title: Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda.
abstract: BACKGROUND
  The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75% reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249-584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda.
  
  
  METHODS
  Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordinates were used to calculate the path distances between each village and its designated health center and district hospital. Bivariate and multivariate logistic regressions were used to identify factors associated with delivery in health facilities.
  
  
  RESULTS
  Analysis of 3106 lifetime deliveries from 859 respondents shows a sharp increase in the percentage of health facility deliveries in recent years. Delivering a penultimate baby at a health facility (OR = 4.681 [3.204 - 6.839]), possessing health insurance (OR = 3.812 [1.795 - 8.097]), managing household finances (OR = 1.897 [1.046 - 3.439]), attending more antenatal care visits (OR = 1.567 [1.163 - 2.112]), delivering more recently (OR = 1.438 [1.120 - 1.847] annually), and living closer to a health center (OR = 0.909 [0.846 - 0.976] per km) were independently associated with facility delivery.
  
  
  CONCLUSIONS
  The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health center. Recent structural interventions in Rwanda, including the rapid scale-up of community-financed health insurance, likely contributed to the dramatic improvement in the health facility delivery rate observed in our study.
authors.affiliation: Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC, Canada
authors.forename: Shahrzad
authors.initials: S
authors.lastname: Joharifard
authors.forename: Stephen
authors.initials: S
authors.lastname: Rulisa
authors.forename: Francine
authors.initials: F
authors.lastname: Niyonkuru
authors.forename: Andrew
authors.initials: A
authors.lastname: Weinhold
authors.forename: Felix
authors.initials: F
authors.lastname: Sayinzoga
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Wilkinson
authors.forename: Jan
authors.initials: J
authors.lastname: Ostermann
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Thielman
mesh_terms: D000293:Adolescent; D000328:Adult; D016000:Cluster Analysis; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D006293:Health Promotion / Q000592:standards; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006700:Home Childbirth / Q000523:psychology / Q000706:statistics & numerical data; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008875:Middle Aged; D015995:Prevalence; D012424:Rural Population; D012432:Rwanda / Q000453:epidemiology; D055815:Young Adult