all reasons why better implementation of BP/CR has the potential to lead to considerable improvements in pregnancy outcome in Rwanda [21, 33, 34].

This study revealed low levels of knowledge of obstetric danger signs and low levels of birth preparedness among women referred to a Rwandan hospital. Prenatal advice by community health workers and knowledge of danger signs during pregnancy are associated with being better prepared for birth. Investments in health promotion with regard to BP/CR, at all stages of a woman’s reproductive life, and with support from community health workers are much needed. We recommend a review of the quality and methods of antenatal care education, including an evaluation of how multiparous women are also to benefit from such education, in order to improve the effectiveness of BP/CR.