Title : Assessing the continuum of maternal and child health: Correlations between ANC indicators and immunization coverage in Rwanda

Background: Antenatal care (ANC) and childhood immunization are central components of the maternal and child health continuum, yet their linkages within routine health systems remain insufficiently documented. Understanding how ANC performance aligns with immunization outcomes at facility level is essential for strengthening integrated service delivery in Rwanda.

Methods: We conducted a retrospective observational study using Rwanda's national Health Management Information System (HMIS) data from 2017–2024. Eight ANC indicators and two immunization outcomes DTP-HepB-Hib3 (DTP3) and Measles-Rubella second dose (MR2)were extracted and merged by facility-year. Indicators with >30% missingness were excluded, leaving four ANC variables for the primary analysis. Descriptive statistics were computed, followed by Pearson correlation analyses with confidence intervals, facility-level comparisons based on ANC volumes, and time-series and lag analyses to assess temporal alignment between ANC and immunization outputs.

Results: The dataset included 1,271 health facilities nationwide. Annual reporting remained stable between 2017 and 2022 but expanded sharply in 2023–2024 due to system-wide increases in reporting coverage. ANC new registrations showed substantial variation across facilities (mean 438; SD 585), as did immunization outputs (DTP3 mean 406; MR2 mean 380). All ANC indicators demonstrated strong positive correlations with DTP3 and MR2 (all p < 0.001). The highest correlations were found for ANC new registrations (r = 0.804 for DTP3; r = 0.793 for MR2) and early ANC contact in the first trimester. Facilities with higher ANC volumes generally exhibited higher immunization performance, though notable exceptions suggested potential gaps in service delivery or reporting. Time-series analysis revealed close alignment of ANC and immunization trends. Lag analysis showed near-perfect same-year correlations (DTP3 r = 0.997; MR2 r = 0.993), moderate correlations at lag-1 (~0.82), and minimal associations at lag-2 (~0.39), consistent with vaccine timing and annual data aggregation.

Conclusion: ANC service utilization is strongly associated with childhood immunization outcomes in Rwanda's routine health system. Early ANC engagement and high overall ANC volumes are particularly predictive of DTP3 and MR2 performance. These findings support the role of ANC as a critical entry point for strengthening the continuum of care and improving child health outcomes. Variability across facilities and the effects of reporting expansion highlight the importance of ongoing improvements in data quality and integrated service delivery.

David Mutabazi is a Rwandan Health Economist, Researcher, and Implementation Science leader currently serving as the Director of Research and Implementation at Africa Quantitative Sciences and Technical Director at Veritas. He has extensive experience leading health systems, digital health, and policy research projects across Africa, collaborating with organizations such as World Health Organization, IQVIA, BCG, John Hopkins University, Cordaid, Rwanda Medical Supply, TCP Africa and Rwanda’s Ministry of Health. His work focuses on health economics, implementation research, digital health innovation, and evidence generation to inform policy and strengthen health systems. David is currently pursuing Master’s degrees in Health Economics and Pharmacoeconomics at UPF Barcelona School of Management and Financial Engineering at WorldQuant University. He is also passionate about mentorship, scientific writing, and advancing research capacity among young professionals in Africa.