Access, equity, and ethics: A qualitative exploration of Rwanda’s maternal community health worker program

Improving maternal health outcomes is one of the main health concerns in Rwanda, a country that was shaken by the 1994 genocide against the Tutsi. As part of the rebuilding process, the health sector focused on using community participation to promote access to maternal healthcare. One such initiative was the creation of the maternal community health worker role as part of the community health worker program. Maternal community health workers are volunteer women elected by their communities to provide basic maternal health services while encouraging the utilization of formal healthcare services for antenatal care, delivery, and postpartum care. Using a qualitative case study approach, my dissertation research explores some of the facilitators and barriers to access to the community-based services offered by maternal health community health workers. I draw on the findings from in-depth interviews with maternal community health workers and women who have used their services in five Rwandan districts to pursue three distinct, yet related, analyses. First, I highlight the different aspects of access to maternal health care at the community level in Rwanda: availability, accessibility, affordability, acceptability, and accommodation. Second, I identify specific strategies employed by these volunteer health workers to facilitate equitable access to maternal health services while operating in a low resource setting. Third, through the lens of an ethics of care framework, I examine why women decide to become maternal community health workers and how they are selected in their communities to take on this responsibility. Overall, this research suggests that community participation is valuable for promoting maternal health outcomes but raises health equity concerns for the nature of the maternal community health worker role. Such concerns shape the program’s sustainability and may impact the overall efforts to enhance positive maternal health outcomes in Rwanda. Further research is needed to explore other aspects of community participation in maternal health, such as the involvement of local leaders who work closely with maternal community health workers to enhance the success of this program.