(Illustration courtesy of the Robert Wood Johnson Foundation)
The echoes of Rwanda’s past resonate with a profound message of resilience and transformation. Emerging from the shadows of a devastating genocide that resulted in the grievous loss of more than 1 million lives, Rwanda has carved a path of recovery that reverberates with hope, resilience, and achievements. Amidst this historical context, the nation’s strides in maternal and child health take on a significant mantle, showcasing the power of renewal. In the last 10 years, Rwanda has achieved notable advancements in reducing maternal mortality rates by 42 percent, lowering them from 487 to 203 per 100,000 live births. And an impressive 93 percent of women deliver their babies in health-care facilities. One of the key elements driving this accomplishment has been the education and training of midwives.
As we close in on the deadline for achieving the Sustainable Development Goals (SDGs) in 2030, it is crucial to evaluate global progress in maternal and child health (MCH) to gain insights into improving health outcomes in local communities. Rwanda stands as a beacon of success, having made remarkable strides in reducing maternal and child mortality rates. In contrast, the United States continues to face challenges in improving outcomes. This essay delves into Rwanda’s achievements and explores the principles and practices that contribute to Rwanda’s progress.
Success in Maternal and Child Health Despite a Pandemic
Rwanda has exhibited remarkable progress in maternal and child survival. In addition to reducing maternal mortality rates, according to the July 2013-June 2018 Rwanda Biomedical Report, the country successfully decreased under-five mortality rates by 50 percent, declining from 152 deaths per 1,000 live births to 76. These achievements exemplify Rwanda’s strategic approach to MCH.
During the COVID-19 pandemic, in many countries, MCH achievements regressed for several reasons, including the death of health professionals, the diversion of professionals to respond to the pandemic, and the population’s fear of going to health facilities and contracting COVID-19. However, this was not the case in Rwanda, where the spread of the virus was effectively controlled thanks to different proactive pandemic response measures and innovative approaches to help keep health workers safe as they cared for the patients. These included monitoring COVID-19 patients through robots and using drones to deliver supplies, resulting in lower infection and mortality rates. Out of the 133,194 confirmed cases, only 1.1 percent resulted in death. Unfortunately, a global average figure for COVID-19 mortality rates is not readily available. Nevertheless, Rwanda’s sustained MCH achievements can be attributed to the swift, proactive, and effective response to COVID-19 that ensured patients still received necessary health-care services amid the pandemic.
Lessons From Rwanda
Trust in Local Practitioners
Rwanda’s success in MCH outcomes can be attributed to the trust between the population and local practitioners. By prioritizing community engagement and leveraging existing health-care structures, Rwanda has fostered strong relationships between health-care providers and the communities they serve. This trust enables women, particularly those in vulnerable situations, to seek and receive appropriate maternal care without fear or hesitation. In contrast, the United States faces challenges in building trust, resulting in disparities in access and outcomes among marginalized communities, especially Black Americans. Generations of racism and mistreatment at the hands of medical professionals in the United States has left many Black Americans distrustful of the health-care system and even wary of taking a COVID-19 vaccine during the pandemic.
To build greater trust, in 2007, Rwanda launched a reform of its national community health system, originally established in 1995, and mandated that Community Health Workers (CHWs) possess at least six years of education and be chosen through community elections. Three CHWs would serve each village, including two general CHWs responsible for community health, nutrition, and HIV/AIDS prevention, as well as a maternal health worker who oversaw infant and maternal care before and after birth. Furthermore, each village had a dedicated CHW for social affairs (CHSA) focused on enhancing the well-being of both individuals and the community. CHWs were generally selected by their communities based on several criteria, including social acceptance, a crucial factor in building trust because they were part of the communities they were serving.
Participatory Approach to Identifying Challenges
Rwanda’s approach to identifying MCH challenges is highly participatory, ensuring that the voices of women and communities are heard. Through community dialogue and involvement, women can express their needs, concerns, and expectations. This inclusive process allows health-care interventions to be tailored to the specific requirements of each community, ultimately leading to improved health outcomes.
For example, in Rwanda’s participatory approach, CHWs play a pivotal role in identifying and addressing health challenges. These workers are selected from and by the local community, which enhances trust and enables them to deliver culturally sensitive care.
Humility in Developing Solutions
Rwanda’s success in MCH can also be attributed to its approach to developing solutions. Rather than imposing external models, Rwanda embraces a context-specific approach. By understanding the unique challenges faced by women in their communities, local solutions can be crafted to address these issues effectively. This approach emphasizes the importance of cultural competence and tailoring interventions to the specific needs of each community. In contrast, the United States often relies on standardized approaches, which may not sufficiently consider the nuances of diverse communities.
Comparing Situations in Rwanda and the United States
When comparing maternal health outcomes, Rwandan women in more vulnerable situations often fare better than their counterparts in the United States. In contrast, the United States continues to face challenges in reducing maternal deaths among the vulnerable, particularly among marginalized populations.
According to the World Health Organization, the maternal mortality ratio in Rwanda decreased from 1,007 deaths per 100,000 live births in 2000 to 259 deaths per 100,000 live births in 2020, presenting a 74 percent reduction. In the United States, the maternal mortality ratio increased from 12 deaths per 100,000 live births in 2000 to 21 deaths per 100,000 live births in 2020, a 175 percent increase. Despite the United States having a lower rate and Rwanda having a higher maternal mortality ratio, Rwanda is seeing significant improvements from the efforts and initiatives put in place while the United States is struggling to minimize its ratio.
The disparities in maternal health outcomes between Rwanda and the United States can be attributed to various factors. Firstly, Rwanda has implemented a comprehensive health-care system with a strong emphasis on primary health care and community-based interventions. This approach ensures that women receive essential prenatal, childbirth, and postnatal care. In the United States, although access to health-care services is available, the fragmented nature of the health-care system, combined with socioeconomic disparities, often results in unequal access and inconsistent quality of care.
Furthermore, Rwandan women benefit from a strong network of community health workers who play a pivotal role in improving maternal and child health outcomes and supporting women during pregnancy and during childbirth. Their presence creates a continuum of care, fostering trust and bridging the gap between health-care providers and communities. In the United States, although community health worker programs exist, they are often limited in scope and coverage, leading to gaps in community engagement and support.
Additionally, Rwanda has invested significantly in maternal health infrastructure, ensuring that quality health-care services are accessible across the country. Health centers and maternity waiting homes provide antenatal care and facilitate safe deliveries, particularly in remote and rural areas. These health centers offer comprehensive antenatal care services to expectant mothers, ensuring that they receive necessary medical attention and providing safe spaces for expectant mothers to stay in the days leading up to their due dates. These facilities are equipped to offer not only medical care but also emotional and psychological support to mothers. In contrast, the United States faces challenges in providing equitable access to health-care facilities, particularly in remote and underserved regions. This lack of accessibility exacerbates disparities in maternal health outcomes.
Rwanda’s success also lies in its proactive approach to health-care delivery, which incorporates a strong focus on preventive measures, early detection, and prompt management of complications. The country has implemented programs to improve family planning services, promote antenatal and postnatal care visits, and increase access to skilled birth attendants. These initiatives have contributed to the significant reduction in maternal and child mortality rates. In the United States, while similar programs exist, variations in health-care coverage, socioeconomic factors, racism, and other systemic barriers limit the impact and effectiveness of these interventions.
Conclusion
Rwanda’s remarkable progress in maternal and child health serves as an inspiring example for the global community. By prioritizing trust in local practitioners, adopting a participatory approach, and developing context-specific solutions, Rwanda has significantly improved health outcomes, particularly for vulnerable populations. Rwanda’s success can provide valuable insights for other countries, including the United States, in their efforts to improve maternal and child health.
To address the disparities in maternal health outcomes, the United States must prioritize community engagement, invest in comprehensive primary health care, strengthen the role of community health workers, and ensure equitable access to quality health-care services. By adopting a holistic and culturally sensitive approach, the United States can make significant progress in reducing maternal and child mortality rates and improving the health outcomes of all women, especially those in vulnerable situations. As this series has highlighted, it is through the practice of global learning that we can achieve the health goals incorporated in the SDGs and ensure a healthier future for women and children worldwide.
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Read more stories by Agnes Binagwaho & Kevin Kubwimana.