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Background: Maternal and child mortality remain a global health concern despite different interventions that have been implemented to address this issue. Adequate antenatal care (ANC) is crucial in reducing maternal and neonatal morbidity and mortality. However, in Rwanda, there is still suboptimal utilization of ANC services. This study aims to assess the relationship between perceived barriers to accessing health care and inadequate ANC visits among women of reproductive age in Rwanda. Methods: This study is cross-sectional using secondary data from the 2014-15 Rwanda demographic and health survey (RDHS). The study included 5876 women aged 15-49 years, and the primary outcome of the investigation was inadequate ANC visits defined as delayed first ANC visit and non-completion of at least four recommended visits during the pregnancy period. The primary exposure was perceived barriers to accessing health care, operationalized using the following 4 variables: distance to the health facility, getting money for treatment, not wanting to go alone and getting permission to go for treatment. A survey-weighted multivariable logistic regression analysis and backward elimination method based on Akaike information criterion (AIC) was used to select the final model. We conducted a number of sensitivity analyses using stratified and weighting propensity score methods and investigated the relationship between the outcome and each barrier to care separately.Results: Of 5, 876 women included in the analysis, 53% (3132) aged 20 to 34 years, and 44% (2640) were in the lowest wealth index. Overall, 64% (2375) of women who perceived to have barriers to health care had inadequate ANC visits. In multivariable analysis, women who perceived to have barriers to health care had higher odds of having inadequate ANC visits (OR: 1.14; 95% CI: 0.99, 1.31). However, the association was borderline statistically significant. The findings from sensitivity analyses were consistent with the main analysis results. Conclusion: The study suggests a positive association between perceived barriers to health care access and inadequate ANC visits. The findings speak to a need for interventions that focus on improving access to health care in Rwanda to increase uptake of ANC services.

Reducing barriers to use maternal health care is one of the critical components to improving maternal health. Rwanda is among the countries that have made tremendous efforts to reduce maternal mortality. However, the current maternal mortality ratio is still high which calls for further efforts to be considered. This study used a qualitative approach to understand mothers' perceptions and experiences of using maternal health care in Rwanda. Using in-depth interviews and focus group discussions, data were collected in the Western and Eastern provinces of the country where forty-five women participated in the study from June to August 2014. This paper highlights perceptions of these participants regarding issues that contribute to suboptimal use of maternal health-care services. The geographical, financial, and social-cultural barriers that emerged in this study highlight the need to understand mothers' experiences and perceptions when using maternal health care as Rwanda and other countries strive to reduce negative maternal health outcomes.

BackgroundIn Rwanda, community health workers (CHWs) are an integral part of the health system. For maternal health, CHWs are involved in linking members of the communities in which they live to the formal health care system to address preventative, routine, and acute maternal care needs. Drawing on the findings from in-depth interviews with maternal health CHWs and observational insights in ten Rwandan districts, we identify specific strategies CHWs employ to provide equitable maternal care while operating in a low resource setting.MethodsUsing case study methodology approach, we conducted interviews with 22 maternal health CHWs to understand the nature of their roles in facilitating equitable access to maternal care in Rwanda at the community level. Interviews were conducted in five Rwandan districts. Participants shared their experiences of and perceptions on promoting equitable access to maternal health service in their communities.ResultsFour key themes emerged during the analytic process that characterize the contexts and strategic ways in which maternal health CHWs facilitate equitable access to maternal care in an environment of resource scarcity. They are: 1) community building; 2) physical landscapes, which serve as barriers or facilitators both to women’s care access and CHWs’ equitable service provision; 3) the post-crisis socio-political environment in Rwanda, which highlights resilience and the need to promote maternal health subsequent to the genocide of 1994; and, 4) the strategies used by CHWs to circumvent the constraints of a resource-poor setting and provide equitable maternal health services at the community level.ConclusionRwanda’s maternal CHWs are heavily responsible for promoting equitable access to maternal health services. Consequently, they may be required to use their own resources for their practice, which could jeopardize their own socio-economic welfare and capacity to meet the demands of their families. Considering the unpaid and untrained nature of this position, we highlight the factors that threaten the sustainability of CHWs’ role to facilitate equitable access to maternal care. These threats introduce turbulence into what is a relatively successful community-level health care initiative.