The postnatal period, defined as the first six weeks after birth, is an important time in the life of the mother and child [1]. Care received during this period is important for preventing morbidity and mortality in mothers and new-borns [2]. In 2013, more than 289,000 maternal deaths occurred globally, with 62 % occurring in sub-Saharan Africa alone [3]. As a result, millennium development goals 4 and 5 focus on reduction of child mortality by two-thirds, and reduction of maternal mortality by three-quarters between 1990 and 2015, respectively [4, 5]. The United Nations has set targets for 2030 to further reduce child and maternal mortality [6].

The first week postpartum is especially critical in the life of the mother and the baby because half of all postnatal maternal deaths and 850,000 neonatal deaths happen during this window [7, 8]. The most common causes of maternal mortality in Africa are postpartum haemorrhage (33.9 %), hypertensive disorders (9.1 %) and postpartum sepsis (9.1 %) [9]. For new-borns, the most common causes of death are infection (26 %), low birth weight (28 %), and asphyxia (23 %) [7]. Almost all causes of maternal and neonatal mortality are preventable with good postnatal care (PNC) within the first week [10].

By emphasizing maternal and child health services, countries in sub-Saharan Africa brought the percent of pregnant women accessing antenatal care (ANC) from 66 % to 79 % between 2000 and 2009 [11]. Despite achievements in linking women to ANC services, PNC utilisation is still very low. For example, 98 % of pregnant women in Tanzania and Rwanda attend at least one ANC visit, while only 31 % and 18 % of women receive PNC within two days of delivery in those countries, respectively [12, 13].

Reported PNC figures in national household surveys assume that women who delivered at a facility were provided a post-natal check-up before discharge; however, anecdotal evidence observed by co-author JPS, a practicing clinician in Rwanda, suggests that full PNC services are not consistently or fully provided at delivery discharge. Furthermore, PNC for new-borns is often lower and not well tracked; for example, Tanzania does not track new-born PNC, and it is only 5 % in Rwanda [12, 13].

This paper focuses on Rwanda where strong governmental support for maternal and child health interventions has recently resulted in massive reductions in child and maternal mortality [14]. The Rwanda Ministry of Health has introduced interventions that could improve PNC utilisation including training of health care providers in emergency obstetric and new-born care, linking women and neonates in need of care to community health workers (CHWs) via SMS, community performance-based financing to motivate CHWs to support mothers and babies, free maternal services (ANC, PNC and family planning) and incentives to women who utilized these services [14]. A key barrier to PNC in Rwanda is the cultural practice of kwita izina which discourages both the mother and new-born from leaving the house until the new-born is named at eight days. The Rwandan Ministry of Health recently set a target to have 50 % of women and new-borns seen by a medical professional in the first seven days of life [15].

The goal of this study is to identify factors associated with utilisation of PNC to inform future PNC policies and programs in Rwanda.

PNC utilisation in Rwanda is much lower than desired, though we identified several factors that may be associated with utilisation. Engagement with the health system before delivery was not associated with PNC, but engagement with the health system at delivery was. There are mixed results linking ANC and PNC utilisation, in some studies women’s PNC utilisation was associated with previous ANC [16–18], while in other studies it was not [19, 20]. Numerous studies find that delivery at a health facility is associated with PNC utilisation [17, 18, 21, 22]. This may be because women who deliver at a health facility are encouraged to come back within a few days by their health providers, and those women are already familiar with the health facility. Women who deliver at a facility also demonstrated ability to overcome cultural, geographic, financial and other barriers related to health care access. ANC may not have the same effect because ANC services are received much earlier in time.

Our finding that older age was associated with less PNC utilisation is similar to other studies [2, 22]. One hypothesis is that the health system in Rwanda has experienced large improvements in quality in recent years [23], and therefore older women perceive the health system as low quality based on previous bad experiences. The second hypothesis is that older women have grown up with the mentality that pregnancy is not a disease and therefore does not require women to seek care at a health facility during or after pregnancy; this mind-set, which is common in other settings, suggests that only a “weak woman” would need medical care during pregnancy [24]. Young mothers who have grown up with more messaging around ANC, delivering in a facility, and PNC are therefore more likely to take advantage of community health workers and the medical system [25].

We expected financial and geographic barriers to health care to be associated with low PNC utilisation based on findings in Tanzania and Nigeria [19]; however, our findings suggest that financial and geographic barriers are not main issues in Rwanda. Financial barriers to PNC in Rwanda may be mediated by free universal PNC services offered at all health centres nationwide. Since education level and income are highly correlated, universal access to PNC in Rwanda might also mediate educational barriers to maternal health services that are seen in other similar settings where education is associated with ANC delivery or PNC [17–19]. The lack of geographic barriers to PNC may be explained by good coverage of health centres in all sectors (3rd level administrative unit), which might also explain why rural residence was not a risk factor for low PNC utilisation even though rural women in other African countries are less likely to access PNC [17, 18].

We were surprised to find that women who were not involved in their own health care decision-making were more likely to use PNC services than women involved in their health care decision-making. A pervasive theory in public health is that women who are empowered to make health care decisions will use that power to make healthier choices than their husband [26, 27]. This is reinforced by studies that show health decision-making is associated with higher attendance of health care utilisation for the women and her family [28]. However the pattern in Rwanda appears to be different. Another study of maternal health in Rwanda found that women in male-headed households more likely to attend ANC, deliver at a health facility, and seek PNC than women in female-headed households [29]. They hypothesize that male-headed households have greater ability to overcome social and economic barriers to health care than female-headed households.

Several policies and programs may address the universal problem of low PNC utilisation in Rwanda. Previously BCG vaccination was offered before discharge to women who gave birth at a facility; however, a recent change in protocol means that facilities only offer BCG vaccinations on certain days to prevent wastage in open vials. These vaccination visits which occur in the first week after birth are now being used for PNC; this protocol change was witnessed by authors (JPS and JM) at multiple health facilities in urban and rural Rwanda in early 2014. Although the impact is not yet fully measured, the proportion of babies and mothers receiving PNC might increase if facilities have the capacity to perform mass PNC consultations on these days. Linking older women and poorest women into ANC, delivery, and PNC could further improve health outcomes, and therefore information campaigns should target these populations, specially addressing concerns about health system quality, cultural perceptions, and increased risks associated with pregnancy in older women. These targeted campaigns might occur at hospital maternity homes, which are common in rural Africa for women to stay in their final weeks of pregnancy [30]. One such home near Ruli Hospital in Rwanda offers skills training such as basket weaving that can be used by women to generate income after delivery; we recommend adding PNC information and direct services to these types of programs.

There were several limitations to this study. As a cross-sectional survey, we are unable to draw causal conclusions. Furthermore, as a secondary data analysis, some important variables were not available for analysis such as cultural beliefs about when women are allowed to leave the house in the postpartum period, roles of husbands in maternal health decision-making, and perceptions about whether pregnancy is a medical issue warranting clinical visits.

Low PNC utilisation in Rwanda appears to be a universal problem; other than older age and poverty, few variables appeared to be limiting factors in our analysis. Uptake of PNC services may be widely improved by linking PNC to first BCG vaccination, and special barriers faced by older women and poorer women may be overcome by targeted programs through hospital maternity homes.

ANC, antenatal care; BCG, Bacillus Calmette–Guérin; CI, confidence interval; CHW, community health worker; OR, odds ratio; PNC, postnatal care; RDHS, Rwanda Demographic and Health Survey; SMS, short messaging service