The Quest for Maternal Survival in Rwanda : Paradoxes in Policy and Practice from the Perspective of Near-Miss Women, Recent Fathers and Healthcare Providers

Rwanda has made significant progress in decreasing the number of maternal deaths and increasing the number of antenatal care visits and childbirths at health facilities. This thesis seeks to illuminate potential barriers for Rwanda’s goal for maternal survival. The studies explore the bottom-up perspective of policies and practices in regards to maternal care in Kigali. Semi-structured interviews were conducted between 2013 and 2016 with women who nearly died (‘near-miss’) during pregnancy, their partners, and with other recent fathers and community members, as well as healthcare providers who work within abortion care. The framework of naturalistic inquiry guided the study design and data collection. Analysis was conducted using framework analysis, thematic analysis and naturalistic inquiry. The findings identify paradoxical outcomes in the implementation of maternal care policies. Despite recent amendments of the abortion law, safe abortion was identified as being non-accessible. Abortion-related symptoms continue to carry a criminalized and stigmatized label, which encourages risk-taking and clandestine solutions to unwanted pregnancies, and causes care-seeking delays for women with obstetric complications in early pregnancy. Healthcare providers had limited awareness of the current abortion law, and described tensions in exercising their profession due to fear of litigation. The first antenatal care visit appeared to require the accompaniment of a male partner, which underpinned women’s reliance on men in their care-seeking. Men expressed interest in taking part in maternal care, but faced resistance for further engagement from healthcare providers. Giving birth at a health facility was identified as mandatory, yet care was experienced as suboptimal. Disrespect during counseling and care was identified, leading to repeated care-seeking and may underpin the uptake of traditional medicine. An enhanced implementation of the current abortion law is recommended. Reconsideration of policy is recommended to ensure equitable and complete access to antenatal care: women should be able to seek care accompanied by their person of choice. These findings further recommend action for improved policy to better address men’s preferred inclusion in maternal health matters. The findings of this thesis promote continued attention to implementing changes to strengthen quality, and trust, in public maternal care