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Beyond the numbers of maternal near-miss in Rwanda - a qualitative study on women's perspectives on access and experiences of care in early and late stage of pregnancy
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- & mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Univ Rwanda, Sch Med, Dept Pediat & Child Hlth, Coll Med & Hlth Sci, POB 217 Butare, Huye, Rwanda. (Internationell barnhälsa och nutrition/Mårtensson)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Internationell kvinno- & mödrahälsovård och migration/Essén)
School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
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2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, 257Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting.

METHODS: A framework of Naturalistic Inquiry guided the study design and analysis, and the 'three delays' model facilitated data sorting. Participants included 47 women, who were interviewed at three hospitals in Kigali, and 14 of these were revisited in their homes, from March 2013 to April 2014.

RESULTS: The women confronted various care-seeking barriers depending on whether the pregnancy was wanted, the gestational age, insurance coverage, and marital status. Poor communication between the women and healthcare providers seemed to result in inadequate or inappropriate treatment, leading some to seek either traditional medicine or care repeatedly at biomedical facilities.

CONCLUSION: Improved service provision routines, information, and amendments to the insurance system are suggested to enhance prompt care-seeking. Additionally, we strongly recommend a health system that considers the needs of all pregnant women, especially those facing unintended pregnancies or complications in the early stages of pregnancy.

Place, publisher, year, edition, pages
2016. Vol. 16, 257
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:uu:diva-302494DOI: 10.1186/s12884-016-1051-4ISI: 000382459600001PubMedID: 27590589OAI: oai:DiVA.org:uu-302494DiVA: diva2:957848
Funder
Sida - Swedish International Development Cooperation Agency, SWE 2010-060
Available from: 2016-09-05 Created: 2016-09-05 Last updated: 2016-10-31Bibliographically approved
In thesis
1. The Quest for Maternal Survival in Rwanda: Paradoxes in Policy and Practice from the Perspective of Near-Miss Women, Recent Fathers and Healthcare Providers
Open this publication in new window or tab >>The Quest for Maternal Survival in Rwanda: Paradoxes in Policy and Practice from the Perspective of Near-Miss Women, Recent Fathers and Healthcare Providers
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Rwanda has made significant progress in decreasing the number of maternal deaths and increasing the number of antenatal care visits and childbirths at health facilities. This thesis seeks to illuminate potential barriers for Rwanda’s goal for maternal survival. The studies explore the bottom-up perspective of policies and practices in regards to maternal care in Kigali. Semi-structured interviews were conducted between 2013 and 2016 with women who nearly died (‘near-miss’) during pregnancy, their partners, and with other recent fathers and community members, as well as healthcare providers who work within abortion care. The framework of naturalistic inquiry guided the study design and data collection. Analysis was conducted using framework analysis, thematic analysis and naturalistic inquiry.

The findings identify paradoxical outcomes in the implementation of maternal care policies. Despite recent amendments of the abortion law, safe abortion was identified as being non-accessible. Abortion-related symptoms continue to carry a criminalized and stigmatized label, which encourages risk-taking and clandestine solutions to unwanted pregnancies, and causes care-seeking delays for women with obstetric complications in early pregnancy. Healthcare providers had limited awareness of the current abortion law, and described tensions in exercising their profession due to fear of litigation. The first antenatal care visit appeared to require the accompaniment of a male partner, which underpinned women’s reliance on men in their care-seeking. Men expressed interest in taking part in maternal care, but faced resistance for further engagement from healthcare providers. Giving birth at a health facility was identified as mandatory, yet care was experienced as suboptimal. Disrespect during counseling and care was identified, leading to repeated care-seeking and may underpin the uptake of traditional medicine.

An enhanced implementation of the current abortion law is recommended. Reconsideration of policy is recommended to ensure equitable and complete access to antenatal care: women should be able to seek care accompanied by their person of choice. These findings further recommend action for improved policy to better address men’s preferred inclusion in maternal health matters. The findings of this thesis promote continued attention to implementing changes to strengthen quality, and trust, in public maternal care.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 91 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1275
Keyword
abortion, maternal near miss, severe maternal morbidity, maternal health, male involvement, gender equity, empowerment, policy, bottom-up
National Category
Obstetrics, Gynecology and Reproductive Medicine Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-306604 (URN)978-91-554-9747-7 (ISBN)
Public defence
2016-12-17, Gustavianum, Akademigatan 3, Uppsala, 09:15 (English)
Opponent
Supervisors
Funder
Sida - Swedish International Development Cooperation Agency, SWE-2010-060
Available from: 2016-11-23 Created: 2016-10-30 Last updated: 2016-11-28

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