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To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB ( p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits ( p = 0.81). Neither decentralization of ambulatory reproductive healthcare ( p = 0.10) nor intrapartum care ( p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits ( p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB ( p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB. [ABSTRACT FROM AUTHOR]

Background New World Health Organization guidelines recommend high-risk human papillomavirus (hrHPV) screen-and-treat strategies for cervical cancer prevention. We describe risk of, and risk factors for, testing hrHPV positive in a pilot study of hrHPV screen-and-treat conducted in Rwanda. Methods A total of 2,964 women, 1,289 HIV-infected (HIV [+]) and 1,675 HIV-uninfected (HIV [-]), aged 30-60 years and living in Rwanda were enrolled in 2010. Cervical specimens were collected and tested by careHPV, a DNA test for a pool of 14 hrHPV types. Prevalence with binomial 95% confidence intervals (95%CI) and determinants of testing hrHPV positive were calculated. Results hrHPV prevalence was higher in HIV [+] (31.8%, 95%CI = 29.2-34.4%) than HIV [-] women (8.2%, 95%CI = 6.7-9.8%; P < 0.0001). Among HIV [+] women, there was a significant trend (ptrend <0.001) of higher hrHPV prevalence with lower CD4 cell count, with the highest hrHPV prevalence among those with <200 CD4 cell counts (45.5%, 95%CI = 34.8-56.4%). In multivariate analysis of HIV [+] women, testing hrHPV positive was positively associated CD4 count of <200 cells/µL, history of 3 or more sexual partners, and history of using hormonal contraception, and negatively associated with older age. In HIV [-] women, testing hrHPV positive was negatively associated only with older age groups of 45-49 and 50-60 years and surprisingly was not associated with lifetime number of sexual partners. Conclusion hrHPV prevalence is high in HIV [+], especially in women with the lowest CD4 cell counts, which may have implications for utilizing hrHPV-based screening strategies such as screen-and-treat in these high-risk subgroups. [ABSTRACT FROM AUTHOR]