Background
According to the World Health Organization (WHO), low birth weight (LBW) is defined as an infant’s birth weight of less than 2500 g, regardless of gestational age or other factors [
1]. LBW causes 60–80% of all newborn deaths worldwide and increases the risk of mortality by 20–30 times [
2,
3]. Immediately following delivery and for the first year of life, surviving newborns are more susceptible to pathological diseases like infection [
4]. Later-life morbidity is also linked to LBW, including psychosocial disorders [
5], poor cognitive function [
6], coronary heart disease [
7], and non-insulin-dependent diabetes [
8].
Low and middle-income countries(LMICs) and especially Sub-Saharan Africa(SSA) countries are affected by a higher rate of LBW, WHO estimates that roughly 95.6% of the more than 20 million LBW babies (representing 15.5% of all live births) are in LMICs [
9], estimated LBW levels in SSA are at 15% [
10,
11]. This is related to the inadequate health infrastructure and permeable social support systems found in the majority of developing nations, which have a detrimental effect on health outcomes. Several studies on LBW in SSA have demonstrated that adherence to antenatal care (ANC) services, maternal body mass index(BMI), the receipt of iron and folic acid during pregnancy, gender of the newborn, demographic and socioeconomic factors such as household wealth index, maternal age, and maternal education were associated to LBW of the newborn [
12‐
15].In addition, the risk of LBW has been linked to both maternal malnutrition and malaria infection [
16]. During the second and third trimesters of pregnancy, intermittent preventative therapy (IPT) for malaria is administered in places where the disease is endemic [
17,
18]. Malaria-related birth outcomes can be worsened by inadequate prenatal care attendance, which can also reduce the amount of IPT doses provided [
18].
The aforementioned ANC package components have been demonstrated to be cost-effective in reducing the prevalence of LBW elsewhere in SSA [
19,
20]. The majority of research on the relationship between ANC and birth weight has been done in high-income countries, even though the prevalence of LBW is higher in low and middle-income countries [
21].
The Rwanda Demographic and Health Survey (RDHS) report indicates a prevalence of LBW of 7% [
22]. Rwanda’s neonatal mortality rate is estimated to be 18 per 1000 live births, far higher than the United Nations(UN) Sustainable Development Goal 3.2(SDG), which is to reduce neonatal mortality to less than 12 per 1000 live births [
23,
24].LBW has been significantly associated with neonatal mortality in resource-limited settings [
25,
26]. A study conducted in Rwanda found that 70% of perinatal deaths included low birth weight newborns [
27]. For Rwanda to achieve the SDGs in neonatal mortality, determinants of LBW should be assessed to inform the policymakers in the health sector. The 2016 WHO guidelines on ANC recommend at least 8 contacts for every pregnant woman; however, Rwanda still implements the 2001 policy which only recommended 4 visits [
22]. According to studies, the quality and content of ANC rather than the number of visits has a stronger influence on maternal and newborn health [
28‐
31]. Quality ANC is when a woman had her first ANC visit within 3months of pregnancy, had 4 or more ANC visits as recommended by WHO [
32], and received services components of ANC during the visits(found to be crucial for quality pregnancy care by WHO) [
33] by a skilled provider [
34]. The choice of this model was adapted from Bollini and colleagues who proposed indicators to help measure quality ANC [
35] and referred to a cross-sectional study conducted in India in 2019 [
36]. To improve neonatal outcomes in Rwanda, it is imperative to examine the quality and uptake of ANC and their association with LBW.
Few studies have been conducted at the Rwanda country level to examine the associations between quality ANC, health and socioeconomic factors, and LBW [
14]. We sought to breach this gap by exploring the associations between quality ANC and potential confounders on LBW.
Discussion
The current study investigated the association between quality ANC and LBW. We found that 8.94% of the mothers had high-quality ANC visits and 2.82% of the newborns were low birth weight; this result shows that high-quality antenatal care enabled a reduction by 4.18% of the low birth weight to the national average which stands for at 7% according to the report of the most recent survey [
22].
Our study showed that high-quality ANC visits was a predictor of LBW. When compared to low-quality ANC visits, high-quality ANC visits had a lower risk of LBW. A recent hospital-based study in Rwanda discovered that women who received four or more ANC visits had a decreased incidence of LBW [
41]. Several studies have shown similar conclusions [
42‐
45]. The World Health Organization (WHO) recommends at least four antenatal checkups throughout pregnancy since this is a time when babies are vulnerable to issues such as preterm birth, restricted fetal growth, and congenital infections, all of which increase the likelihood of neonatal death [
46]. In addition, attending ANC has been suggested as a possible avenue for mothers and their families to receive information and advice on obstetric care as well as the identification and management of infections such as Malaria, HIV/AIDS, syphilis, and other sexually transmitted diseases that affect the fetus [
46]. This emphasizes the necessity of implementing population-based interventions that promote early ANC attendance [
44].
Other predictors of LBW include the female gender of newborn. Female neonates were more likely than male neonates to have low birth weight. Findings in Ghana, India, and Brazil corroborate our findings [
47‐
49]. According to Volder and colleagues’ research, paternal birth weight has a considerable impact on boys’ birth weight, but not on girls’ birth weight [
50]. LBW was also found to be negatively linked with the rich tercile. Low birth weight neonates were less likely to be delivered by mothers in the rich tercile than by mothers in the poor tercile. Previous research has found that having a higher socioeconomic status lowers the risk of LBW [
51‐
54]. Low birth weight has been linked to poor prenatal nutrition among mothers of lower socioeconomic classes, according to studies [
55,
56]. The likelihood of LBW decreases as the newborn’s birth order rises. Several studies have come to the same conclusion [
43,
44,
57]. A recent longitudinal study in Germany discovered an increase in birth weight with the newborn’s birth order, implying that the biological intrauterine component is likely to alter mother physiology in favor of later borns and recommending additional research into sibling pregnancies [
58].
Our findings demonstrate that a small percentage of women received a high-quality ANC and that their number increased throughout the three waves of surveys. The increase in high-quality ANC played a key role in reducing the prevalence of LBW. However, the prevalence of LBW is still high, future research would examine the effect of several mediator variables such as maternal nutrition during pregnancy on LBW to effectively address this adverse neonatal outcome.
Strengths and limitations
The study’s use of a nationally representative population-based, combined dataset is a notable strength. We were able to generate a large sample size by merging the three surveys, which allowed us to assess the impact of various factors on LBW with acceptable precision. Because the three DHS used similar sample procedures and questionnaires, used comparable data collection tools, and were planned and implemented by the same institutions, they allowed researchers to look into trends in low birth weight over the past 15 years. This study provided evidence-based information for the decision-makers which can help in the implementation of public health policies regarding ANC improvement and evaluations. Data on key major determinants of maternal healthcare consumption, such as health insurance, was only gathered for the most recent survey, which limited our ability to assess the impact of such variables. Not all potential confounders were included in our study; for instance, gestational age, could have reduced the quality of the results. Variables such as facility readiness, interpersonal relationships between clinicians and women, transportation, and other cultural norms and beliefs that could have influenced a high-quality ANC utilization were not included in this study. Due to the cross-sectional nature of the data, we were only able to investigate relationships rather than causality. Further researchers would conduct a longitudinal study design to assess the causality between ANC and LBW.
Conclusion
Our findings demonstrate that the use of high-quality ANC has gradually increased. However, the vast majority of the women are still receiving low-quality ANC. The prevalence of LBW has decreased over the years of the surveys, however, it remains high. Addressing the coverage but also the quality of the content in ANC, especially to the poor and primiparous women results in the reduction of the prevalence of LBW. The study revealed that the utilization of high-quality ANC can greatly contribute to lessening LBW and thus neonatal mortality and therefore achieving the SDGs.
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