Knowledge of Pregnancy Complications and Utilization of Antenatal Care Services in Rwanda.

8
Kpienbaareh, D., Kofinti, R. E., Konkor, I., Amoak, D.,

Kansanga, M. M., & Luginaah, I. (2022). Knowledge of
pregnancy complications and utilization of antenatal
care services in Rwanda. The International Journal of
Health Planning and Management.
https://onlinelibrary.wiley.com/doi/abs/10.1002/hp
m.3434
(Scopus/Q1/ Social Sciences Citation Index)

10991751, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/hpm.3434 by INASP - GHANA, Wiley Online Library on [23/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 12 September 2021 Revised: 30 December 2021 Accepted: 24 January 2022
DOI: 10.1002/hpm.3434
RESEARCH ARTICLE
Knowledge of pregnancy complications and

utilization of antenatal care services in Rwanda
Daniel Kpienbaareh1 | Raymond Elikplim Kofinti2 |

Irenius Konkor3 | Daniel Amoak1 |
Moses Mosonsieyiri Kansanga | Isaac Luginaah1
4
1
Department of Geography and Environment,
University of Western Ontario, London, Abstract
Ontario, Canada
Background: While Rwanda's progress towards achieving
2
School of Economics, University of Cape
the maternal health care targets of the Sustainable Devel-
Coast, Cape Coast, Ghana
3
Department of Geography, Geomatics
opment Goals is impressive, evidence of women’s limited
and Environment, University of Toronto utilization of antenatal care (ANC) services in the context
Mississauga, Mississauga, Ontario, Canada
of an improved health care system provides an opportunity
Department of Geography, George
4
Washington University, Washington, DC, USA for exploring other essential but less highlighted factors that
may shape ANC service utilization. In this study, we exam-
Correspondence
ined the association between women’s knowledge of preg-
Daniel Amoak, Department of Geography and
Environment, University of Western Ontario, nancy complications and the utilization of maternal health
London N6A 5C2, Canada.
services.
Email: damoak@uwo.ca
Methods: We employed logistic regression analysis using
the 2015 Rwanda Demographic and Health Survey data.
Our analytical sample consisted of women (n = 5883) in their
reproductive ages (15–49 years). Three maternal health care
indicators, namely, timing of first ANC visit, number of ANC
visits, and place of delivery, were explored. We controlled
for the effects of socioeconomic and demographic charac-
teristics, including marital status, place of residence and age.
Results: The results show that women with no knowledge
of pregnancy complications were less likely to utilize ANC
services within the first trimester (odds ratio [OR] = 0.76,
p < 0.01), achieve the WHO recommended minimum of
eight visits (OR = 0.66, p < 0.01), and deliver at a health fa-
cility (OR = 0.77, p < 0.10).
1680 Int J Health Plann Mgmt. 2022;37:1680–1693. wileyonlinelibrary.com/journal/hpm © 2022 John Wiley & Sons Ltd.
KPIENBAAREH et al. 1681
Conclusion: Given these findings, we recommend restruc-

turing existing maternal health care programs to include rig-
orous maternal health education.
KEYWORDS
knowledge on pregnancy complication, maternal health care utili-
zation, Rwanda, sub-Saharan Africa
Highlights
• Meeting the number of and timing of antenatal care (ANC) visits
continue to be major issues for many women in Rwanda despite
significant improvements in infrastructure, human resources, and
health insurance over the years
•
Lack of knowledge on pregnancy complications hinder the
attainment of optimum maternal health care utilization
•
When women lack adequate knowledge of pregnancy
complications, they are less likely make an ANC visit in their
first trimester or meet the World Health Organization (WHO)
recommendation for how many visits they should make.
• The dissemination of health information in local languages to
effectively communicate with non-English speakers should be
prioritized as a new approach to health communication.
1 | BACKGROUND
Despite global improvements in maternal health care indicators, Sub-Saharan Africa (SSA) continues to grapple with
reducing child and maternal mortality due mainly to the inability to provide adequate care for its increasing popu-
lation. According to the World Health Organization (WHO), about 303,000 women and adolescent girls, and 2.6
million babies died from pregnancy and childbirth-related complications in 2015 worldwide, the majority of which
were recorded in developing countries.1 Meanwhile, the majority of these deaths are preventable if women and
adolescent girls have access to quality antenatal care (ANC) services, including sufficient knowledge of pregnancy
complications.1
As empirical evidence suggests that the focussed antenatal care (FANC) model of the WHO is associated with
higher perinatal mortality rates than ANC models involving eight or more contact between pregnant women and
skilled health care providers,2,3 in 2016, the WHO approved a new ANC model that increased contacts during preg-
nancy from 4 to 8. This new directive has been put forth amidst concerns that the challenges that militated against
the achievement of the previous four times ANC visit benchmark has been ill-understood. Without fully recognizing
and addressing the impediments to achieving the prior standard of four visits, the current benchmark is bound to
face similar setbacks. The existing complexity with achieving four ANC visits is compounded by the fact that in rural
areas, a significant proportion of deliveries take place at home without the presence of a skilled birth attendant, even
when health care facilities are accessible. At the same time, those who initiate ANC visits either do not complete the
required number of visits or are unable to keep to the right timing between ANC visits.4–6 Therefore, for the new
WHO recommendation to accomplish the objective of reducing maternal mortality, a better understanding needs to
be developed of the factors influencing women's willingness to attend ANC sessions.
1682 KPIENBAAREH et al.
Relative to other countries in SSA, Rwanda is one of the few that has made significant progress towards reducing
maternal mortality following their adherence to the MDGs and SDGs. Evidence from the 2015 Rwandan Demograph-
ic and Health Survey indicates a maternal mortality rate of 210 per 100,000 live births, a significant improvement
from the 2003 figure of 870 deaths, largely attributed to the Community Health Worker Programme that implement-
ed in the country.7,8 While Rwanda is arguably one of the few fast progressing countries in terms of improvement
in health care in SSA,8 there are still challenges militating against achieving universal maternal health care coverage,
especially in rural areas as observed in spatial and temporal variations in the access and unitarization of ANC.9–11 For
instance, although the Community Health Workers Programme implemented to extend health services to remote
and underserved areas significantly improved maternal health care delivery and other ancillary health practices such
as exclusive breastfeeding and family planning, there is still a lag in the number of pregnant mothers utilising ANC
services.12,13 Paradoxically, many women still do not meet the timing and requirement for ANC visits despite the
significant improvements in infrastructure, human resources, and health insurance over the years. Accordingly, there
is the need to explore other underlying demand-side factors that may be shaping women's willingness, decision, and
ability to access ANC services.
Notwithstanding the need for a broader approach to understanding women's uptake of ANC services, research
has largely focussed on understanding the contributory role of broader socioeconomic factors such as income, em-
ployment, place of residence, and domestic violence.11–15 Studies have shown that ANC visitations arising from im-
provements in health infrastructure improve women's knowledge of pregnancy complications.16–18 However, what
remains underexplored is whether receiving information on pregnancy complications plays any role in women's deci-
sion to access and utilise maternal health care services, including ANC. Additionally, many women remain uninformed
on pregnancy complications even after multiple ANC sessions in many SSA communities19 and rely on longstanding
channels outside of skilled birth attendants to gain knowledge on pregnancy complications, including interpersonal
relationships, media, and personal experience.20,21 This is despite the evidence that knowledge about health risks
induces health-seeking behaviours.15,22–24
Drawing insights from the literature on antenatal health care utilization and using data from the Rwandan 2015
DHS, we examine the effect of women's knowledge of pregnancy complications on three maternal health indicators:
uptake of ANC, timing of ANC visits and use of skilled birth attendants during childbirth. A compelling and unique
context such as Rwanda offers an excellent opportunity to test other crucial but less highlighted underlying factors
such as women's awareness of pregnancy complications on their uptake of ANC services. Second, the noteworthy
progress made in reducing maternal mortality compared to other SSA countries has led to many African governments
emulating Rwanda's approach to maternal health care. Hence, knowing what factors prevent Rwanda from meeting
the SDG3 maternal mortality goal of fewer than 70 deaths per 100,000 live births will provide important insights for
health care managers in Rwanda and other countries in SSA to formulate a more comprehensive and effective policy
on maternal health care. This paper proceeds on the theoretical realization that health-seeking behaviours are shaped
by a complex set of factors operating at both the individual and broader societal levels. By extending the analysis
on the uptake of ANC to include the role of pregnant women's knowledge on pregnancy complications, we aim to
generate relevant policy pointers for improving maternal health care provision and utilization in SSA.
2 | MATERIALS AND METHODS
2.1 | Data and sample
This study employed the 2015 Rwanda Demography and Health Survey (RDHS), implemented through collaborative
efforts from the Rwanda National Institute of Statistics, Ministry of Finance and Economic Planning, and the Ministry of
Health, with technical support from ICF International, Maryland, USA. The RDHS is a nationally representative survey
of women aged 15–49 and men aged 15–59 in Rwanda, with reliable demographic and health indicators, including
information on pregnancy complications and maternal health care utilization. The RDHS employed a multistage sam-
pling strategy in which a stratified probability proportional to size sampling methodology was applied. Face-to-face
interviews were conducted with 13,497 women and 6217 men. For this analysis, we restricted the sample to women
(n = 5883) in their reproductive ages (15–49 years) who answered questions on knowledge of pregnancy complications.
2.2 | Study context
Rwanda has generally made significant socioeconomic progress since the shattering genocide in 1994. The World
Bank estimated its population at 11.92 million in 2016, an increase from 5.93 million in 1995. Its population growth
rate has plummeted massively from 7.92% in 1998 to 2.45% in 2016.25 The country's Gini index deteriorated from
0.289 in 1984 to 0.504 in 2013. Despite an overall reduction in the poverty rate from 24.4% in 2005 to 14.8% in
2010,25 socioeconomic inequality persists, especially between rural and urban residents. These rural-urban, as well
as rich-poor disparities, influence health outcomes, including maternal mortality.26,27
In consonance with the MDGs, significant progress has been made in the health sector. The number of women
receiving ANC has remained high, increasing from 92% in 2000 to 99% in 2015.28,29 In addition, the rate of neonatal
death declined from 46 per 1000 live births in 1994 to 20 per 1000 live births in 2015. This reduction occurred as
physician to patient ratio improved from 0.06 in 2011 to 0.09 per 1000 in 2015, while the ratio of nurses and mid-
wives per 1000 of the population within the same period also improved from 0.77 to 0.88, and from 0.01 to 0.25, re-
spectively.29 However, these modest accomplishments in maternal health are below the WHO-recommended targets
and reflect noticeable locational and wealth disparities.10 The Rwandan Vision 2020 agenda, which was launched in
2000 sought to reduce annual maternal mortality ratio (MMR) from 1071 per 100,000 live births reported in 2000 to
200 per 100,000 live births by 2020.30 By 2015, the MMR had reduced to 210 live births per 100,000, a reduction of
80.4%, considerably better than the 46% average for SSA.31 Going forward, the Rwandan Ministry of Health (RMoH)
is placing emphasis on improving the uptake of antenatal and assisted deliveries.32 One strategy for achieving this is
to further increase access to maternal health services by strengthening the implementation of a community-based
health insurance scheme, which so far has largely reduced out-of-pocket expenditure on healthcare access.
To consolidate these modest gains and achieve even greater feats under the SDGs, it is crucial to identify the
underlying constraints that continue to hinder the attainment of optimum maternal health care utilization, hence the
need for this study.
2.3 | Study variables
2.3.1 | Dependent variables
Three dependent variables were explored to reflect the multifaceted nature of maternal health utilization. These
dependent variables were informed by the 2002 WHO guideline, which was in effect at the time the RDHS was con-
ducted. The first dependent variable is timing of maternal health care utilization measured as a continuous variable
in months. We recoded this variable into a binary variable (1, 0), with ‘1’ denoting the case where a pregnant woman
visited an antenatal care service provider within the first trimester of pregnancy and ‘0’ denoting timing beyond the
first trimester. The second dependent variable was the number of antenatal care visits. Although this variable could
largely be an outcome of medical need, vulnerability, and genetic composition of the woman in question, the 2002
WHO standard maintains that at least a minimum of four ANC visits are necessary from the onset of pregnancy to
delivery. It is noteworthy that the current guideline recommends at least eight visitations. Consistent with the 2002
standard, this study recodes number of visits into recommended four or more visits which assumes the value of ‘1’
and below four visits taken on the value of ‘0’. The final dependent variable of the study was the place of delivery. The
WHO recommends delivery at a health facility as against home delivery, given that deliveries in skilled health facilities
are more likely to mitigate complication challenges. Informed by this recommendation, the place of delivery variable
was recoded into a binary dependent variable with health facility delivery coded as ‘1’, and home deliveries, ‘0’.
2.3.2 | Independent variables
The key independent variable is women's knowledge of pregnancy complications. The question asked in the DHS data-
set was ‘are you aware of the pregnancy dangers, including vaginal bleeding, tiredness, breathlessness, prolonged labour,
fever, convulsion, swollen limbs?’. In the context of the study and as assessed by the questionnaire, the term ‘knowledge
of pregnancy complications’ refers to the awareness of one or more of the above conditions. This variable is a dummy
variable with ‘1’ representing women who are not knowledgeable about pregnancy complications, and ‘0’ for those
informed about pregnancy complications. Consistent with multivariate regression tenets, we coded ‘yes’ as the refer-
ence category because it had the most observations as seen in Table 1. We also wanted to understand how women's
knowledge of pregnancy complications affects pregnant women's health seeking behaviour or decision making. In order
to ensure unbiased coefficients, we controlled for a broad range of relevant variables to account for the effect of poten-
tial confounding factors, grouped into predisposing (socio-cultural characteristics of individuals that exist prior to their
illness, e.g., age, social structure, demographic characteristics, and health beliefs), enabling (logistical aspects of obtaining
care, e.g., employment status, income, health insurance, and the availability of health care facilities), and need factors
(most immediate cause of health service use, from functional and health problems that generate the need for health
care services, e.g., perceived and evaluated need for health care utilization).22 We included the following explanatory
variables: women's level of education (none = 0; primary = 1; and secondary or higher education = 2), employment status
(unemployed = 0; and employed = 1), marital status (never in a union = 0, currently in a union and living with a man = 1;
formerly in a union and living with a man = 2), age of the woman (15–24 = 1; 25–34 = 2; 35–44 = 3; 45 and above = 4),
religious affiliation of the woman (non-Christian = 0; and Christians = 1). We also controlled for wealth (poorest = 1;
poorer = 2; middle = 3; richer = 4; and richest = 5), province of stay (Kigali city = 1; South = 2; West = 3; North = 4 and
East = 5), place of residence (urban = 0; and rural = 1), parity (1–3 children = 0; and 4 or more children = 1). We also
controlled for women's pregnancy intention, with intended pregnancy coded as 0 and unintended pregnancy = 1.
2.3.3 | Data analysis
Given the dichotomous nature of the dependent variable,33 we employed a series of logistic regression analyses to
understand the associations between knowledge on pregnancy complications and the three maternal health out-
comes: timing of first ANC visits, number of ANC visits and place of delivery. We first estimated the bivariate asso-
ciation between knowledge of pregnancy complications and the three maternal health outcomes (see Table 2). We
further conducted multivariate analysis, adjusting for socioeconomic factors and demographic factors (see Table 3).
We reported results in odds ratios (ORs). ORs greater than one indicates that respondents were more likely to access
maternal care within the first trimester, complete the required number of ANC visits and deliver at a skilled health
facility, while those less than one implies lower odds of doing so.
3 | RESULTS
Table 1 shows characteristics of the study sample. Findings indicate that more than two-thirds of pregnant women
(79%) had adequate knowledge on pregnancy complications. In terms of maternal health outcomes, 57% of women
accessed ANC services during their first trimester, 56% completed the required number of visits and 92% delivered
TA B L E 1 Distribution of selected dependent and independent variables of the sample
Variables Frequency (%)

Timing of antenatal care visits
First trimester 3332 (56.64)
Beyond first trimester 2551 (43.36)
Number of antenatal care visits
Less than four visits 3271 (55.60)
Four or more visits 2612 (44.40)
Place of delivery
Delivered at home 500 (8.50)
Delivered at a health facility 5383 (91.50)
Knowledge on pregnancy complications
Yes 4658 (79.18)
No 1225 (20.82)
Province of stay
Kigali city 701 (11.92)
South 1468 (24.95)
West 1384 (23.53)
North 858 (14.58)
East 1472 (25.02)
Area of residence
Rural 4586 (77.95)
Urban 1297 (22.05)
Pregnancy intention
Intended 3556 (60.45)
Unintended 1569 (39.55)
Mother's level of education
No education 825 (14.02)
Primary education 4191 (71.24)
Secondary and higher 867 (14.74)
Mother's employment status
Employed 5055 (85.93)
Not employed 828 (14.07)
Marital status
Never in a union 614 (10.44)
Currently in a union and living with a man 4694 (79.79)
Formerly in a union and living with a man 575 (9.77)
Age categories of mothers
15–24 1243 (21.13)
25–34 3139 (53.36)
35–44 1364 (23.19)
45 and above 137 (2.33)
(Continues)
TA B L E 1 (Continued)
Variables Frequency (%)
Religion
Christian 5715 (97.14)
Non-Christians 168 (2.86)
Wealth index
Poorest 1380 (23.46)
Poorer 1226 (20.84)
Middle 1106 (18.80)
Richer 1031 (17.53)
Richest 1140 (19.38)
Parity
1–6 5380 (9.45)
7 or more 503 (8.55)
Total observation 5883
in a health facility. In addition, there were other noteworthy socioeconomic and demographic differences among
women sampled worth highlighting. For instance, majority of women resided in urban areas (77%), were employed
(85%), were Christians (97%) and currently in a union and living with a man (80%). Also, about half the sample (53%)
were between the ages of 25–34. Most women (85%) had primary education or higher whiles close to half (43%)
were poor. In terms of parity, about two-thirds (66%) of the sample had between 1 and 3 children.
Bivariate findings are shown in Table 2. Generally, lack of knowledge on pregnancy complications was associated
with lower odds for attaining all three maternal health outcomes. Compared with women with adequate knowledge
on pregnancy complications, women with no knowledge of pregnancy complications had lower odds of making the
first ANC visit within the first trimester of pregnancy (OR = 0.74, p < 0.01), completing the required number of ANC
visits (OR = 0.65, p < 0.01) and delivering at a health facility (OR = 0.71, p < 0.05).
At the multivariate level, our findings indicate that the significant association between knowledge on pregnancy
complication and all three maternal health care outcomes remained statistically significant even after controlling for
the effect of predisposing, need and enabling factors (see Table 3). Compared to their counterparts with knowledge
on pregnancy complications, women who lack knowledge about pregnancy complications were less likely to utilise
maternal health care services within the first trimester of their pregnancy (OR = 0.76, p < 0.05), attain the minimum
number of antenatal care visits (OR = 0.66, p < 0.05), and deliver in a health facility (OR = 0.77, p < 0.01).
Apart from knowledge on pregnancy complications, a range of predisposing, enabling, and need factors were
significantly associated with timing of ANC attendance, frequency of ANC attendance and place of delivery. Women
with unplanned/unintended pregnancies were less likely to utilise maternal health care services within the first tri-
mester of their pregnancy (OR = 0.76, p < 0.05), achieve the recommended number of antenatal care visits (OR = 0.69,
p < 0.01) and deliver in a health facility (OR = 0.76, p < 0.05) compared to those whose pregnancies were intended/
planned. Similarly, compared to women 1-6 children, women with 7 or more children were less likely to attend ANC
during their first trimester (OR = 0.67, p < 0.01), complete the required number of visits (OR = 0.77, p < 0.10) and
deliver in a health facility (OR = 0.61, p < 0.05). Also, women with lower education, had lower odds of attending ANC
during the first trimester of pregnancy (OR = 0.49, p < 0.01), attain the required number of ANC visits (OR = 0.57,
p < 0.01) or deliver at a health facility (OR = 0.37, p < 0.01). The results also show that the province of stay is a signif-
icant predictor of ANC service utilization. Apart from women living in the Eastern province of Rwanda, participants
T A B L E 2 Bivariate analyses of the effect of knowledge about pregnancy complications on Maternal Health
Care Utilization in Rwanda and other correlates in Rwanda
Timing ANC Place of delivery

OR (SE) OR (SE) OR (SE)
Knowledge on pregnancy complication (base = yes)
No 0.744 (0.05)*** 0.655 (0.04)*** 0.717 (0.08)**
Province (base = Kigali)
South 1.493 (0.11)*** 1.131 (0.08) 0.613 (0.11)**
West 1.406 (0.10)*** 0.895 (0.06) 0.705 (0.13)
North 1.325 (0.10)*** 1.145 (0.09) 0.781 (0.16)
East 1.659 (0.12)*** 0.663 (0.04)*** 0.576 (0.10)**
Residence (base = Urban)
Rural 1.199 (0.06)*** 0.776 (0.04)*** 0.354 (0.05)***
Pregnancy intention (base = intended)
Unintended 0.551 (0.03)*** 0.641 (0.03)*** 0.666 (0.06)***
Mothers education (base = at least secondary)
No education 1.601 (0.12)*** 0.298 (0.02)*** 0.129 (0.03)***
Primary 1.827 (0.09)*** 0.380 (0.02)*** 0.292 (0.06)***
Employment status (base = yes)
No 0.459 (0.03)*** 1.951 (0.11)*** 1.329 (0.19)*
Marital status (base = married)
Never in union 0.090 (0.01)*** 6.958 (0.40)*** 1.440 (0.25)*
Formerly in union/living with a man 0.423 (0.03)*** 1.781 (0.12)*** 0.575 (0.07)***
Age (base = 45 years and beyond)
15–24 2.362 (0.32)*** 0.643 (0.08)*** 4.566 (1.18)***
25–34 10.299 (1.39)* **
,
0.152 (0.02)*** 2.523 (0.58)***
35–44 4.493 (0.62)*** 0.249 (0.03)*** 1.427 (0.33)
Religion (base = Christian)
Non-Christian 1.011 (0.12) 0.710 (0.08)** 0.834 (0.21)
Wealth quintile (base = richest)
Poorest 1.685 (0.10)*** 0.468 (0.03)*** 0.156 (0.03)***
Poorer 1.454 (0.09)*** 0.581 (0.04)*** 0.275 (0.06)***
Middle 1.416 (0.09)*** 0.693 (0.04)*** 0.324 (0.07)***
Richer 1.238 (0.08)*** 0.790 (0.05)*** 0.379 (0.08)***
Parity (base = 1–6)
7 or more 0.398 (0.03)*** 1.190 (0.09)* 0.347 (0.04)***
N 5883 5883 5883
Abbreviations: ANC, antenatal care; OR, odds ratios; SE, Standard errors.
*p < 0.10, **p < 0.05, ***p < 0.01, coefficients adjusted for clustering and robust standard errors presented in brackets.
T A B L E 3 Multivariate analyses of the effect of knowledge about pregnancy complications on Maternal Health
Care Utilization in Rwanda
Timing ANC Place of delivery

OR (SE) OR (SE) OR (SE)
Knowledge on pregnancy complication (base = Yes)
No 0.763 (0.05)*** 0.666 (0.05)*** 0.775 (0.09)*
Provinces (base = Kigali)
South 2.046 (0.22)*** 1.881 (0.20)*** 1.670 (0.34)*
West 1.695 (0.19)*** 1.574 (0.17)*** 2.126 (0.45)***
North 1.850 (0.22)*** 1.504 (0.18)*** 1.876 (0.42)**
East 1.642 (0.18)*** 1.057 (0.11) 1.437 (0.29)
Residence (base = urban)
Rural 0.925 (0.08) 0.942 (0.08) 0.683 (0.13)*
Pregnancy Intention (base = Intended)
Unintended 0.619 (0.04)*** 0.699 (0.04)*** 0.765 (0.08)**
Mother's education (base = at least secondary)
No education 0.498 (0.06)*** 0.576 (0.07)*** 0.378 (0.10)***
Primary 0.599 (0.05)*** 0.702 (0.06)*** 0.581 (0.14)*
Employment status (base = yes)
No 0.864 (0.07) 0.918 (0.07) 1.022 (0.16)
Marital status (base = married)
Never in union 0.638 (0.06)*** 0.635 (0.06)*** 1.185 (0.24)
Formerly in union/living with a man 0.896 (0.08) 0.891 (0.08) 0.823 (0.12)
Age category (base = 45 and over)
15–24 1.367 (0.28) 1.139 (0.24) 2.556 (0.77)**
25–34 1.242 (0.25) 1.041 (0.21) 1.530 (0.41)
35–44 0.922 (0.18) 1.030 (0.20) 1.107 (0.28)
Religion (base = Christian)
Non-Christian 0.888 (0.15) 0.747 (0.13) 0.841 (0.25)
Wealth Quintile (base = richest)
Poorest 0.847 (0.10) 0.932 (0.10) 0.225 (0.06)***
Poorer 0.798 (0.09)* 0.963 (0.11) 0.374 (0.10)***
Middle 0.927 (0.11) 1.084 (0.12) 0.469 (0.12)**
Richer 0.895 (0.10) 1.050 (0.11) 0.502 (0.13)**
Parity (base = 1–6)
7 or more 0.679 (0.08)*** 0.778 (0.09)* 0.616 (0.10)**
N 5883 5883 5883
Log pseudo likelihood −3866.913 −3918.747 −1571.963
Pseudo R2 0.039 0.030 0.081
Abbreviations: ANC, antenatal care; OR, odds ratios; SE, standard errors.
*p < 0.10, **p < 0.05, ***p < 0.01, coefficients adjusted for clustering and robust standard errors presented in bracket.
living in all the other provinces compared to Kigali were more likely to use ANC services in the first trimester of
pregnancy, attain the recommended number of ANC visits, and deliver at a health facility.
4 | DISCUSSION
This paper examined the association between knowledge of pregnancy complications and women's uptake of ANC
services; timing of first ANC visit, number of ANC visits during pregnancy, and place of delivery among Rwandan
women using data from the 2014/15 Rwandan Demographic and Health survey. While Rwanda has made significant
progress in reducing maternal mortality by three-quarters,9,34 there are significant disparities yet to be unravelled.
Indeed, under the SGDs, the focus has shifted to ensuring that disparities within groups, for example, rural/urban,
rich/poor etc., are further reduced or eliminated, for which the need to explore other individual-level factors such as
knowledge of pregnancy complications becomes crucial. Besides, the increasing number of SSA governments that
model their maternal healthcare policy in line with Rwanda's suggest that many countries would benefit from the
insights on ways to further strengthen Rwanda's maternal health care sector by further exploring current challenges
encountered in the health sector.
Overall, this study shows that women who lack adequate knowledge of pregnancy complications were less likely
to either make an ANC visit in the first trimester of their pregnancy or meet the WHO-recommend number of visits
(4+ visits). Also, women with inadequate knowledge of pregnancy complications were less likely to deliver at a health
facility with skilled health attendants, compared with their counterparts with knowledge of pregnancy complica-
tions (Tables 2 and 3). These findings are consistent with other studies that have identified the lack of knowledge
as an inhibiting factor to seeking maternal health services.35–38 Pregnant women are often prone to complications
including cardiovascular failure, obesity, vaginal bleeding, blurred vision, convulsion, high fever, and abdominal pains
that can lead to morbidity and disabilities.39,40 Mbalinda et al. report that knowledge about pregnancy compilations
can inform birth preparedness/complications readiness (BPCR) among pregnant women.41 The BPCR assumes that
knowledge of complications leads to self-motivated efforts, including appropriate timing and attending the required
number of ANC services to mitigate the effects of pregnancy and childbirth complications. As such, lack of appro-
priate knowledge of pregnancy complications is associated with a lack of preparedness, including failure to seek
and utilise ANC services and designated health facilities during delivery.11 Although a qualitative study in Rwanda
revealed that women with knowledge that their pregnancies are not complicated may likely prefer to deliver at home,
especially if they have previous birthing experience11,42 and Wagle et al. have reported that previous knowledge on
the potential risk and complications of pregnancy improves women's uptake of maternal health services.43 The choice
of place of delivery is relevant in ensuring the safety of both mother and child since home deliveries have a higher
incidence of maternal and newborn complications than deliveries in a health facility.44 Indeed, in 2008, about 72% of
all pregnancy-related deaths in Rwanda were due to postpartum haemorrhage and obstructed labour,45 highlighting
the need for health-facility-based deliveries.
Consistent with the literature,46–49 education provides incentives for the utilization of maternal health services.
Economically, women with higher educational attainment generally tend to have well-paid jobs, which may empower
them to be able to afford maternal health care services. Similarly, women with higher levels of education and in high-
er wealth households are able to afford and access media tools such as TV, radio and newspapers, often employed
to educate women on maternal health issues in Rwanda.50 In addition to the fact that educated women are more
empowered to autonomously decide on utilization of maternal health services,51 they are also more informed about
availability and need for maternal health services as well as the risk of pregnancy complications compared to those
with no or lower education.
Moreover, marital status and pregnancy intention were significant predictors of the utilization of ANC services
among women in Rwanda. Unmarried women were less likely to utilize ANC services (in terms of timing and the
required number of visits), likely due to constraining socio-cultural dynamics and limited access to resources for
maternal health services. Unintended pregnancies among unmarried women is a social taboo in Rwanda and such
women may be stigmatized and considered as social misfits.11,52 Women with unintended pregnancies, especially if
they are unmarried, may often avoid public spaces, thus compelling unmarried pregnant women to renege on utilizing
these public health services to avoid social stigma and public ridicule. Indeed, Levandowski et al. have also reported
the role of stigma associated with unwanted pregnancy in low utilization of maternal health services in Malawi.50
Culture has also been blamed for most home deliveries in rural Africa since women prefer to use traditional birth
attendants and healers to fulfill the cultural practices that underpin childbirth.51,53,54 This could also be responsible for
the higher odds of rural women in Rwanda choosing to deliver at home. Apart from constraining women from utilizing
formal health care services, these sociocultural barriers continue to delink women from maternal health information
from health facilities and professionals, and therefore, their knowledge on pregnancy complications. Moreover, giv-
en that marriage provides socioeconomic support through spouses, unmarried women may lack the emotional and
financial support necessary to patronize ANC services if they do not have health insurance.55
Despite the relevance of our findings, there are limitations to the study worth highlighting. The cross-sectional
nature of the RDHS data used in the analysis makes it difficult to infer causality hence our findings are limited to as-
sociations. Also, the RDHS is a self-reported dataset with the potential for recall and social desirability biases. In this
regard, we recommend that longitudinal and in-depth qualitative approaches be considered in future studies on the
impact of knowledge of pregnancy complications on the uptake of ANC services. Moreover, utilization of maternal
health services and choice of place of delivery are influenced by a complex web of factors, including health insurance
coverage and quality of maternal health care, which are not part of the current study because of data limitations.
In fact, studies by Ngabonzima et al.56 emphasized that even knowledge of these complications by health care pro-
fessional contribute significantly toward reducing newborn deaths in Rwanda, further highlighting the relevance of
understanding women's comprehension of pregnancy complications. That notwithstanding, the findings are generally
intuitive and consistent with the literature and provide relevant policy pointers for improving maternal health policy
in Rwanda and the Global South in general.
5 | CONCLUSION
Rwanda has made tremendous strides at reducing child and maternal mortality, as expressed in the remarkable im-
provement in health infrastructure and implementation of a functional community-based health insurance scheme,
alongside robust economic development strategies within the Rwanda Vision 2020 framework and beyond. While
these initiatives have significantly addressed structural barriers, the need to pay attention to behavioural factors that
induce the utilization of health infrastructure is crucial. Indeed, the findings from this study demonstrate that wom-
en's lack of knowledge on pregnancy complications could be a major contributory factor against the attainment of
universal maternal health care coverage in Rwanda. As Rwanda and the developing world, in general, make efforts to
achieve the SDGs, a more proactive approach to educating both pregnant women and prospective mothers on preg-
nancy complications is crucial. In the Rwandan context, programs such as Maternal and Child Health (MCH), Training
Support and Access Model (TSAM), the Mentoring and Enhanced Supervision at Health Centres (MESH), which aim
to enhance maternal health, could be mainstreamed into health policies to build the capacity of women and increase
coverage to all rural areas through mentorship programs.56
A crucial challenge militating against effective sensitization of people on health issues in SSA is language limita-
tion. While health information is mostly presented in English, most of the population is not literate. As recommended
by Kansanga et al.48 a new approach to health communication should be prioritized whereby health information
is presented in the diverse local languages to effectively communicate to non-English speakers. The mass media,
especially the radio, will be an effective tool in this approach to health education. Health education must also be
integrated into the public awareness initiatives of other institutions such as schools and development organisations
to tackle harmful sociocultural beliefs that militate against the uptake of maternal health services. The call for a
broadening of the approach to health policymaking and implementation is particularly crucial given that in most parts
of SSA, emphasis on maternal health has mostly tilted towards the provision of health infrastructure to the neglect
of health education.
ACKNOWLE DG E ME NTS
The authors wish to acknowledge the insightful comments of Professor Tiago Correia, the Editor-in-Chief, and the
two anonymous reviewers. The authors did not receive any funding for this study.
ET HICS STATE ME NT
Not applicable.
DATA AVAI LABI LI TY STATE M E N T

The dataset used in this study is available at the Demographic and Health Survey Repository: http://dhsprogram.com/
data/available-datasets.cfm.
O RC ID
Daniel Amoak https://orcid.org/0000-0002-3879-7233
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How to cite this article: Kpienbaareh D, Kofinti RE, Konkor I, Amoak D, Kansanga MM, Luginaah I.
Knowledge of pregnancy complications and utilization of antenatal care services in Rwanda. Int J Health
Plann Mgmt. 2022;37(3):1680-1693. https://doi.org/10.1002/hpm.3434

Knowledge of Pregnancy Complications and Utilization of Antenatal Care Services in Rwanda.

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Kpienbaareh, D., Kofinti, R. E., Konkor, I., Amoak, D.,

(Scopus/Q1/ Social Sciences Citation Index)

Knowledge of pregnancy complications and

Daniel Kpienbaareh1 | Raymond Elikplim Kofinti2 |

Conclusion: Given these findings, we recommend restruc-

2 | MATERIALS AND METHODS

2.1 | Data and sample

2.2 | Study context

2.3 | Study variables

2.3.1 | Dependent variables

2.3.2 | Independent variables

2.3.3 | Data analysis

TA B L E 1 Distribution of selected dependent and independent variables of the sample

Variables Frequency (%)

Variables Frequency (%)

Timing ANC Place of delivery

Timing ANC Place of delivery

DATA AVAI LABI LI TY STATE M E N T

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