KNOWLEDGE NOTE: 1 RWANDA Preserving Rwanda's progress towards reducing maternal and child mortality and ensuring access to sexual and reproductive health services: A long-standing commitment with a new perspective Amparo Gordillo-Tobar, Neia Prata, Francisca Ayodeji Akala, Nataliya De Francisco Serpa MARCH 2024 Photo: World Bank INTRODUCTION particularly striking against the backdrop of poor access to maternal health services across the African continent, Improvements in the health outcomes of where two thirds of all maternal deaths occur. However, women, young girls, and children will be key to Rwanda the disparity of the high percentage of birth delivery at attaining three of the 17 Sustainable Development Goals the health care facility and the existent maternal (SDG) focused on good health and wellbeing (SDG3), mortality, reflects the need of quality improvement of gender equality (SDG5), and reduced inequalities the care provided at birth delivery across the country. (SDG10). However, the direct and indirect effects of responding to the COVID-19 pandemic, natural disasters Despite these incredible achievements, gaps remain. and other emergencies threaten to stall and even Compared with data from 2014-15 Demographic Health undermine these achievements. To promote continue d Survey (DHS), findings from the 2020 DHS suggest that progress towards reducing maternal and child mortality chronic child malnutrition declined to 33% from 38%; the and ensure equitable access to sexual and reproductive proportion of children aged 6-59 months who are anemic health services, Rwanda may consider prioritizing stagnated at 37%, and exclusive breastfeeding declined initiatives that ensure a steady provision of those from 87 to 81% over the last five years. Additionally, an services with a well-informed population to maintain and estimated 39% of women in unions have an unmet need increase the demand of these routine health services, for family planning services. particularly in the context of the unexpected. This estimate may be higher among vulnerable subgroups like poor or uneducated women and girls. ACHIEVEMENTS AND GAPS While available for the general population, sexual and reproductive health services in Rwanda are not Compared to other East African countries, specifically designed for adolescents1. Access to these Rwanda has continually sustained high coverage of services among adolescent girls remains sub-optimal, maternal and child health services. In 2021, under 5 child with an estimated 32 births per 1,000 among girls ages mortality was estimated at 39.4 per 1,000 live births and 15-19 in 2021. High rates of teen pregnancies have maternal mortality at 259 per 100,000 live births. This important spillover effects on young girls’ educational contrasts with an average under 5 child mortality of 73 and socio-economic attainment. per 1,000 (2021) and maternal mortality of 545 per More so, complications of pregnancy and 100,000 live births (2021) in sub-Saharan Africa, childbirth among 15–19-year-old women are some of the respectively. According to the recent 2020 Demographic leading causes of death and health complications in this Health Survey, coverage of at least one antenatal care age group as well as low birth weight. GAVI-supported visit is universal (98%), nearly all pregnant women are HPV vaccination programs reporting a coverage of 98% tested for HIV, 94% of deliveries take place in health of eligible girls between 2011 and 2018. However, given facilities, and over 96% of 12–23-month-old infants are previous cohorts that were never tested for the disease, fully immunized. Additionally, the proportion of women cervical cancer ranks as the second most frequent cancer benefiting from postnatal care rose to 70%, while among women in Rwanda and the first most frequent expansion of modern contraception, particularly among cancer among women between 15 and 44 years of age married women, rose to almost 60%. The high coverage with the crude incidence rate of 18. 7 cases per 100,000 of maternal and child health (MCH) services in Rwanda is population and annual number of associated deaths of have been implicated as reasons for decreases in 829 women. Increasing access to, and uptake of, sexual utilization. On the supply side, health personnel were and reproductive health services among young and diverted from providing essential services to responding vulnerable women thus remains a critical gap to reaching to the pandemic, or became ill or died, which led to SDG in Rwanda. shortages in healthcare providers for other routine services. Similarly, delivery of essential health supplies was delayed due to decreases in global production and NEW CHALLENGES restrictions in transport or movement. On the demand side, people were hesitant to seek services out of fear of contracting COVID-19, lockdowns led to income losses, These efforts are particularly valid in the light of affecting people’s ability to pay for services, and the climate change agenda. Rwanda is making a serious lockdown restrictions made some services completely stride towards ensuring environmental sustainability of unattainable. the national development programs. According to the Other countries have reported similar service findings of Gender, Women’s Rights, Environment and disruptions at the height of the COVID pandemic. A study Climate Change in Rwanda (2021), in the current on MCH service utilization during pandemics and anthropogenic era, climate change creates barriers to disasters in low- and middle-income countries suggests fulfilling reproductive health and rights resulting that the lack or shortage of personal safety equipment, problems with birth outcomes, such as miscarriages and coupled with fear of infection, are primary factors in preterm births, higher risk of sexually transmitted avoiding routine services. Other factors include lack of infections due to forced migrations and engagement in transportation, needing to pay for typically “free” commercial risky behaviors when faced with livelihood services, and gender sensitivity—whereby women threats, as well as longer term implications on the patients report a scarcity of female providers and families across the life course. Moreover, emergency discomfort associated with receiving reproductive health situations such as the COVID-19 pandemic, natural services from male providers only. disasters, and other emergencies threat to undermine important achievements. Evidence suggests that during the pandemic, Irrespective of the reason, such disruptions in utilization of routine maternal and child health services MCH services can severely derail Rwanda’s progress in declined on 13 indicators across all five provinces in decreasing maternal and child mortality to date. Indeed, Rwanda: ANC first standard visits from 0.49 to 0.45, modeling estimates suggest that service disruptions deliveries at health facility from 0.99 to 0.89, live births could lead to almost 400,000 fewer women receiving from 0.98 to 0.88, vaccinations: bacille Calmette–Guérin family planning services, a 29% increase in child (BCG) from 1.06 to 0.95, polio zero from 0.97 to 0.86, mortality, and a 23% increase in maternal mortality over polio 1 from 0.97 to 0.89, polio 2 from 0.95 to 0.88, the next year. Importantly, mitigating disruptions to diphtheria, tetanus, pertussis, hepatitis B and educational attainment including other related health hemophilus influenza (DTP_HepB_Hib) 1 from 0.97 to interventions such as HPV vaccinations during 0.89, DTP HepB_Hib 2 from 0.95 to 0.88, pneumococcus pandemics for young and adolescent girls is a critical 1 from 0.97 to 0.89, pneumococcus 2 from 0.95 to 0.88, strategy to reduce unintended teen pregnancies and rotavirus 1 from 0.98 to 0.89 and rotavirus 2 from 0.95 cervical cancer cases in the future. to 0.88. Barriers to the supply and demand for services WAY FORWARD FOR MCH Additional country-specific resources: As Rwanda continues to respond to health emergencies, ensuring continued access and uptake of Fourth Health Sector Strategic Plan: 2018-2024. MCH and reproductive health services is paramount to Rwanda Ministry of Health. furthering health and gender parity outcomes in the https://www.childrenandaids.org/sites/default/f country. Delivery of services need to consider integrating iles/2018- 05/Rwanda_Nat%20Health%20Sector%20Plan_2 the provision of routine services with necessary response 018-2024.pdf for vaccination or surveillance activities, deployment and distribution or medications etc. For instance, studies Vision 2050. Republic of Rwanda. have suggested the need for satellite clinics to continue https://www.minecofin.gov.rw/fileadmin/user_u services during pandemic threats. These clinics can serve pload/Minecofin/Publications/REPORTS/Nationa as secondary vaccination posts in the community.16 l_Development_Planning_and_Research/Vision_ 2050/English- Strengthening community and/or home-based care Vision_2050_Abridged_version_WEB_Final.pdf models will be further scaled up. Additionally, dissemination of communications around vaccine safety and effectiveness could be leveraged to promote uptake of routine services, like antenatal care, immunizations, and other health-promoting behaviors. References 1. 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