Facilitating equitable community-level access to maternal health services: exploring the experiences of Rwanda’s community health workers

Abstract

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.

“I cannot say no when a pregnant woman needs my support to get to the health centre”: involvement of community health workers in Rwanda’s maternal health

“…For example, M-CHW's often report that they use their own limited resources to pay for pregnant women's transportation. Because these unpaid volunteers receive no salary or reimbursement for expenses, these costs are an economic burden for them and their families Different studies conducted in LIMCs have highlighted the role of CHWs in improving maternal health [6,22,24] . Surprisingly, even though different countries have incorporated CHWs in their maternal health systems, in most of these countries it is still unclear what exactly CHWs roles are and where their responsibilities start and end [13].…”

“…Similarly to any health worker involved in maternal health service delivery, M-CHWs act with urgency in most situations to save both the mother and the baby. Hence the burden to fulfill this role could be high on M-CHWs, mainly when operating in limited resources settings [6,28]. There is a need of programs targeting the promotion of capacity building and community based empowerment of M-CHWs that would impact the access and provision of maternal health services and overall outcome of maternal health in Rwanda.…”

“…In Rwanda, maternal community health workers (M-CHWs) are volunteers selected from their villages to link communities to the formal health system. They operate as part of Rwanda's CHW program, an integral part of the country's health system [6]. M-CHWs' roles involve educating the community on timely and adequate utilization of health facilities [7] and they play a direct role within their communities where they are in close contact with women who need maternal health services [2].…”

“He lets me go although he does not go with me.”: Rwandan women’s perceptions of men’s roles in maternal health

“…Also, there are no socio-cultural expectations for men to be involved in providing care for infants and children. However, these entrenched gender roles are being reformed, which is influenced by more women becoming educated and or participating in income-generating activities [31]. These changes are informing a broader social desire to achieve gender equality in the country in both urban and rural communities, including as this relates to maternal health.…”

“…Such questions provided a general overview on access to maternal health services in the community, including understanding the appointment day and any related household and community dynamics regarding attending appointments. Results on these factors have been published elsewhere [31,33] as part of a larger study that qualitatively explored the aspects of access to community-based maternal health services in Rwanda.…”