Regular antenatal care visits were associated with low risk of low birth weight among newborns in Rwanda: Evidence from the 2014/2015 Rwanda Demographic Health Survey (RDHS) Data

Introduction

Antenatal care (ANC) globally is an important health strategy that has been considered as an essential intervention to contribute to the health of newborns and their mothers. This health intervention reduces low birth weight (LBW) which is a foremost public health burden that weakens the development of families and nations due to its harmful effects on quality of life.¹ LBW is defined when a baby weighs less than 2.5 kilograms at birth. This health burden particularly, in low- and middle-income countries (LMICs) may cause multiple effects, such as birth asphyxia, amniotic fluid aspiration, hypoglycemia and hyponatremia.^2–4 The estimate of 15.5% to 15.9% of LBW worldwide was reported^5,6 and the high prevalence (95.6%) of LBW newborns occurred in LMICs.^7,8 ANC visits were found to play a great role in the health promotion of mothers and children before, during and after delivery. It specifically contributes to the reduction of morbidity and mortality of mothers and children.^9,10 Epidemiological studies have shown that the children weighing less than 2.5 kilograms are nearly 20-times more likely to die than those who weigh 2.5 kilograms and more.¹¹ Other studies have stated that newborns with LBW were 5–10-times more likely to die than those who weighed 2.5 kilograms and more.^2,3 Prior studies have indicated that the newborn may develop macrosomia, defined as birth weight more than 4 kilograms. These newborns are considered to have an excessive birth weight. Its prevalence varies globally between 3 and 15% depending on the region, due to various factors where it remains higher in the developing world.^12,13

Prior studies indicated that maternal and environmental factors are major factors with regard to LBW.^14,15 The number of ANC visits attended by the pregnant women and the amount of recommended packages of the interventions provided during ANC are the main factors contributing to LBW.^14,16 A low socio-economic status and limited access to qualified health services related to pregnancy are risk factors for LBW.¹⁶ Multiple studies established that accessibility to poor food consumption behaviors, problems of health status for pregnant women, low caloric intake, hypertension, urinary infections, smoking behaviors, genital infections and psychological distress were found to be risk factors of LBW.^4,17,18 Earlier studies conveyed that consumption of iron, birth order, and calcium supplementation reduces the risk to develop LBW.^18–20

ANC refers to the routine health management of presumed healthy pregnant women without the symptomatology or screening so as to diagnose and detect the diseases or complicating symptoms.^16,21,22 The World Health Organization (WHO) recommended pregnant women attend a minimum of four ANC visits for obtaining the basic health education and interventions that promote health of babies. The more they attend ANC services, the more they receive the maximum health package that plays a crucial role in their health and the health of their newborn.²³ Prior studies have documented that two-thirds of all pregnant women worldwide attended at least one ANC service during pregnancy. They also documented that ANC is the significant predictor of birth weight where attending the required ANC increases the probability of achieving full life-saving potential and having a newborn with more than 2,500 grams.^24–27 In ANC visits, pregnant women are offered health education, such as adequate nutrients to be consumed during and after delivery, vitamin intake, proper vaccination, changing risk behaviors such as smoking, and place of delivery.^28,29 The package provided to pregnant women consists of many interventions like the identification and management of the obstetric complications including pre-eclampsia, tetanus toxoid immunization, de-worming, iron, folic acid, and interventions related to infectious diseases, such as malaria prevention, during pregnant period and insecticide-treated nets (ITNs). The fundamental rudiments of a focused approach to ANC are surveillance of health issues among pregnant woman and their babies, management of complications occurring in the pregnancy period, such as hypertension, treatment of underlying or concurrent illness, screening for health conditions and diseases, mental health problems and intra-partner violence or domestic violence.^25,29,30 ANC visits are obviously the opportunities for promoting the use of skilled attendance at birth, injury prevention, adherence support for preventive interventions, healthy lifestyle safety, and healthy behaviors such as breastfeeding, early postnatal, and planning for the optimal pregnancy spacing.^24,31,32 Pregnant women are provided supplementary nutrients for enhancing the baby’s and mother’s health, screening for genetic and congenital disorders, and offered folic acid supplementation to reduce the risk of neural tube defects.^1,8,28,33,34

Earlier researchers documented that through ANC services, pregnant women and their newborns develop physiological and psychosocial wellbeing. It also reduces risk to have a LBW newborn. ANC visits contributed to development of healthy behaviors and compromise of the emergency preparedness plan to intensify the maternal awareness, improving the newborn needs and self-care.²⁹ Other studies indicated that ANC visits contribute to weight gain and weight regulation of women. They confirmed that ANC services increase the weight of pregnant women and contribute to the growth of the fetal and maternal tissues and fluids.^21,35 This health intervention plays a great role in the provision of information about lifestyle, pregnancy, and delivery. They prevent the potential determinants associated with morbidity and mortality of mothers and children. ANC services not only contribute to pregnant women and their fetus, but also foster a virtuous social and family cohesion and resilience. It was found that more than 80% of pregnant women who attended at least four ANC visits reported showed effectively controlled pregnancy complications.^33,36,37 ANC services contribute to preparing women for delivery and understanding warning signs during the pregnancy and childbirth.³⁸ It was scientifically found that the ANC interventions attended early become the best opportunity for appropriate screening and medical testing for health problems in which pregnant women are exposed to have during and after pregnancy.³⁹ ANC coverage was an important indicator for reducing the risks to neonatal, infant mortality, maternal mortality and stunting issues to the child.³⁷

Previous studies indicated that there is a substantial influence of ANC on increase of birth weight for the children and their development of a good life characterized by prevention and management of pregnancy-related or concurrent diseases and psychosocial development.^37,40 Maternal health production function explained that early onset of ANC, prenatal care and have a minimum number of ANC and prenatal care visits.^41,42

The rationale of this study was to increase the accessibility to ANC services that were documented to be practiced, but there was no scientific evidence that was conducted to indicate its effect on neither LBW nor contributing determinants to the reduction of children and maternal morbidity and deaths in Rwanda. Through the findings from this research, the investigators indicated how pregnant women achieve the third goal of Sustainable Development Goal (SDG-III) related to the reduction of infant and maternal mortality and morbidity by completing four ANC visits and more. Although it is known that ANC visits are an important intervention that contributes to prediction of the newborn birth weight, little has been conducted on effect of ANC visits on birth weight in developing countries, including Rwanda. This research, therefore, aimed to determine the effect of antenatal care visits on the LBW of children in Rwanda using the secondary data analysis of Rwanda Demographic and Health Survey (RDHS) 2014-2015. We hypothesize that ANC visits result in reducing the high incidence of LBW among newborns of Rwanda.

Methods

Results

Discussion

This study revealed that LBW remains a public health burden at the national level and it remains higher in Rwanda. The results found that the prevalence of LBW and macrosomia was 5.8% and 17.6%, respectively; however, the newborns weighing more than 2.5kg were 94.2%. These results were coincided with the previous studies that documented an improvement of ANC services contributing to birth weight of the newborns.³⁴ Similarly, the prevalence of LBW is low compared with other counties in the same region such as Zambia, Uganda and Nigeria.^51–53 It is also less than the prevalence of some countries in Asia such as in China where the accessibility to ANC visits remains challenging.⁵⁴ The present prevalence of LBW is less than the previous document which was 7.1% and low access of four recommended ANC visits was 35.4%.⁵⁵ There is a significant reduction of the prevalence of LMICs compared with the prevalence (15.9%) found in developing countries.⁶ Among the women with the newborns who weigh less than 2.5kg, only 44.1% of pregnant women attended four recommended ANC visits. Within this study, a strong correlation between ANC and LBW was discovered and the results of inadequate ANC visit for pregnant women. However, almost all pregnant women (99%) attended ANC visits and only 44.1% obtained 4 recommended ANC packages, there is a need to increase attendance of ANC visits for reducing the number of newborns with LBW. These results corroborated preceding studies.^54,56

We observed that pregnant women who attended four and more ANC visits had less risk of having LBW children than those who attended fewer than four recommended ANC visits. This finding is consistent with previous data that indicated that the more pregnant women attend ANC visits, especially more than four, the more their children do not have LBW.^57,58 Pregnant women who attended fewer than four ANC check-ups had 2.8-times greater odds of LBW than those who attended four and more ANC visits. These findings are relevant with the previous studies that indicated that ANC visits are significant maternal factors contributing to birth weight babies, since it normalizes the birth weight of the child and their mother due to the prevention, intervention and health education that are effectively provided in each visit.^54,59,60 They are also relevant to prior studies conducted in central African counties that indicated that the attendance of ANC visits and being provided the recommended packages for pregnant women reduce the risk for delivering LBW outcome.^27,61–63 Results revealed that the pregnant women who were not provided Coartem for malaria treatment were 0.6-times likely to have LBW children compared with the pregnant women who were provided Coartem for malaria treatment.^57,64 It was found that the pregnant women who received no drug for malaria treatment had 0.3-times greater risk of having LBW children than the women who received the drugs for malaria.²¹ These results were similar to the previous studies that documented that children born to educated pregnant women and pregnant women with high wealth index who attend are less likely to weigh less than 2.5kg than other pregnant women.^32,65 Prominently, in this research, the results are robust to adjustment for the socio-demographic characteristics of the recruited pregnant women. They revealed that marital status increased the odds of LBW. It was found that pregnant women who were married or living with the cohabitants were 1.9-times likely to have LBW compared with pregnant women who were single. They also revealed that the pregnant women who divorced or separated had 1.7-greater risks to have newborns who weigh less than 2.5 kg. These results challenged the previous studies that indicated that pregnant women who were single had a greater risk of having LBW children than others.^52,66,67

Newborns whose mothers were had normal BMI (18.5–24.9 kg/m²) and mothers who were overweight (or obese;) were less likely to have new-born with LBW when compared to those mothers who were underweight. This result is consistent with the earlier research carried out in Uganda.⁶⁸ Newborns of women who smoke during pregnancy had low birth weight when compared with babies whose mothers did not smoke during pregnancies. Our findings are in congruence with the studies conducted in Tanzania.⁶⁹ Mothers from rural areas had 1.1 times greater risks of having an LBW newborn than those residing in urban settings. Mothers with secondary and higher education were less likely to have an LBW newborn than those who were illiterate. Our results concur with the earlier studies that established that the residence of pregnant women, HWI, family size, maternal age, utilization of tetanus injections and iron tablets consumption are factors of LBW.^42,69

Maternal anemia was identified as a risk factor, where we found that pregnant women with anemia had 3.5- times greater odds of delivering a newborn who weighed less than 2.5 kg than those who are not anemic. This result is in line with the prior studies conducted in Nigeria.⁵² The mothers who were not provided health counseling and education about nutrients were 2.5-times more likely to have LBW newborns than those who received nutritional counseling and education during ANC visits. The mothers who were not informed about maternal complications had 3.3-times greater risks of having newborns who weighed less than 2.5 kg than those who received information about health complications during pregnancy. Mothers with a weight at delivery greater than 80 kg were more likely to deliver newborn with LBW than the mothers who weighed less than 80 kg. This result is not in line with the previous studies carried out in Ethiopia.⁷⁰ The findings of this study did not reveal a significant association between maternal age, parity, HWI, sex of child, family size and LBW, however, the prior studies conducted in sub-Saharan African countries confirmed a significant association between maternal age, parity, sex of child, HWI, and LBW.^52,70

Strengths and limitations

The present research has numerous prominent strengths. The first strength is that the RDHS 2014/2015 used the validated and standardized tools for interviewing the eligible participants. Second, the research data about birth weight that we used were obviously verified through records and recall bias was prevented. However, several limitations also warrant discussion. First, it was limited to a study design that did not actually explore for modifiable factors of ANC visits, such as HIV status of pregnant women, maternal gestational age, prenatal depression, receiving the supplementary vitamins (like vitamin A) during the pregnant period, maternal weight gain during pregnancy, eclampsia, gestational diabetes, high blood glucose level during pregnancy, antiretroviral (ART) for HIV-positive women and reducing transmission of HIV from pregnant mother to child. Second, birth weight data was available for only babies whose weight was measured at birth. This limited us for estimating the real prevalence. Third, the selection bias resulted in the underestimation of the association between ANC and birth weight. This was because not all babies’ weight was measured. The other limitation was that the qualitative aspects data from the participants was not included for exploring some factors and to triangulate the findings of the quantitative methods used. Additionally, as the methods used for measuring birth weight were not validated by the survey team, the misclassification could occur in this research. As we do not know the exact timing of the birth weight measurement, this causes misclassification.

Conclusion

In conclusion, this study found several risk factors of LBW in Rwanda that remains a national public health concern. However, ANC services for pregnant women are a fundamental intervention for reducing LBW. This integral part of primary health care, ANC services, is the population-based intervention that reduces the risk to deliver the newborn with LBW. Therefore, there is a need of a multifaceted approach for addressing the factors of LBW through reinforcing ANC coverage and quality of ANC services for pregnant women. Information on anthropometric measurement and increased awareness of the importance of regular ANC visits is also desirable. Attending four or more ANC visits is a step toward improving maternal health by providing maximum required packages and this strategy reduces the risk to LBW. The policy makers and researchers should prioritize maternal education and families with low socio-economic status for preventing LBW in Rwanda.

We recommend further research be conducted on the risk factors of macrosomia in Rwanda. Additionally, further study to explore the barriers to access ANC visits effectively for pregnant women from the rural settings is recommended. In the meantime, pregnant women in Rwanda are required to attend ANC visits appropriately and regularly for benefiting from the required packages that increase the probability to attenuate the LBW among the newborns. We recommend to measure birth weight immediately after birth for reducing the recall bias and misclassification.

Data availability

Authors’ contributions

EB conceptualized the study, did study design, formal analysis, wrote the protocol, requested the permission from the DHS website, drafted the manuscript and coordinated the study. SH contributed to data analysis, data curation and methodology. DR substantially contributed to the conceptualization. He also wrote the original draft preparation. He revised and reviewed the manuscript, and searched the relevant journal to which the study is submitted. HE reviewed and edited the study. All investigators approved the final manuscript. They also agreed to take responsibility and be accountable for the content of the manuscript. All of them agreed on all versions of the manuscript before submitting it in the international journal. They also agreed on the final version accepted for publication.

Ethics and consent to participate

The present study was exempt from searching the ethical approval because the RDHS 2014/15 obtained the ethical approval from the Institutional Review Board (IRB) of the Rwanda National Ethics Committee (RNEC).