Maternal and Child Health Journal

, Volume 19, Issue 9, pp 1949–1955 | Cite as

Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study

  • Lisa M. NathanEmail author
  • Quihu Shi
  • Kari Plewniak
  • Charles Zhang
  • Damien Nsabimana
  • Marc Sklar
  • Eugene Mutimura
  • Irwin R. Merkatz
  • Mark H. Einstein
  • Kathryn Anastos


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.


Global Decentralization Skilled birth attendance 



The project described was supported by the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), through CTSA grant numbers UL1TR000086, TL1RR000087, and KL2TR000088. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Conflict of interest

No authors have conflicts of interest to disclose.


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Lisa M. Nathan
    • 1
    Email author
  • Quihu Shi
    • 2
  • Kari Plewniak
    • 1
  • Charles Zhang
    • 3
  • Damien Nsabimana
    • 4
  • Marc Sklar
    • 1
  • Eugene Mutimura
    • 5
  • Irwin R. Merkatz
    • 1
  • Mark H. Einstein
    • 1
    • 6
  • Kathryn Anastos
    • 1
    • 6
    • 7
  1. 1.Department of Obstetrics, Gynecology and Women’s HealthAlbert Einstein College of MedicineBronxUSA
  2. 2.School of Health Sciences and PracticeNew York Medical CollegeValhallaUSA
  3. 3.Data Solutions LLCBronxUSA
  4. 4.Kibogora District HospitalKibogoraRwanda
  5. 5.Women’s Equity in Access to Care and TreatmentKigaliRwanda
  6. 6.Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxUSA
  7. 7.Department of MedicineAlbert Einstein College of MedicineBronxUSA

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