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Open Access Research article

Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda

Shahrzad Joharifard1, Stephen Rulisa23, Francine Niyonkuru23, Andrew Weinhold4, Felix Sayinzoga5, Jeffrey Wilkinson6, Jan Ostermann7 and Nathan M Thielman7*

Author Affiliations

1 Department of Surgery, Division of General Surgery, University of British Columbia, Vancouver, BC, Canada

2 Department of Clinical Research, Kigali University Teaching Hospital, Kigali, Rwanda

3 National University of Rwanda, Butare, Rwanda

4 Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

5 Ministry of Health, Republic of Rwanda, Kigali, Rwanda

6 Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

7 Duke Global Health Institute, Duke University, Durham, NC, USA

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BMC Public Health 2012, 12:1049  doi:10.1186/1471-2458-12-1049

Published: 5 December 2012



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.


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.


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.


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.

Maternal health; Service delivery; Health financing; Health systems; Sub-Saharan Africa