Abstract
Rwanda is one of nine post-conflict heavily indebted poor countries (HIPC) of the world. There was a worsening of health indicators since the early nineties on account of conflict. In light of this, we examine factors affecting maternal health care seeking behavior in Rwanda using three rounds of Rwanda Demographic and Health Survey (RDHS) data (1992, 2000, and 2005). We find that progress towards increasing the share of assisted deliveries has been slow. There has been no significant increase in the proportion of women seeking antenatal care. This could partially explain why a large proportion of women continue to deliver at home without professional assistance. Further, women who gave birth in the 5 years preceding the 2000 RDHS are less likely to deliver in a health facility than those who gave birth in the 5 years preceding the 1992 RDHS. We do not find such a result for the year 2005. We also find that women are more likely to deliver at home with professional assistance in 2000 and 2005 compared to 1992.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
Source: WHO Statistical Information System, http://www.who.int/whosis/en/.
Prunier (1995) points out that over the period 1976–1990, the per capita income of Rwanda was comparable with the People’s Republic of China. He states, “If we look at the dynamics of the Rwandese economy, they compared most favorably with the other countries (Burundi, Zaire, Uganda, and Tanzania) of the region” (p. 78).
Source: http://hdr.undp.org/en/statistics/.
Henceforth we refer to this report as RDHS 2006.
It is also true that women and children suffer disproportionately from the long term effects of civil war (Ghobarah et al. 2003). They establish that there was an increase in the incidence of death and disability.
“Because every pregnancy may have complications, the emphasis is to promote use of skilled and trained delivery care providers and to ensure that all women have access to lifesaving emergency interventions at the time of labor and delivery. In many countries, deliveries occur at home, attended by traditional birth attendants (TBAs). Previously there were extensive efforts and funds expended toward upgrading the skills of TBAs, but safe motherhood program initiatives have concluded that, in almost all cases, “the level of skill among ‘skilled birth attendants’ is lower than is ‘safe’ for safe motherhood. In-service training cannot improve the skill level of trained providers to the level of competency desired in all skills” (MNH 2001b). With this conclusion has come a shift in the definition of qualified delivery providers to persons with “midwifery skills who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose and manage or refer complicated cases” (MotherCare Policy Brief #3) (Koblinsky, 2000)”. (Chapter 6 page 79 Ministry of Health [Rwanda], National Population Office [Rwanda], and ORC Macro. 2003 Rwanda Service Provision Assessment Survey 2001 Calverton, Maryland: Ministry of Health, National Population Office, and ORC Macro).
There are no households with a value of wealth index between −0.98 and −1.23. Given that 60% of the population lived below the poverty line in 2000, splitting the households into the four wealth groups, with the first two groups reflecting the population living below the poverty line makes sense.
There are different channels through which health systems and health outcomes are affected. In times of war and conflict, there is a marked reduction in expenditure on public health. Higher the risk of civil war, higher is the military expenditure as a percentage of gross domestic product (Collier et al. 2003). One of the consequences of this shift in expenditure is that it leads to a reduction in availability of health services and thereby contributes to a marked deterioration in health outcomes. In addition, an increase in violence, incidence of poverty, destruction of infrastructure, and displacement of people also contribute to worsening health outcomes.
References
Akresh, R., Verwimp, P., & Bundervoet, T. (2007). Civil war, crop failure and child stunting in Rwanda. World Bank Policy Research Working Paper No. 4208. The World Bank, Washington D.C. Cited July21, 2008.
Banerjee, A. V., & Duflo, E. (2007). The economic lives of the poor. Journal of Economic Perspectives, 21(1), 141–167.
Bloom, S., Lippeveld, T., & Wypij, D. (1999). Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning, 14, 38–48.
Caldwell, B. K., (2005). Why women continue to die from childbirth in Dhaka, Bangladesh. In S. Lerner & E. Vilquin (Eds.), Reproductive health unmet needs and poverty (Chapter 7, pp. 311–342). CICERD.
Collier, P., Elliot, V. L., Hegre, H., Hoeffler, A., Reynal-Querol, M., Sambanis, N. (2003). Breaking the Conflict Trap Civil War and Development Policy. A World Bank Policy Research Report.
Gage, A. J., & Calixte, M. G. (2006). Effects of the physical accessibility of maternal health services on their use in rural Haiti. Population Studies, 60(3), 271–288.
Garenne, M., & Gakusi, E. (2006). Health transitions in sub-Saharan Africa: Overview of mortality trends in children under 5 years old (1950–2000). Bulletin of World Health Organization, 84(6), 470–478.
Ghobarah, H. A., Huth, P., & Russett, B. (2003). Civil wars kill and maim people—long after the shooting stops. American Political Science Review, 97(2), 189–202.
Government of Rwanda. (2002). The Government of Rwanda Poverty Reduction Strategy Paper (PRSP), National Poverty Reduction Programme, Ministry of Finance and Economic Planning. Accessed October 23, 2008, from http://www.imf.org/External/NP/prsp/2002/rwa/01/063102.pdf.
Harvey, S. A., Blandón, Y. C. B, McCaw-Binns, A., Sandino, I., Urbina, L., Rodríguez, C., Gómez, I., Ayabaca, P., & Djibrinaf, S. (2007). The Nicaraguan Maternal and Neonatal Health Quality Improvement Group. (2007). Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bulletin of the World Health Organization, 85(10).
Hoeffler, A., & Reynal-Querol, M. (2003). Measuring the costs of conflict. Accessed http://heisun1.unige.ch/sas/files/portal/issueareas/victims/Victims_pdf/2003_Hoeffler_Reynal.pdf.
Human Rights Watch. (1996). Shattered lives: Sexual violence during the Rwandan Genocide and its Aftermath, Human Rights Watch Women’s Rights Project.
International Development Association and International Monetary Fund. (2007). Heavily Indebted Poor Countries (HIPC) Initiative and Multilateral Debt Relief Initiative (MDRI)—Status of Implementation. Accessed October 23, 2008, from http://siteresources.worldbank.org/INTDEBTDEPT/ProgressReports/21656521/HIPCProgressReport20070927.pdf.
Magadi, M., Diamond, I., & Madise, N. (2001). Analysis of factors associated with maternal mortality in Kenyan hospitals. Journal of Biosocial Science, 33, 375–389.
Magadi, M. A., Zulu, E., & Brockerhoff, M. (2003). The inequality of maternal health in urban sub-Saharan Africa. Population Studies, 57(3), 349–368.
Ministry of Health [Rwanda], National Population Office [Rwanda], and ORC Macro. (2003). Rwanda Service Provision Assessment Survey 2001. Calverton, Maryland: Ministry of Health, National Population Office, and ORC Macro.
Ministry of Health, Republic of Rwanda. (2006). Rwanda National Health Accounts 2003, Ministry of Health, Republic of Rwanda.
Mishra, V., & Retherford, R. D. (2008). The effect of antenatal care on professional assistance at delivery in rural India. Population Research and Policy Review, 27(3), 307–320.
Montgomery, M. R. M., Gragnolati, Burke, K. A., & Paredes, E. (2000). Measuring living standards with proxy variables. Demography, 37(2), 155–174.
Prunier, G. (1995). The Rwanda crisis. Columbia University Press: New York.
Rockers, P. C., Wilson. M. L., Mbaruku, G., Kruk, M. E. (2008). Source of antenatal care influences facility delivery in rural Tanzania: A population-based study maternal child health journal. Accessed http://www.springerlink.com/content/px28891008891602/.
Rwanda Demographic Health Survey 1992. (1994). Barrère, Bernard, Juan Schoemaker, Monique Barrère, Tite Habiyakare, Athanasie Kabagwira, and Mathias Ngendakumana. Enquête Démographique et de Santé, Rwanda 1992. Calverton, MD: Macro International.
Rwanda Demographic Health Survey 2000. (2001). Office National de la Population (ONAPO) [Rwanda] et ORC Macro. Enquête Démographique et de Santé, Rwanda 2000. Kigali, Rwanda et Calverton, Maryland, USA: Ministère de la Santé, Office National de la Population et ORC Macro.
Rwanda Demographic and Health Survey 2005. (2006). Institut National de la Statistique du Rwanda (INSR) and ORC Macro. Rwanda Demographic and Health Survey 2005. Calverton, Maryland, U.S.A.: INSR and ORC Macro.
Sarin, A. R. (1997). Underutilization of maternal health services. World Health Forum, 18, 67–68.
Shen, C., & Williamson, J. B. (1999). Maternal mortality, women’s status, and economic dependency in less developed countries: A cross national analysis. Social Science and Medicine, 49, 197–214.
Short, S., & Zhang, F. (2004). Use of maternal health services in rural China. Population Studies, 58(1), 3–19.
United Nations. (1995). Report of the International Conference on Population and Development: Cairo, 5–13 September 1994. United Nations, New York.
United Nations. (2007). World Population Prospects: The 2006 Revision and World Urbanization Prospects: The 2007 Revision, Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat,
Verwimp, P., & Bavel, J. V. (2005). Child survival and fertility of refugees in Rwanda. European Journal of Population, 21, 271–290.
Wagstaff, A., & Claeson, M. (2004). The Millennium Development Goals for Health Rising to the Challenges. The World Bank, 2004.
World Health Organization. (2007). Maternal mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and The World Bank, 2007.
Acknowledgments
Anuja Jayaraman is grateful for support provided by the United States Agency for International Development (USAID) through the MEASURE DHS project #GPO-C-00-03-00002-00. An earlier version of this paper was presented at the Fifth African Population Conference organized by Government of the United Republic of Tanzania and the Union of Africa Population Studies in December 2007 and the Second Annual Workshop on The Unit of Analysis and the Micro-Level Dynamics of Violent Conflict organized by Households in Conflict Network in January 2007. We are grateful to Vinod Mishra and two anonymous referees of this journal for their comments. The views expressed are those of the authors. The usual disclaimer applies.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chandrasekhar, S., Gebreselassie, T. & Jayaraman, A. Maternal Health Care Seeking Behavior in a Post-Conflict HIPC: The Case of Rwanda. Popul Res Policy Rev 30, 25–41 (2011). https://doi.org/10.1007/s11113-010-9175-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11113-010-9175-0