BackgroundEarly initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda.MethodsThis is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15–49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design.ResultsSeveral factors were significantly associated with delayed ANC including having many children (4–6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46).ConclusionThis analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.

Objective: Despite documented associations between stunting and cognitive development, few population-level studies have measured both indicators in individual children or assessed stunting's associations with other developmental domains. Design: Meta-analysis using publicly available data from fifteen Multiple Indicator Cluster Surveys (MICS-4) to assess the association between stunting and development, controlling for maternal education, family wealth, books in the home, developmentally supportive parenting and sex of the child, stratified by country prevalence of breast-feeding ('low BF' <90 %, 'high BF' ≥ 90 %). Ten-item Early Childhood Development Index (ECDI) scores assessed physical, learning, literacy/numeracy and socio-emotional developmental domains. Children on track in three or four domains were considered 'on-track' overall. Setting: Fifteen low-and middle-income countries. Subjects: Publically available data from 58 513 children aged 36-59 months. Results: Severe stunting (height-for-age Z-score <− 3) was negatively associated with on-track development (OR = 0·75; 95 % CI 0·67, 0·83). Any stunting (Z-score <− 2) was negatively associated with on-track development in countries with high BF prevalence (OR = 0·82; 95 % CI 0·75, 0·89). Severe and any stunting were negatively associated with physical development (OR = 0·77; 95 % CI 0·66, 0·89 and OR = 0·82; 95 % CI 0·74, 0·91, respectively) and literacy/numeracy development in high BF countries (OR = 0·45; 95 % CI 0·38, 0·53 and OR = 0·59, 95 % CI 0·51, 0·68, respectively), but not low BF countries (OR = 0·93; 95 % CI 0·70, 1·23 and OR = 0·95, 95 % CI 0·79, 1·12, respectively). Any stunting was negatively associated with learning (OR = 0·79; 95 % CI 0·72, 0·88). There was no clear association between stunting and socio-emotional development. Conclusions: Stunting is associated with many but not all developmental domains across a diversity of countries and cultures. However, associations varied by country breast-feeding prevalence and developmental domain.