BackgroundPostnatal care (PNC) in the first seven days is important for preventing morbidity and mortality in mothers and new-borns. Sub-Saharan African countries, which account for 62 % of maternal deaths globally, have made major efforts to increase PNC utilisation, but utilisation rates remains low even in countries like Rwanda where PNC services are universally available for free. This study identifies key socio-economic and demographic factors associated with PNC utilisation in Rwanda to inform improved PNC policies and programs.MethodsThis is a secondary analysis of the 2010 Demographic and Health Survey, a national multi-stage, cross-sectional survey. In bivariate analysis, we used chi-square tests to identify demographic and socio-economic factors associated with PNC utilisation at α = 0.1. Pearson’s R statistic (r > 0.5) was used to identify collinear covariates, and to choose which covariate was more strongly associated with PNC utilisation. Manual backward stepwise logistic regression was performed on the remaining covariates to identify key factors associated with PNC utilisation at α = 0.05. All analyses were performed in Stata 13 adjusting for sampling weights, clustering, and stratification.ResultsOf the 2,748 women with a live birth in the last two years who answered question about PNC utilisation, 353 (12.8 %) returned for PNC services within seven days after birth. Three factors were positively associated with PNC use: delivering at a health facility (OR: 2.97; 95 % CI: 2.28–3.87), being married but not involved with one’s own health care decision-making (OR: 1.69; 95 % CI: 1.17, 2.44) compared to being married and involved; and being in the second (OR: 1.46; 95 % CI: 1.01–2.09) or richest wealth quintile (OR: 2.04; 95 % CI: 1.27–3.29) compared to the poorest. Mother’s older age at delivery was negatively associated with PNC use (20–29 – OR: 0.51, 95 % CI: 0.29–0.87; 30–39 – OR: 0.47, 95 % CI: 0.27–0.83; 40–49 – OR: 0.32, 95 % CI: 0.16–0.64).ConclusionsLow PNC utilisation in Rwanda appears to be a universal problem though older age and poverty are further barriers to PNC utilisation. A recent change in the provision of BCG vaccination to new-borns might promote widespread PNC utilisation. We further recommend targeted campaigns to older mothers and poorest mothers, focusing on perceptions of health system quality, cultural beliefs, and pregnancy risks.

SummaryBackgroundCommunity health clubs are multi-session village-level gatherings led by trained facilitators and designed to promote healthy behaviours mainly related to water, sanitation, and hygiene. They have been implemented in several African and Asian countries but have never been evaluated rigorously. We aimed to evaluate the effect of two versions of the community health club model on child health and nutrition outcomes.MethodsWe did a cluster-randomised trial in Rusizi district, western Rwanda. We defined villages as clusters. We assessed villages for eligibility then randomly selected 150 for the study using a simple random sampling routine in Stata. We stratified villages by wealth index and by the proportion of children younger than 2 years with caregiver-reported diarrhoea within the past 7 days. We randomly allocated these villages to three study groups: no intervention (control; n=50), eight community health club sessions (Lite intervention; n=50), or 20 community health club sessions (Classic intervention; n=50). Households in these villages were enrolled in 2013 for a baseline survey, then re-enrolled in 2015 for an endline survey. The primary outcome was caregiver-reported diarrhoea within the previous 7 days in children younger than 5 years. Analysis was by intention to treat and per protocol. This trial is registered with ClinicalTrials.gov, number NCT01836731.FindingsAt the baseline survey undertaken between May, 2013, and August, 2013, 8734 households with children younger than 5 years of age were enrolled. At the endline survey undertaken between Sept 21, 2015, and Dec 22, 2015, 7934 (91%) of the households were re-enrolled. Among children younger than 5 years, the prevalence of caregiver-reported diarrhoea in the previous 7 days was 514 (14%) of 3616 assigned the control, 453 (14%) of 3196 allocated the Lite intervention (prevalence ratio compared with control 0·97, 95% CI 0·81–1·16; p=0·74), and 495 (14%) of 3464 assigned the Classic intervention (prevalence ratio compared with control 0·99, 0·85–1·15; p=0·87).InterpretationCommunity health clubs, in this setting in western Rwanda, had no effect on caregiver-reported diarrhoea among children younger than 5 years. Our results question the value of implementing this intervention at scale for the aim of achieving health gains.FundingBill & Melinda Gates Foundation.

Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177 . Electronic supplementary material The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.

ObjectiveCommunity health clubs (CHCs)—multi‐session village‐level gatherings led by trained facilitators, designed to promote healthful behaviors—have been implemented in several African and Asian countries but have never been rigorously evaluated. We aimed to evaluate the impact of CHCs on child health and nutrition outcomes.MethodsWe conducted a cluster‐randomized controlled trial to evaluate the health impact of two versions of the CHC model in Rusizi district, western Rwanda. We enrolled 8734 households with children under five years of age in a baseline survey in 2013. A total of 150 villages were randomized to three groups: no intervention (control, n=50), eight sessions (Lite, n=50), or 20 sessions (Classic, n=50). We re‐enrolled 7934 (91%) of the households in an endline survey in 2015. The primary outcomes were caregiver‐reported diarrhea in children <5 years within the previous seven days and nutritional status of children <2 years, measured through length‐for‐age (LAZ) and weight‐for‐length (WLZ) z‐scores. We measured intermediate outcomes related to water, sanitation, hygiene, infant and young child feeding, and food security. To analyze impact on dichotomous variables at the individual level, we used log‐binomial regression with a log link function and generalized estimating equations (GEE) to account for community level clustering, then exponentiated the coefficients to obtain prevalence ratios (PRs). For dichotomous outcomes at the household level, we used binomial regression with an identity link function and GEE, to obtain risk differences (RDs). For continuous variables, we used linear regression with GEE. All analyses accounted for clustering at the village level. Analysis was by intention to treat and per‐protocol.ResultsWe observed no impact on caregiver‐reported diarrhea in the Lite (PR=0.97, 95% CI: 0.81–1.16) or the Classic group (PR=0.99, CI: 0·85–1·15). We observed no impact on LAZ in the Lite (β=−0·04, 95% CI: −0·18–0·11) or the Classic (β=−0·08, 95% CI: −0·23–0·08) group, nor on WLZ in the Lite (β=−0·01, 95% CI: −0·12–0·10) or the Classic (β=−0·07, 95% CI: −0·18–0·05) group. The Classic intervention had a positive impact on reported household water treatment (RD=0·086, 95% CI: 0·029–0·14), use of improved sanitation facilities (RD=0·085, 95% CI: 0·015–0·16), and presence of structurally complete sanitation facility (RD=0·065, 95% CI: 0·0013–0·13). There was no impact on the remaining intermediate outcomes, including improved microbiological water quality; drinking water source; presence of a hand washing station with soap; exclusive breastfeeding for children <6 months; dietary diversity for children 6–23 months; or household food security. In the Lite intervention, there was no impact on any intermediate outcomes. Per‐protocol analysis of households in the Classic arm who reported attending all 20 sessions suggested positive impacts on reported household water treatment (RD=0·20, 95% CI: 0·12–0·28), use of improved sanitation facility (RD=0·14, 95% CI: 0·053–0·22), and presence of structurally complete sanitation facility (RD=0·075, 95% CI: 0·0014–0·15). No other differences were noted.ConclusionsThe CHC approach, as implemented in this setting in western Rwanda, had no impact on any main outcomes, but it had a positive impact on household water treatment and type and structure of sanitation facility. Our results raise questions about the value of implementing this intervention at scale.Support or Funding InformationBill & Melinda Gates Foundation