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The Quest for Maternal Survival in Rwanda: Paradoxes in Policy and Practice from the Perspective of Near-Miss Women, Recent Fathers and Healthcare Providers
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (International Maternal and Reproductive Health and Migration)
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 [en]
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: urn:nbn:se:uu:diva-306604ISBN: 978-91-554-9747-7OAI: oai:DiVA.org:uu-306604DiVA: diva2:1042525
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
List of papers
1. 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
Open this publication in new window or tab >>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
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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.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-302494 (URN)10.1186/s12884-016-1051-4 (DOI)000382459600001 ()27590589 (PubMedID)
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
2. 'They would never receive you without a husband': Paradoxical barriers to antenatal care scale-up in Rwanda.
Open this publication in new window or tab >>'They would never receive you without a husband': Paradoxical barriers to antenatal care scale-up in Rwanda.
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2015 (English)In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 12, 1149-1156 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss').

DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda.

FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy.

CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

Keyword
Policy; HIV-testing; Partner testing; Male involvement; Health inequity; Care-seeking
National Category
Public Health, Global Health, Social Medicine and Epidemiology Nursing
Identifiers
urn:nbn:se:uu:diva-268579 (URN)10.1016/j.midw.2015.09.010 (DOI)000366009900007 ()26471934 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-12-08 Created: 2015-12-08 Last updated: 2016-10-31Bibliographically approved
3. 'You try to play a role in her pregnancy' - a qualitative study on recent fathers' perspectives about childbearing and encounter with the maternal health system in Kigali, Rwanda.
Open this publication in new window or tab >>'You try to play a role in her pregnancy' - a qualitative study on recent fathers' perspectives about childbearing and encounter with the maternal health system in Kigali, Rwanda.
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2016 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Rwanda has raised gender equality on the political agenda and is, among other things, striving for involving men in reproductive health matters. With these structural changes taking place, traditional gender norms in this setting are challenged. Deeper understanding is needed of men's perceptions about their gendered roles in the maternal health system.

OBJECTIVE: To explore recent fathers' perspectives about their roles during childbearing and maternal care-seeking within the context of Rwanda's political agenda for gender equality.

DESIGN: Semi-structured interviews were conducted with 32 men in Kigali, Rwanda, between March 2013 and April 2014. A framework of naturalistic inquiry guided the overall study design and analysis. In order to conceptualize male involvement and understand any gendered social mechanisms, the analysis is inspired by the central principles from relational gender theory.

RESULTS: The participants in this study appeared to disrupt traditional masculinities and presented ideals of an engaged and caring partner during pregnancy and maternal care-seeking. They wished to carry responsibilities beyond the traditional aspects of being the financial provider. They also demonstrated willingness to negotiate their involvement according to their partners' wishes, external expectations, and perceived cultural norms. While the men perceived themselves as obliged to accompany their partner at first antenatal care (ANC) visit, they experienced several points of resistance from the maternal health system for becoming further engaged.

CONCLUSIONS: These men perceived both maternal health system policy and care providers as resistant toward their increased engagement in childbearing. Importantly, perceiving themselves as estranged may consequently limit their engagement with the expectant partner. Our findings therefore recommend maternity care to be more responsive to male partners. Given the number of men already taking part in ANC, this is an opportunity to embrace men's presence and promote behavior in favor of women's health during pregnancy and childbirth - and may also function as a cornerstone in promoting gender-equitable attitudes.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-302345 (URN)27566715 (PubMedID)
External cooperation:
Available from: 2016-09-01 Created: 2016-09-01 Last updated: 2016-10-31
4. Healthcare providers’ paradoxical situation in providing abortion care and enforcing the amended abortion law in Rwanda – A qualitative study
Open this publication in new window or tab >>Healthcare providers’ paradoxical situation in providing abortion care and enforcing the amended abortion law in Rwanda – A qualitative study
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(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-306603 (URN)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2016-10-30 Created: 2016-10-30 Last updated: 2016-10-31

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