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.
