Ovulatory cycle knowledge and its correlates among reproductive-age women in Rwanda: evidence from the 2019-2020 demographic and health survey

¹Reproductive Health Program, Pan African University Life and Earth Sciences Institute (including Health and Agriculture), University of Ibadan, Ibadan, Nigeria, ²Obstetrics and Gynaecology Department, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria, ³Institute of Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria, ⁴Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Uganda Ministry of Health, Kampala, Uganda

^&Corresponding author
Winny Clemence Uwidutatse, Reproductive Health Program, Pan African University Life and Earth Sciences Institute (including Health and Agriculture), University of Ibadan, Ibadan, Nigeria

Introduction    

Ovulation in women of reproductive age is a natural physiological process and a key indicator of fertility. It refers to the rupture of a fully mature ovarian follicle, releasing the female gamete (i.e., ova or egg) into the fallopian tube for fertilisation [1]. Knowledge of this cycle is fundamental to fertility awareness and reproductive health, forming the basis of natural family planning methods (NFPMs) such as periodic abstinence and condom use on ovulation days, particularly in contexts where access to modern contraceptive methods is limited [2,3]. Beyond family planning, ovulatory knowledge assists in diagnosing certain medical conditions (i.e., Polycystic Ovary Syndrome (PCOS), endometriosis) [4,5], supports reproductive autonomy, and reduces the likelihood of unintended pregnancies and unsafe abortions [6], making it both a clinical and public health priority.

Despite its importance, ovulatory cycle knowledge remains limited in low and middle-income countries (LMICs). In sub-Saharan Africa (SSA), only 15.5% of women correctly identified their fertile period [7]. A cross-sectional study in Papua New Guinea found that just 22% of women of reproductive age had correct ovulatory cycle knowledge [8], similar studies conducted in Ethiopia [9], Kenya [10], and Sierra Leone [11] also revealed that only 23.6%, 38.1%, and 39.8% of women were knowledgeable about their ovulatory cycle, respectively. In Ghana, women lacking correct knowledge of the fertile period were almost twice as likely to experience unsafe abortions [12]. Incorrect knowledge of the ovulatory cycle has significant implications for reproductive health [8]. These findings highlight that limited fertility awareness contributes directly to adverse reproductive health outcomes, including unintended pregnancies and unsafe abortions, particularly in settings with poor access to modern contraceptives.

Rwanda has made notable progress in reproductive health, including increased contraceptive prevalence, comprehensive sexual education, and reduced fertility rates [13,14]. While modern contraceptives are available, uptake and continuation rates remain constrained by side effects, socio-cultural norms, and limited awareness of alternatives, resulting in persistent unmet need for contraception and high rates of unintended pregnancies [15,16]. In this context, knowledge of the ovulatory cycle becomes an important tool for women to plan conception or avoid unintended pregnancies, thereby improving maternal health outcomes. Given Rwanda's youthful population and ongoing challenges with early pregnancies among adolescents and young women [15], which contribute to high rates of unintended pregnancies, maternal mortality, school dropouts, and unsafe abortions [17,18], assessing fertility awareness is critical to complement modern contraceptive programs.

Studies conducted across SSA have shown that correct ovulatory cycle knowledge is significantly associated with various correlates. Women aged 30-49, those with higher educational levels [6], health insurance coverage [19], mobile phone ownership, use of traditional contraceptive methods [8], residing in urban areas, getting family planning counselling [9], and exposure to media [10] were associated with higher odds of correct ovulatory cycle knowledge. In Rwanda, reproductive health research has largely concentrated on contraceptive use [20-22], antenatal care services utilization [23,24], breast and cervical cancer [25], risky sexual behaviours [26], caesarean section [27], and teenage pregnancy [14]. However, studies investigating the correlates of ovulatory cycle knowledge in Rwanda remain limited. Therefore, this study aimed to determine the prevalence and correlates of ovulatory cycle knowledge among reproductive-age women in Rwanda using data from the 2019-2020 Rwanda Demographic and Health Survey (RDHS). The findings from this study aim to inform targeted interventions for strengthening family planning initiatives, improve reproductive health education, reduce unintended pregnancies, and improve overall reproductive health outcomes.

Methods     

Study design: this was a cross-sectional study utilising nationally representative data from the 2019-2020 RDHS.

Study setting: the study was conducted in Rwanda, a landlocked country in East-Central Africa bordered by Uganda to the north, Tanzania to the east, Burundi to the south, and the Democratic Republic of Congo to the west, with an estimated population of 14 million people [28]. Rwanda is administratively divided into four provinces (i.e., Eastern, Northern, Western, and Southern), and the City of Kigali, each further subdivided into districts, sectors, cells, and villages [29].

Data source: data for this study were drawn from the 2019-2020 RDHS, a nationally representative survey that provides detailed information on demographic, health, and sexual and reproductive health indicators. We utilised the women's individual recode (IR) dataset, which includes responses from women aged 15-49 years. The DHS applies a two-stage stratified sampling design: in the first stage, Enumeration Areas (EAs) are selected within strata using probability proportional to size; in the second stage, households are systematically sampled from each selected EA. All DHS datasets used are publicly accessible from the DHS Program website.

Study population: after applying sampling weights to account for the complex survey design, the final analytic sample included 14,503 women aged 15-49 years with complete data on ovulatory cycle knowledge and selected explanatory variables. Women with missing data on the outcome and explanatory variables were excluded from the analysis.

Study variables

Outcome variable: the outcome variable in this study was ovulatory cycle knowledge, which was assessed using women's responses to a standard DHS question on the timing of the fertile period. Response options included: "during her period," "after the period ended," "middle of the cycle," "before the period begins," "at any time," "other," and "don't know." For analysis, a binary variable was created where women who reported the middle of the cycle were classified as having correct knowledge (coded = 1), while all other responses were categorised as incorrect knowledge (coded = 0). This operational definition has been widely used in previous studies [6,8,10].

Explanatory variables: explanatory variables were selected based on their availability in the DHS dataset and their established association with ovulatory cycle knowledge from previous studies [6,9,10]. These included: age group (15-19, 20-29, 30-39, 40-49 years), educational level (no education, primary, secondary, higher education), marital status (not married, married, cohabiting), employment status (employed, not employed) household wealth index (poor, middle, rich) religion (Catholic, Protestant, Adventist, Muslim, other), media exposure (no, yes), History of pregnancy loss (no, yes), fertility desire (yes, undecided, no), contraceptive use (non-user, traditional, modern), parity (zero, one birth, two and three births, four or more births), perceived distance to health facility (not a big problem, big problem), place of residence (urban, rural), province (Kigali City, Southern Province, Western Province, Northern Province, Eastern Province).

Statistical analysis: data was analysed using STATA version 17.0. Survey weights were applied to account for the complex sampling design of the DHS, ensuring nationally representative estimates and reliable standard errors. Multicollinearity among independent variables was assessed using the variance inflation factor (VIF), and no evidence of collinearity was observed. Descriptive statistics were performed, with categorical variables summarised as frequencies and percentages. A bivariate analysis was conducted using chi-square tests of independence at a 95% confidence interval. Variables with a p-value less than 0.10 in the bivariate analysis were considered eligible for inclusion in the multivariate analysis. A multivariable logistic regression model was fitted to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs), and statistical significance was set at p < 0.05.

Ethical considerations: this study was a secondary analysis of the RDHS, utilising publicly available data from the DHS program; therefore, separate ethical approval was not required. The study drew on a large-scale national dataset that had already received approval from Macro International, the Rwandan National Institute of Statistics, and the National Ethics Review Board in Rwanda. Access to the dataset was granted through the DHS program's online application process.

Results     

Background characteristics of the study participants: this study analysed a weighted sample of 14,503 women of reproductive age in Rwanda. The majority of women were aged 35-49 years (32.6%; n = 4,726). Most participants had completed primary education (58.3%; n = 8,452) and nearly half of the respondents were not married (49.5%; n = 7,175). A majority of women were employed (73.2%; n = 10,619), and most belonged to rich households (43.7%; n = 6,333). In terms of religion, the majority identified as Protestant (47.5%; n = 6,890). Most participants reported media exposure (81.9%; n = 11,881). The majority had no history of pregnancy loss (87.6%; n = 12,711). Fertility desire was common, with 61.8% (n = 8,961) reporting a desire for children. Regarding contraceptive use, 61.5% (n = 8,914) were non-users, while only 3.4% (n = 492) used traditional methods. In terms of parity, 36.4% (n = 5,276) had no children. Most participants perceived distance to a health facility as not a big problem (78.9%; n = 11,436). The majority resided in rural areas (80.1%; n = 11,617). Geographically, most respondents came from the Eastern province (27.3%; n = 3,958), while the least came from Kigali city (14.8%; n = 2,142) (Table 1).

Prevalence of correct ovulatory cycle knowledge among reproductive-age women in Rwanda: the pooled prevalence of correct ovulatory cycle knowledge among reproductive-age women in Rwanda was 16.6% (95% CI: 15.8-17.5). The prevalence varied across provinces, with women in the Eastern province reporting the highest knowledge (21.8%, 95% CI: 20.2-23.5) and those in the Western province the lowest (12.3%, 95% CI: 11.1-13.6) (Figure 1).

Correlates of correct ovulatory cycle knowledge among reproductive-age women in Rwanda: as shown in Table 2, the adjusted logistic regression model identified several factors significantly associated with correct ovulatory cycle knowledge among reproductive-age women in Rwanda. For instance, women aged 20-24 years (aOR = 1.66, 95% CI: 1.38-2.00), 25-34 years (aOR = 1.93, 95% CI: 1.55-2.39), and 35-49 years (aOR = 2.15, 95% CI: 1.68-2.77) were associated with higher odds of correct ovulatory cycle knowledge compared to adolescents aged 15-19 years, holding other variables constant in the model. Compared to women with no formal education, those with primary education (aOR = 1.65, 95% CI: 1.33-2.06), secondary education (aOR = 4.36, 95% CI: 3.42-5.55), and higher education (aOR = 9.58, 95% CI: 7.10-12.92) were associated with higher odds of correct ovulatory cycle knowledge. Married women were also associated with higher odds compared to unmarried women (aOR = 1.24, 95% CI: 1.06-1.46). Employment status was significantly associated with correct ovulatory cycle knowledge, with employed women having higher odds compared to women who were not employed (aOR = 1.34, 95% CI: 1.18-1.53). In terms of wealth status, women from rich households were associated with higher odds of correct ovulatory cycle knowledge compared to those from poor households (aOR = 1.42, 95% CI: 1.24-1.63), holding other variables constant in the model. Women exposed to media had higher odds of correct ovulatory cycle knowledge compared to those not exposed (aOR = 1.57, 95% CI: 1.33-1.85). Regarding contraceptive use, women using traditional methods were associated with higher odds of correct ovulatory cycle knowledge compared to non-users (aOR = 1.39, 95% CI: 1.08-1.79). Geographical variations were also observed. Women residing in the Northern (aOR = 1.47, 95% CI: 1.20-1.79) and Eastern provinces (aOR = 2.16, 95% CI: 1.80-2.60) had higher odds of correct ovulatory cycle knowledge compared to those residing in Kigali, holding other variables constant in the model.

Discussion     

This study sought to estimate the pooled prevalence of ovulatory cycle knowledge and its correlates among reproductive-age women in Rwanda. The overall prevalence was 16.6% (95% CI: 15.8-17.5), which is notably lower than findings from other SSA countries, including Ethiopia (23.6%) [9], Kenya (38.1%) [10] and Ghana (42.3%) [6]. These variations in prevalence may be attributable to differences in cultural norms surrounding family planning, disparities in health care systems, and unequal access to reproductive health information among these countries.

In the adjusted logistic regression model, higher odds of correct ovulatory cycle knowledge were observed among women aged 20-24 years, 25-34 years, and 35-49 years, those with primary, secondary and higher education, married and employed women, women from rich households, those exposed to media, women using traditional contraceptive methods, and women residing in the Northern and Eastern provinces.

This study found that women aged 20-49 years had higher odds of correct ovulatory cycle knowledge. This finding is consistent with studies conducted in Ethiopia [30], and other African countries [31], suggesting that reproductive health knowledge improves with age. This may be explained by increased exposure to reproductive health information over time, including interactions with healthcare systems, peer networks, and life experiences such as marriage and childbearing. Older women are also more likely to have engaged with family planning services, which often include fertility education [32]. This finding underscores the need to target younger women with age-appropriate fertility education to improve early awareness.

Education was also associated with correct ovulatory cycle knowledge, with women who had secondary and higher education having higher odds. This finding aligns with previous studies from other SSA countries [33,34], showing that education enhances women's ability to access, understand, and utilise reproductive health information. Educated women are more likely to be exposed to sexual and reproductive health (SRH) information through formal curricula, media, and digital platforms, and are better equipped to interpret biological concepts such as the menstrual cycle [35]. This highlights the importance of promoting female education as a long-term strategy for improving reproductive health outcomes.

This study further revealed that married women had higher odds of correct ovulatory cycle knowledge. This may be explained by the fact that married women are more likely to access antenatal care during pregnancy, where counselling on fertility and reproductive health is routinely provided. Married women also tend to engage more frequently with family planning services, which emphasise understanding the ovulatory cycle as part of contraceptive counselling. In addition, marital communication often involves discussions about fertility, childbearing, and family planning, which can reinforce awareness and knowledge [36]. While this association highlights the role of marriage in shaping reproductive health knowledge, it also underscores a potential gap among unmarried women. Addressing this disparity requires broadening reproductive health education beyond marital and antenatal care contexts, ensuring that adolescents, unmarried women, and men also receive comprehensive fertility information.

Consistent with a study conducted in Haiti [37], being employed was found to be associated with higher odds of correct ovulatory cycle knowledge, which may be explained by the fact that economically empowered women often have greater access to health information and services. Employment can enhance women's autonomy, expand their social networks, and increase exposure to diverse information channels, all of which contribute to improved reproductive health knowledge [38]. Similarly, women from rich households demonstrated higher odds of correct ovulatory cycle knowledge, likely reflecting their better access to education, media, and healthcare services [19]. These findings underscore the importance of addressing socio-economic disparities in reproductive health education to ensure that women across different economic strata are equally equipped with the knowledge necessary for informed fertility and family planning decisions.

The finding that higher media exposure is associated with higher odds of correct ovulatory cycle knowledge is similar to a study conducted in Kenya [10], highlighting the role of mass media as a key channel for disseminating reproductive health information. Media platforms can influence knowledge by providing accurate information on fertility, contraception, and menstrual hygiene and health. This underscores the importance of leveraging media campaigns to improve fertility awareness and address misconceptions around reproductive health and fertility issues.

The use of traditional contraceptive methods was associated with higher odds of correct ovulatory cycle knowledge. This can be explained by the fact that traditional contraceptive methods such as the rhythm method rely directly on understanding the timing of ovulation [39]. Women using these methods may actively seek and receive information about their menstrual cycle to use these methods effectively.

Geographic disparities were also observed, with women residing in the Northern and Eastern provinces having higher odds of correct ovulatory cycle knowledge. These differences can be attributed to several reproductive health interventions targeted at rural provinces in Rwanda, where the government relies heavily on community health workers to deliver direct, personalised education on reproductive health. For instance, community health workers were trained in obstetrics, newborn care, family planning, HIV/STI prevention, and sexual and gender-based violence (SGBV) response, while peer educators and female mentors were equipped to deliver adolescent sexual and reproductive health information. Community leaders also received training to empower their communities to use family planning, antenatal care, and SRH services [40]. This finding underscores the need to address geographic inequalities in access to reproductive health information and services across the country.

Strengths and limitations: this study has several important strengths. Firstly, it utilized a weighted nationally representative RDHS data, ensuring that the findings are generalizable across the country. The large sample size enhanced statistical power and reliability. Another strength lies in the study's focus on ovulatory cycle knowledge, which is an underexplored area in reproductive health research. By examining this dimension, the study contributes new insights into fertility awareness, an aspect often overlooked in favor of contraceptive use in SSA. Despite these strengths, the study also has limitations. Its cross-sectional design makes it impossible to establish causality and temporality between correlates and outcome. The reliance on self-reported data introduces the risk of response bias and social desirability bias, particularly around sensitive reproductive health topics. Additionally, because the study relied on already available DHS data, it lacked socio-cultural variables such as norms, beliefs, and attitudes that could provide a deeper context for understanding variations in ovulatory cycle knowledge. This absence limits the ability to fully capture the cultural and social dynamics influencing ovulatory cycle knowledge in Rwanda.

Conclusion     

This study found that correct ovulatory cycle knowledge among reproductive-age women in Rwanda remains low. Older age, higher education, marriage, employment, higher wealth status, media exposure, and use of traditional contraceptive methods were significantly associated with correct ovulatory cycle knowledge, with notable geographic disparities across the country. Therefore, there is a need to strengthen comprehensive sexuality education and fertility awareness programs, particularly targeting younger, less educated, and economically disadvantaged women. Policymakers and stakeholders, including the Rwanda Ministry of Health, should scale up targeted interventions that utilise mass media and community-based platforms to disseminate accurate reproductive health information. Additionally, efforts should focus on reducing geographic disparities by improving access to SRH services and information in underserved areas. Integrating fertility awareness education into routine healthcare services and school curricula will be critical to enhancing women's reproductive autonomy and improving overall reproductive health outcomes.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Winny Clemence Uwidutatse and Costly Aderibigbe-Saba: conceptualisation. Winny Clemence Uwidutatse: data curation. Samkeliso Gift Shongwe: visualisation. Samkeliso Gift Shongwe and Kooko Ronald: formal analysis. Winny Clemence Uwidutatse and Samkeliso Gift Shongwe: writing the original draft. Costly Aderibigbe-Saba: writing and reviewing the manuscript. Imran Oludare Morhason-Bello and Kooko Ronald: review. Imran Oludare Morhason-Bello: supervision, editing of the manuscript. Kooko Ronald and Imran Oludare Morhason-Bello: validation of the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgments     

We gratefully acknowledge the Pan African University Life and Earth Sciences Institute (including Health and Agriculture), Ibadan, Nigeria, for supporting the conduct of this research. We also thank the DHS Program for granting access to the RDHS Survey datasets, and we extend our appreciation to the women who participated in the surveys.

Tables and figure     

Table 1: background and distribution of the study participants in Rwanda

Table 2: correlates of ovulatory cycle knowledge among reproductive-age women in Rwanda

Figure 1: prevalence of ovulatory cycle knowledge among reproductive-age women in Rwanda

References