bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 1 Understanding variation in maternal health service coverage and 2 maternal health outcomes among districts in Rwanda 3 4 Felix Sayinzoga1 5 Maternal, Child and Community Health Division 6 Rwanda Ministry of Health/ Rwanda Biomedical Center 7 Kigali, Rwanda 8 E-mail:[email protected] 9 PO Box 84 Kigali 10 Phone:+250788517814 11 12 Tetui Moses2 13 Makerere University School of Public Health 14 PO Box 7072, Kampala, Uganda 15 E-mail: [email protected] 16 17 Koos van der Velden3 18 Department of Primary and Community Care 19 Radboud University Medical Centre 20 Nijmegen, The Netherlands 21 E-mail: [email protected] 22 23 Jeroen van Dillen4 24 Department of Obstetrics and Gynaecology 25 Radboud University Medical Centre 26 Nijmegen, The Netherlands 27 E-mail: [email protected] 28 Leon Bijlmakers5 29 Department for Health Evidence 30 Radboud University Medical Centre 31 Nijmegen, The Netherlands 32 E-mail: [email protected] 33 Tel: +31 243613337 34 Corresponding author 35 1 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 36 Abstract 37 Objective: To identify factors that explain variations between districts in maternal 38 health service coverage and maternal health outcomes. 39 Methods: Individual key informant interviews and focus group discussions using 40 structured topic lists were conducted in May 2015 in four purposively selected 41 districts. 42 Results: The solidarity support for poor people and the interconnectedness between 43 local leaders and heads of health facilities were identified as enablers of health service 44 utilization. Geographical factors, in particular location close to borders with mobile 45 populations and migrants, and large populations with sparsely distributed health 46 infrastructure, exacerbated by hilly topography and muddy roads were identified as 47 barriers. Shortages of skilled health providers at the level of district hospitals were 48 cited as contributing to poor maternal health outcomes. 49 Conclusion: There is a need to take into account disparities between districts when 50 allocating staff and financial resources in order to achieve universal coverage for 51 high-quality maternal health services and better outcomes. Local innovations such as 52 the use of SMS and WhatsApp text messages by health workers and financial 53 protection schemes for poor patients improve solidarity and are worth to be scaled up. 54 55 Keywords: Rwanda, maternal health, district performance, disparities, local 56 innovations 57 2 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 58 Introduction 59 Worldwide in 2015, an estimated 303,000 women died due to complications of 60 pregnancy or childbirth [1]. Most of them died because of severe bleeding after 61 childbirth, infections, hypertensive disorders or unsafe abortions. Low and middle 62 income countries account for 99% of these deaths, with sub-Saharan Africa alone 63 accounting for roughly two-thirds (201,000 deaths in 2015) [1]. Maternal mortality is 64 one of the health outcomes that typically show very wide gaps between rich and poor 65 populations [1]. 66 The 2014/15 Demographic and health survey (DHS) in Rwanda estimated the 67 maternal mortality ratio (MMR) at 210 deaths per 100,000 live births [2], which is 68 significantly less than the ratios reported in the 2010 DHS (476 per 100,000) and the 69 2000 DHS (1071 per 100,000) [3,4]. Although everything points to significant 70 improvements, deaths related to pregnancy and childbirth are still too common and 71 will need to be reduced further in order to reach the SDG target MMR of 70 per 72 100,000 by the year 2030. 73 Globally, health service coverage rates have increased but many countries are still a 74 long way from universal coverage for most essential reproductive, maternal, newborn 75 and child health (RMNCH) interventions. Furthermore, intra-country variations in 76 service coverage rates are reducing in most countries but the pace is slow. The main 77 impediments to the delivery of high-quality services are a combination of health 78 sector specific and non-health sector drivers [5]. Reliable and timely information is 79 required for effective remedial action at local, regional and national health sector 80 management levels, in order to address intra-country inequalities in maternal health 81 care. 3 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 82 The present study was conducted to obtain an in-depth understanding of the factors 83 that explain variations between districts in maternal health outcomes, including 84 certain emergency obstetric care indicators, and identify the prevailing barriers and 85 enablers to improve maternal health. 86 Materials and Methods 87 Study setting 88 We performed a mixed-methods study combining individual interviews and focus 89 group discussions that were conducted in May 2015 in four districts: Bugesera, 90 Gicumbi, Nyagatare and Rwamagana. These districts had a combined population of 91 around 1.65 million people [6-9; see Table 1]. 92 93 Table 1: Demographic and geographic information Bugesera Gicumbi Nyagatare Rwamagana Province Eastern Northern Eastern Eastern Area 1,288 km2 829 km2 1,741 km2 682 km2 Population in 2013 361,914 395,606 466,944 313,461 Population density 280/km2 480/km2 243/km2 460/km2 # of health centres 16 24 21 15 # of hospitals 1 1 1 1 Distance to Kigali 35 km 55 km 161 km 60 km 94 95 96 The districts were chosen on the basis of their performance on a set of key maternal 97 health indicators, which included four service coverage, four service process 98 indicators and four health outcomes, according to data reported in 2013 through the 4 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license. 99 national health formation system (Table 2) [10]. Bugesera district was selected 100 because of its relatively good performance on all three types of indicators. Gicumbi 101 district was chosen because of its good performance on health outcome indicators, but 102 poor performance on service coverage indicators, which seemed rather contradictory. 103 For Rwamanaga it was the reverse: high service coverage rates, but poor health 104 outcome indicators. Nyagatare was included in the study because of its relatively poor 105 overall performance in 2013. 106 107 Table 2: Selected key indicators for the four districts in 2013 and the national 108 average (rank numbers indicated in brackets, <1> indicating the best performing 109 district, and <30> the worst performing district).* National Bugesera Gicumbi Nyagatare Rwamagana average district district district district (range) Service coverage indicators Pregnant women with 1st antenatal 51% 34% 46% 69% 45% care visit in 1st trimester of <11> <22> <12> <3> (15-84) pregnancy Pregnant women with four or 42% 27% 22% 62% 35% more standard antenatal care visits <9> <20> <24> <3> (9-74) 4.5% 3.1% 9.1% 4.4% 4.5% Deliveries at home <17> <11> <28> <15> (0.6-10.3) Women who delivered and 65% 60% 63% 63% 58% attended at least one postnatal <11> <18> <13> <14> (22-86) care visits Process indicators 2-5 Tetanus toxoid vaccinations 66% 67% 59% 70% 74% received <26> <24> <30> (18> (59-100) High-risk pregnancies detected 3.9% 9.4% 6.1% 6.9% 9.4% during antenatal care visits <n/a> <n/a> <n/a> <n/a> (3.9-32.3) High risk pregnancies referred 76% 20% 27% 26% 43% during antenatal care visits <1> <27> <22> <24> (7-76) Women with (pre-)eclampsia who 77% 28% 80% 71% 95% received magnesium-sulphate <16> <27> <14> <18> (0-100) 14% 11% 11% 16% 14% Caesarean sections <n/a> <n/a> <n/a> <n/a> (3-34) Health outcomes Still births fresh, ≥22 weeks or 0.7% 0.9% 1.2% 1.1% 0.9% >500 grams <7> <16> <27> <23> (0.4-1.5) Still births macerated, ≥22 weeks 1.0% 0.8% 1.3% 1.2% 1.0% or >500 grams <17> <8> <28> <26> (0.5-1.5) 5 bioRxiv preprint doi: https://doi.org/10.1101/516112; this version posted January 9, 2019. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under aCC-BY 4.0 International license.