title: Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study.
abstract: To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.
authors: Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA, lnathan@montefiore.org.
authors: Lisa M
authors: LM
authors: Nathan
authors: Quihu
authors: Q
authors: Shi
authors: Kari
authors: K
authors: Plewniak
authors: Charles
authors: C
authors: Zhang
authors: Damien
authors: D
authors: Nsabimana
authors: Marc
authors: M
authors: Sklar
authors: Eugene
authors: E
authors: Mutimura
authors: Irwin R
authors: IR
authors: Merkatz
authors: Mark H
authors: MH
authors: Einstein
authors: Kathryn
authors: K
authors: Anastos
mesh_terms: D000293:Adolescent; D002983:Clinical Competence / Q000592:standards*; D015331:Cohort Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data; D036801:Parturition; D011057:Politics; D011247:Pregnancy; D011295:Prenatal Care / Q000592:standards* / Q000706:statistics & numerical data; D011446:Prospective Studies; D012424:Rural Population; D012432:Rwanda; D055815:Young Adult
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