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Background: In Rwanda, childhood stunting has declined over the last two decades, yet the Northern Province remains a high-burden area, an apparent contradiction given its fertile soils and robust agricultural activity. This thesis sets out to understand that disconnection. Rather than relying onnational averages or single-discipline explanations, it asks where stunting concentrates, whichfactors are most influential and modifiable, and what the key caregivers' experiences are behindthe fact that available resources and programs do not translate into better child growth.

Methods: A population-based cross-sectional study was conducted among 601 households with children aged 1–36 months across all five districts of Northern Province. Maternal, child, and household characteristics were collected using structured questionnaires. Climatic, environmental, and agroecological data were collected from remote sources. Parents were separately reached through focus group discussions. The design integrated five components: (1) spatial statistics to test randomness and identify sector-level hotspots; (2) machine learning to quantify the roles of climatic and environmental features alongside caregiving proxies; (3) multivariable logistic regression to determine modifiable factors; (4) wealth-inequality analysis to identify contributors to pro-poor inequalities; and (5) reflexive thematic analysis of gender-segregated focus groups to explore the caregivers’ experiences and understanding of childhood stunting risk in the studyarea.

Results: The stunting prevalence was 27.1% among children 1-36 months. Its distribution was non-random and clustered, with statistically significant hotspots in three districts of the province. The machine-learning model indicated that location, in combination with climatic and environmental features, explained a large share of the variability in child low height-for-age. The multivariable regression analysis identified several modifiable household-level risk factors, including male children, maternal stature, inadequate breastfeeding, female-headed household, and inadequate handwashing facilities. Inequality analysis showed that the burden of stunting falls disproportionately on households within the poorest quintiles, with partners involved in non-skilled/unemployment and food insecurity. Exploring parents’ experiences and understanding ofchildhood stunting, four main themes emerged: power struggles and broken care underminingchild nutrition, vulnerabilities across the first 1,000 days shaping stunting trajectories, the paradox of plenty where livestock and food don’t nourish children, and fragile substitute careleaving children behind.

Conclusion: Childhood stunting in the Northern Province of Rwanda remains complex with spatial clustering, many hidden and localised climatic and environmental pressures intersecting with household behaviours, caregiving constraints, and poverty, preventing available resources from reaching the child’s plate. The thesis lists several possible venues to move the needle on stunting prevention in the study area.

Bakgrund: I Rwanda har andelen barn med hämmad längdtillväxt minskat under de senaste två decennierna. Den Norra provinsen är dock ett område med fortsatt hög förekomst, en uppenbar motsägelse med tanke på dess bördiga jordar och robusta jordbruksverksamhet. Denna avhandling syftar till att förstå denna skillnad. Snarare än att förlita sig på nationella genomsnitt eller förklaringar från enstaka vetenskapsområden tar den ett multidisciplinärt angrepp och frågar sig var förekomsten av hämmad längdtillväxt är koncentrerad, vilka faktorer som är mest inflytelserika och modifierbara, och vilka de viktigaste vårdgivarupplevelserna är som ligger till grund för det faktum att tillgängliga resurser inte leder till bättre tillväxt i barndomen. 

Metoder: Avhandlingen bygger på en populationsbaserad tvärsnittsstudie bland 601 hushåll med barn i åldrarna 1–36 månader i de fem distrikten i Norra provinsen. Mödra-, barn- och hushållskarakteristika samlades in med hjälp av strukturerade frågeformulär. Klimat-, miljö- och ekologiska data samlades in från externa källor. Föräldrar inbjöds separat till fokusgruppsdiskussioner. Designen integrerade fem komponenter: (1) rumslig statistik för att testa slumpmässighet och identifiera områden med ökad förekomst på sektornivå; (2) maskininlärning för att kvantifiera klimat- och miljöfaktorernas roll tillsammans med data på omständigheter som speglar omsorg om familjens barn; (3) multivariabel logistisk regression för att identifiera modifierbara faktorer; (4) analys av skillnader i ekonomiska resurser för att identifiera bidragande faktorer till omständigheter som missgynnar de fattiga; och (5) reflexiv tematisk analys av könsuppdelade fokusgrupper för att utforska vårdgivarnas erfarenheter och förståelse av risken för hämmad tillväxt i barndomen i studieområdet. 

Resultat: Förekomsten av hämmad tillväxt var 27,1 % bland barn i åldrarna 1–36 månader. Dess fördelning var icke-slumpmässig, utan ansamlad i vissa områden, särskilt i tre distrikt i provinsen. Maskininlärningsmodellen indikerade att plats, i kombination med klimat- och miljöfaktorer, förklarade en stor del av variationen i barns längd i förhållande till ålder. Den multivariata regressionsanalysen identifierade flera modifierbara riskfaktorer på hushållsnivå, inklusive manligt kön, moderns längd, otillräcklig amning, ensamstående mödrar och otillräckliga möjligheter att tvätta händerna. Analysen av ekonomiska skillnader visade att andelen hämmad tillväxt faller oproportionerligt mycket på de fattigaste hushållen, med partners som är arbetslösa eller involverade i okvalificerade arbeten och i hushåll som saknar säker tillgång på mat. En undersökning av föräldrars erfarenheter och förståelser av hämmad tillväxt i barndomen visade fyra huvudteman: maktkamper och sviktande omsorg som undergräver barns näringsintag, sårbarheter under de första 1 000 dagarna som formar hämmad tillväxt, överflödsparadoxen där tillgång till boskap och mat inte ger näring till barnen, och bräckliga alternativ till barnomsorg. 

Slutsats: Hämmad tillväxt hos barn i Rwandas norra provins är en komplex fråga med rumslig anhopning, flera dolda och lokala klimat- och miljöpåverkansfaktorer som skär sig mot hushållsbeteenden, fattigdom samt begränsningar inom barnomsorg, vilket hindrar tillgängliga resurser från att nå barnets tallrik. Avhandlingen listar alternativa sätt att förebygga förekomsten av hämmad tillväxt i studieområdet.

Objective: Childhood stunting is a significant health issue in Rwanda, particularly within the Northern Province. While demographic and socio-economic factors have been more extensively studied, the impact of environmental and climatic factors on stunting prevalence has received less attention. This study aimed to determine if these factors could be used to better predict localized variations in height-for-age z-scores (HAZ).

Study design: A population-based, cross-sectional study.

Methods: Data were collected on child and maternal characteristics, household socioeconomic status, climate, and environmental predictors. An eXtreme Gradient Boosting (XGBoost) algorithm was used, complemented by GeoShapley for spatial analyses, to explain the spatial variability between low height-for-age and its risk factors.

Results: The model performed well, with the coefficient of determination (R2) value of 0.83, the root mean standardized error (RMSE) of 0.13, and the mean absolute error (MAE) of 0.10. Key predictors of HAZ included rainfall, childcare practices, food insecurity, elevation, and soil fertility. Considering the location feature, environmental and climatic factors significantly contributed to the spatial variability in HAZ.

Conclusion: Many environmental, climatological, and socio-economic factors emerge as predictors for HAZ variability. It is essential to consider their complexity for comprehensive interventions targeting childhood stunting in Rwanda and similar settings.

Background: Childhood stunting, defined as a height-for-age Z-score below − 2 standard deviations, remains a major public health issue in Rwanda, with one in three children under-five affected. Although national prevalence of stunting has declined over the past two decades, less is known about how trends compare across population groups. This study assessed trends in childhood stunting inequalities in Rwanda from 2000 to 2019 using absolute and relative inequality measures across five equity dimensions (wealth, women’s education, place of residence, sex, and regions or provinces).

Methods: We analyzed data from five rounds of the Rwanda Demographic and Health Surveys (2000–2019). Stunting prevalence was disaggregated by wealth quintiles, women’s education, place of residence, child’s gender, and region/province. Absolute and relative inequality measures included the slope index of inequality (SII), concentration index (CIX), absolute difference, and the weighted mean difference to the mean (WMDM). Population attributable risk (PAR) and population attributable fraction (PAF) were estimated to assess public health impact.

Results: Stunting prevalence in Rwanda decreased by 31.0% from 2000 (47.9%) to 2019 (33.1%). However, inequalities widened, with faster progress among the wealthiest, reaching their peak in 2019 (SII = -41.7, CIX = -21.9). Women’s education inequalities persisted in favor of the highly educated (SII = − 29.7 and CIX worsening to -9.2 in 2019), urban areas (16-point absolute difference), and boys (7.8-point absolute difference). Regional disparities were relatively stable, with WMDM around 5.0% points, Kigali having the lowest rate. The measures of impact show wealth had the strongest effect, with a PAR of 23.2% points and PAF of 69.0%; respectively reflecting the amount of stunting rates that are attributable to being in the poorest categories and what could be eliminated if all children were in the wealthiest categories.

Conclusion: Despite overall national progress in reducing stunting, social and economic inequalities remained apparent and widened between 2000 and 2019. Children from the poorest households and those with less educated mothers remain disproportionately affected. To achieve the global nutrition target by 2030, Rwanda must strengthen equity-focused interventions to reach the most vulnerable groups.

Despite national progress, stunting remains prevalent in specific regions of Rwanda, highlighting the limitations of coarse-resolution data for effective mapping and intervention planning. This study explored optimal spatial resolution and analytical approach to capture localised dynamics and the multifactorial nature of stunting. A cross-sectional, population-based study was conducted in the Northern Province of Rwanda, focusing on children aged 1–36 months. Data were collected using structured questionnaires covering socio-demographic, economic, health, childcare, livestock factors and anthropometric measurements. Environmental characteristics were obtained from national datasets, while household geographic coordinates were captured using a customized mobile geodata platform (emGeo). After data cleaning, predictors were analysed using univariable and multivariable logistic regression as well as geographically weighted logistic regression (GWLR) to account for spatial heterogeneity. Among 601 children, stunting prevalence was 27% (boys 33.8%; girls 20.9%). GWLR improved model fit, increasing adjusted deviance explained from 34% to 39%. Significant predictors included child age (adjusted OR = 2.46; 95% CI: 1.78–3.39), male sex (OR = 2.83; 95% CI: 1.65–4.86), birthweight (OR = 0.71; 95% CI: 0.54–0.94), maternal autonomy (ability to refuse sexual intercourse; OR = 0.48; 95% CI: 0.27–0.86), inconsistent maternal social support (OR = 2.30; 95% CI: 1.20–4.42), household electricity access (OR = 0.48; 95% CI: 0.27–0.84) and handwashing facilities (OR = 0.21; 95% CI: 0.07–0.67). GWLR revealed substantial spatial heterogeneity in these factors, delineating areas where each factor matters most. This household-level, spatially explicit analysis reveals localised risk patterns often masked by aggregated national data. Prioritising context-specific interventions (such as electrification, hygiene promotion, and enhanced maternal social support), can enhance effectiveness. The proposed analytical workflow provides a model for addressing persistent stunting in other resource-limited settings.

Background: Childhood stunting, defined as height-for-age below − 2 standard deviations (SD), disproportionately affects the Northern Province of Rwanda. We investigated risk factors contributing to stunting in this region at individual, household, and societal/community levels to inform future interventions. Methods: We conducted a population-based, cross-sectional study using a quantitative questionnaire in households with children aged 1–36 months in the Northern Province. Anthropometric measurements of children and mothers were taken to estimate nutritional status. Multivariable logistic regressions were performed to identify independent risk factors of stunting, reporting odds ratios, 95% confidence intervals and p-values. Results: Overall, stunting prevalence was 27.1% in children aged 1–36 months. At the individual level, boys exhibited 82% higher risk of stunting compared to girls (aOR: 1.82, 95% CI: 1.19, 2.78). Household-level factors such as maternal height and BMI were inversely associated with the risk of childhood stunting (aOR: 0.94, 95% CI: 0.90, 0.97 and aOR: 0.92, 95% CI: 0.86, 0.99, respectively). Other risk factors included no breastfeeding at the time of interview (aOR: 2.00, 95% CI: 1.23, 3.25), presence of twins or triplets aged 1–36 months (aOR: 2.60, 95% CI: 1.21, 5.57), female-headed (single parent) households (aOR: 2.07, 95% CI: 1.00, 4.26), and absence of handwashing facilities near the toilet (aOR: 3.30, 95% CI: 1.36, 7.98). No societal/community factors were significantly associated with childhood stunting in the Northern Province. Conclusion: Childhood stunting in the Northern Province of Rwanda is associated with several factors that could lend themselves to interventions, e.g., improved handwashing facilities, improved childcare practices and targeting vulnerable groups such as boys, households with twins or single parents. Additionally, a thorough exploration of identified risk factors through qualitative approaches involving all stakeholders in child and maternal nutrition is warranted.

Background: Childhood stunting remains a public health challenge, especially in sub-Saharan Africa. In Rwanda, it is the highest in the Northern province, with a prevalence of 40.5% in children under five. Given that poverty is a key determinant of stunting, we aimed to investigate wealth inequalities in childhood stunting and to identify its contributing determinants in the province.

Methods: We included 601 children aged 1 to 36 months. We estimated the concentration index to quantify wealth-related inequalities in stunting, which we further decomposed it by applying the Wagstaff decomposition approach.

Results: The overall concentration index of child stunting was relatively high (-0.190; 95% CI: -0.295, -0.084), suggesting that stunting was concentrated in poorer households. Its decomposition revealed that socio-economic determinants (147.9%), namely wealth index, partner’s unemployment or non-skilled occupation, and household food insecurity, contributed most to the wealth inequalities of childhood stunting. The demographic determinants contributed in the second order, especially living in Musanze district. Psychosocial determinants came last, namely maternal social support.

Conclusion: This study revealed significant wealth inequalities in childhood stunting in the Northern Province of Rwanda, with socio-economic factors being the primary contributors to these inequalities. Targeted interventions, such as household economic strengthening programs, robust food security policies, improved conditions and salaries in non-skilled jobs, and social support programs for the most disadvantaged communities, are essential to reducing these disparities.

Background: In Northern Province, Rwanda, stunting is common among children aged under 5 years. However, previous studies on spatial analysis of childhood stunting in Rwanda did not assess its randomness and clustering, and none were conducted in Northern Province. We conducted a spatial-pattern analysis of childhood undernutrition to identify stunting clusters and hotspots for targeted interventions in Northern Province.

Methods: Using a household population-based questionnaire survey of the characteristics and causes of undernutrition in households with biological mothers of children aged 1–36 months, we collected anthropometric measurements of the children and their mothers and captured the coordinates of the households. Descriptive statistics were computed for the sociodemographic characteristics and anthropometric measurements. Spatial patterns of childhood stunting were determined using global and local Moran's I and Getis-Ord Gi* statistics, and the corresponding maps were produced.

Results: The z-scores of the three anthropometric measurements were normally distributed, but the z-scores of height-for-age were generally lower than those of weight-for-age and weight-for-height, prompting us to focus on height-for-age for the spatial analysis. The estimated incidence of stunting among 601 children aged 1–36 months was 27.1 %. The sample points were interpolated to the administrative level of the sector. The global Moran's I was positive and significant (Moran's I = 0.403, p < 0.001, z-score = 7.813), indicating clustering of childhood stunting across different sectors of Northern Province. The local Moran's I and hotspot analysis based on the Getis-Ord Gi* statistic showed statistically significant hotspots, which were strongest within Musanze district, followed by Gakenke and Gicumbi districts.

Conclusion: Childhood stunting in Northern Province showed statistically significant hotspots in Musanze, Gakenke, and Gicumbi districts. Factors associated with such clusters and hotspots should be assessed to identify possible geographically targeted interventions.

Introduction: Respectful Maternity Care (RMC) is "a universal human right for every childbearing woman". In Rwanda, few studies conducted on RMC assessed how women perceive care provided during childbirth, yet little is known about providers' perspectives. We investigated the perceptions and attitudes of midwives towards the provision of RMC to complement women's viewpoints.

Methods: this qualitative study used individual in-depth interviews in Kinyarwanda language. A purposive sampling method was used to reach out to twenty-eight midwives from three district hospitals in Kigali City. Transcribed interviews were translated into English and thematic content analysis was performed using Atlas Ti, version 7. The University of Rwanda College of Medicine and Health Sciences Institutional Review Board (Ref: 363/CHMS/IRB/2019) ethically approved this study before data collection.

Results: the majority of participants revealed that they have knowledge on RMC and perceive that they provide maternal health care based on women´s rights. Positive attitudes towards providing RMC were reported by midwives, however, a considerable number of participants reported the existence of abusive practices. The majority of midwives reported facing many challenges affecting their ability to provide respectful maternal care.

Conclusion: midwives understand the seven rights of women and have a positive attitude towards providing RMC. However, abusive practices still exist while providing RMC with considerable challenges, including overload and lack of labour monitoring materials. The adjustment of the ratio of midwives to clients and the availability of essential materials in labour monitoring is recommended to improve the quality of healthcare received by women during childbirth.

Background: Childhood stunting remains highly prevalent in the Northern Province of Rwanda. While many risk factors are documented, less is known about social and parenting processes in high-risk child conditions of undernutrition. We aimed to explore parental experiences and understandings of the risk of childhood stunting in the Northern Province of Rwanda. 

Methods: We conducted a qualitative study using gender‑segregated focus group discussions (FGDs) with 120 parents of children aged 1–36 months across all five districts of Northern Province. We analysed data using a reflexive thematic analysis approach.

Results: Parents’ narratives revealed four interconnected themes: “power struggles and broken car undermining child nutrition”, including gendered decision-making, resource diversion, and intimate partner violence; “vulnerabilities across the first 1,000 days shaping stunting trajectories”; “the paradox of plenty – where livestock and food do not nourish children”, but are instead diverted from them; and “fragile substitute care leaving children behind”, when mothers must go for work, leading to irregular feeding, neglect, and reduced responsive care.

Conclusion: In the Northern Province of Rwanda, stunting persists less because assets or advice are absent than because interlinked power–time–cash dynamics divert milk, money, and caregiving away from infants during the first 1,000 days. Policies should re-allocate decision-making power and resources toward infants by strengthening joint household decision-making, empowering mothers during and after pregnancy, aligning livestock and market incentives with infant intake, and restoring reliable substitute care through functioning publicly available platforms.