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 life¹. 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 more¹¹. 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 LBW¹⁶. 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. 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^23–25. 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^26,27. 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 and folic acid. 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^24,27,28. 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^23,29,30. 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^1,8,26,31,32.

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-care²⁷. 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 fluids²¹. 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^31,33,34. ANC services contribute to preparing women for delivery and understanding warning signs during the pregnancy and childbirth³⁵. 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 pregnancy³⁶. ANC coverage was an important indicator for reducing the risks to neonatal, infant mortality, maternal mortality and stunting issues to the child³⁴.

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^34,37. Maternal health production function explained that early onset of ANC, prenatal care and have a minimum number of ANC and prenatal care visits^38,39.

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

Our study investigated the influence of ANC contacts on birthweight and their factors contributing to LBW babsies in Rwanda using RDHS. Interestingly, our results revealed that babies from the women who attended four and more ANC visits were less likely to have LBW than the babies from the pregnant women who attennded less than 4 ANC contacts; however, Rwanda reports a low prevalence of attending 8 recommended ANC contacts.These results were coincided with the previous studies that documented an improvement of ANC services contributing to birth weight of the newborns³². Our results revealed a prevalence of 5.8% for LBW and 17.6% for macrosomia. The previous studies documented that the prevalence of LBW in Rwanda is low when compared with other counties in the same region such as Zambia, Uganda and Nigeria^47–49. This magnitude is also less than the prevalence of some countries in Asia such as in China where the accessibility to ANC visits remains challenging⁵⁰. 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%⁵¹. There is a significant reduction of the prevalence of LBW in Rwanda through the efforts made by the goverment whoen coumpared to the other developping countreis that has a prevalence of 15.9%^6,50,52.

Moreover, women who attended nutritional counseling were found to have a protective effect against LBW in this study, which is supported by previous studies^53,54. This is because nutritional counseling may have a positive impact on the improvement of feeding behaviors of pregnant women and their nutritional status which may significantly contribute to a dicrease of the risk of delivering babies with LBW. Also, pregnant women who were fluently explained about pregnany complications were less likely to deliver LBW babies when compared to their counterparts. These findings are consistenct with the previous studies that indicated that ANC visits are significant contributor to birth weight, 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^50,55,56. Our results indicated that experiencing gestational age of more than 37 weeks reduced the risk for LBW babies. Further, non-smokers women and non-anemic women were at lower level to deliver LBW babies when compared to their counterparts. These results were relevant to prior studies conducted in central African counties that indicated that the attendance of ANC visits for pregnant women reduce the risk for delivering LBW babies. These findings are relevant to the previous studies that documented that smoking is a harmful behavior for the pregnant women that increase the risk for LBW babies^25,57–59 Further, gestationa age of more than 37 weeks was significantly associated with a reduction of the LBW babies. These results agreed with the earlier studies^21,53,60. 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^30,61. 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 as well as divorced and separated from their partner were more likely to deliver LBW newborns than the women who were single during pregnancy. These results challenged the previous studies that indicated being single was significantly associated with a greater risk of having LBW children than others^48,62,63.

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 Uganda⁶⁴. 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 convenance with the studies conducted in Tanzania⁶⁵. Mothers from rural areas had greater odds to deliver LBW babies than those residing in urban settings. Having secondary and higher education levels for pregnant women was significantly associated with a dicrease of LBW newborns than having information education. In agreement with previous studies^63,65, women who were provided iron and folic acid sumplements during pregnancy were at lower risk to deliver LBW babies. This lower risk because iron-alone sumpplement could be protective factor against the LBW as compared to the diverse micronutrients sumpplementation and this sumplement has a significant contribution to a decline in the prevalence of intrauterine growith retardation with folic acid supplementation as it was previously documented by the previous researchers^39,65.

Maternal anemia was identified as a risk factor, where we found that pregnant women with anemia had greater odds of delivering a newborn who weighed less than 2.5 kg than those who are not anemic. This is because moderate to severe anaemia for pregnant women could not only affect the mother but also impair oxygen delivery to the fœtus and thus interfere with normal intrauterine growth. These results are similar to the findings from the previous studies that reported that micronutrients defisciency during pregnacy has harmful impact on the development of fœtus and hence, birth weight. This result is in line with the prior studies conducted in Nigeria^48,60. Females babies were more likely than males. These findings were supported by previous study conducted in Ethiopia⁶⁶. Although several socio-demograpghic factors, nutritional factors, behavioral factors and ANC contacts including maternal age, parity, HWI and family size were not significantly associated with the LBW in our study; however, the previous studies conducted in sub-Saharan African countries peviosuly reported them as the risk factors of LBW^48,66.

Strengths, limitations and future directions

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. Another important strength is that the findings from this study have a primordial implication for preventing LBW and inform the policy makers to promote nutritional education or counseling, provision of the sumplements namely iron-folic acid and prevention of anemia among the pregnent women. 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 like HIV status of pregnant women, prenatal depression, receiving the supplementary vitamins (like vitamin A) during the pregnant, ultrasound, 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. Additionnally, as the attendance of 8ANC visits required by 2016 WHO was very low (less than 1%), it was impossible to categorise the ANC visits as an outcome variables respecting such recommendation. Indeed, the qualitative nature of the risk factors captured in the RDHS, like iron intake and duration, nutrition intake, maternal anemia and malnutrition status, which influence the birth weight. 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. Further, our study design could not determine causal relationship; so, further research on longitidinal study design are needed.

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, the pregant women of Rwanda are encouraged to attend all 8 recommended ANC visits for increasing the quality of their life and the life of the babies. 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.

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).