Associations between perceptions of care and women’s childbirth experience: a population-based cross-sectional study in Rwanda

In recent years Rwanda has achieved remarkable improvement in quality of maternity care services [1, 2]. Almost all pregnant women (99%) attend antenatal care at least once during pregnancy, although only 47% had their first antenatal care visit during the first trimester as recommended. Furthermore, health-facility-based childbirth assistance by skilled care providers has increased from 69% in 2010 to more than 90% in 2014. The majority of women with uncomplicated pregnancy give birth at a health centre, while pregnant women with complications are referred to a district hospital or a tertiary hospital according to severity of complication [3].

The quality progress might be attributed to the introduction of health insurance and Community Health Workers (CHW) who are sufficiently available and motivated. In each village in Rwanda, volunteers are elected to act as CHWs. There are two general CHWs – one male and one female (called a binome) who are responsible for community health, nutrition, and HIV/AIDS prevention – and a maternal health worker (referred to as an Animateur de Santé Maternelle), who manages infants, and pre- and postnatal maternity care. In addition, each village has a CHW in charge of social affairs who is dedicated to addressing the wellbeing of individuals and the community [4, 5].

An important aspect of maternity care involves exploring women’s views [6] but few studies have been conducted in low-income countries. An observational study in five African countries, including Rwanda, found that poor quality of maternity care was related to poor interactions between women and care providers and also to a lack of information provided to the women [7]. Another study, in Nigeria, found that women often were subjected to disrespectful and abusive treatment as part of their childbirth experiences [8].

A positive childbirth experience is important for the woman’s wellbeing, facilitates the mother-child bonding and may have implications for the future health for both the mother and baby [9–11]. On the contrary, a negative experience increases the risk for postpartum depression, secondary fear of childbirth [12] and post-traumatic stress disorder [13]. Despite progress in Rwanda in achieving universal access to reproductive health and maternity services, there is evidence of deficiencies in health care quality [14], and to our knowledge no study has focused on women’s experiences of childbirth in Rwandan health facilities. Therefore, the aim of this study was to investigate how women’s perceptions of care received during labour and birth in Rwanda were related to their overall childbirth experience.

This study is part of the Maternal Health Research Programme in Rwanda (MatHeR) undertaken by the University of Rwanda in collaboration with the University of Gothenburg and Umea University in Sweden.

The majority of women who had given birth the last 1 to 13 months (77.5%) reported a good overall childbirth experience defined as a rating of 8–10 on a numeric rating scale from 0 (Very bad) to 10 (Very good) in response to the question: What was your overall experience of childbirth? Seven statements of perceptions of care were significantly related to a good overall experience in univariate analyses and five of them remained significant as independent predictors in a multivariable logistic regression model: having confidence in staff, receiving enough information during childbirth, being treated with respect, getting support from staff, and having the baby skin-to-skin after birth. The current results corroborate earlier findings [9, 11, 17–22] and also contribute to new knowledge that all these factors independently contribute to an overall good childbirth experience.

Having confidence in the skills of the staff was contributing to a good experience. This fact corroborates earlier findings that confidence in staff is central for the experience [9, 17, 18]. Furthermore, a lack of trust in the childbirth staff may lead to fear to give birth [23] and associated negative consequences [12]. Confidence and trust in staff is facilitated with continuity of care [24]. Continuity is defined as an indicator on good quality of care [25] and therefore can confidence in staff be seen as an indirect indicator on quality of care.

Having received enough information during childbirth was also an independent predictor for a good experience. This finding corresponds to earlier research where information has been identified as an important factor during labour and birth, where lack of communication and information has been shown as a reason for dissatisfaction both in Sweden [19] and in Tanzania [20]. A large observational study in five countries in south and east Africa showed insufficient communication and information to be part of disrespectful care and the authors draw the conclusion that quality of care in maternity care in low-income countries needs to be improved [7].

The next independent predictor, being treated with respect, is interlinked with trust and confidence in staff [9]. Insufficient communication and information is also previously shown as deficiencies in respectful care [7]. Being treated with respect is needed in building a trusting relationship and fundamental in high-quality care [7], where the relationship between the woman and the midwife is central in a theoretical model of women-centred care [26]. Interviews with women with secondary fear of childbirth showed that being treated with dignity was a main theme for a positive experience [27].

Getting support from the staff during childbirth was also shown to be an independent predictor of a good experience. This current piece of evidence adds to very thorough and convincing research evidence that continuous support is associated with maternal satisfaction and furthermore with increased chance of an uncomplicated vaginal birth, less use of medical pain relief methods during labour, shorter labour and a reduced risk for the baby to be born with a low Apgar score [21].

The fifth independent predictor of a good childbirth experience in this study was for the mother to get her newborn baby skin-to-skin after birth. This is shown in a Cochrane review to be a very important caring intervention to promote successful breastfeeding with no adverse effects for the mother or baby [28]. To have the baby skin-to-skin has also shown to increase maternal satisfaction [22].

In summary, the current results add to the evidence of women’s perceptions of childbirth care and how they relate to the overall childbirth experience. The independent predictors of a good experience were interlinked and are also useful indicators for care with good quality. To further improve childbirth care in Rwanda and care for women according to their preferences, it is important to make sure that childbirth care includes the following quality aspects in national and clinical guidelines: build confidence, provide good information, treat women and families with respect, provide good professional support during childbirth and put the newborn baby skin-to-skin with its mother early after birth.