Search

The Sustainable Development Goals (SDGs) in part aim to further improve maternal health outcomes by reducing spatial disparities in utilization of critical services such as antenatal and assisted delivery, with emphasis on decentralization and integration of strategies. Yet, our understanding of within country spatial disparities in maternal health services (MHS) utilization over time has been scant. By fitting multiple regression models to a pooled dataset of the 2010/11 and 2014/15 Rwanda Demographic and Health Surveys (n = 12,273), and employing post-estimation margins analysis, we examined spatial differentiation of MHS trends prior to the SDGs in Rwanda. Our study found that women in 2014/15 were more likely to utilize antenatal services and assisted delivery (OR = 1.757, p ≤ 0.001) compared with 2010/11, but with nuanced spatial variations. Compared with Nyarugenge, women in nineteen out of the twenty-nine remaining districts were more likely to report utilization of antenatal services and skilled birth delivery, while the probability of accessing four or more antenatal services in seven districts declined between 2010/11 and 2014/15. Physical, financial and socio-cultural factors were associated with maternal health service utilization over the period. Based on our findings, we present policy suggestions for improving utilization of MHS in Rwanda and in similar contexts in the SDGs period., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with TBI in low and middle-income countries have worse outcomes than patients in high-income countries. We evaluated important clinical indicators associated with mortality for patients with TBI at University Teaching Hospital of Kigali, Kigali, Rwanda., Methods: A prospective consecutive sampling of patients with TBI presenting to University Teaching Hospital of Kigali Accident and Emergency Department was screened for inclusion criteria: reported head trauma, alteration in consciousness, headache, and visible head trauma. Exclusion criteria were age <10 years, >48 hours after injury, and repeat visit. Data were assessed for association with death using logistic regression. Significant variables were included in a multivariate logistic regression model and refined via backward elimination., Results: Between October 7, 2013, and April 6, 2014, 684 patients were enrolled; 14 (2%) were excluded because of incomplete data. Of patients, 81% were male with mean age of 31 years (range, 10-89 years; SD 11.8). Most patients (80%) had mild TBI (Glasgow Coma Scale [GCS] score 13-15); 10% had moderate (GCS score 9-12) and 10% had severe (GCS score 3-8) TBI. Multivariate logistic regression determined that GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were significantly associated with death., Conclusions: GCS score <13, hypoxia, bradycardia, tachycardia, and age >50 years were associated with mortality. These findings inform future research that may guide clinicians in prioritizing care for patients at highest risk of mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

In limited resource settings such as Rwanda, visual inspection with acetic acid (VIA) is the primary model for cervical cancer screening. The objective of this study was to describe clinical characteristics and outcomes for women presenting for cervical cancer screening. A prospective, observational study was conducted between September 2015 and February 2016 at Kigali University Teaching Hospital (CHUK). Women referred to the VIA clinic were enrolled and completed a semi-structured questionnaire. During the six-month study period, 150 women were enrolled and evaluated with VIA followed by colposcopy directed biopsy for VIA positive. The median age was 42 years (IQR 36-49). Only 20 (13.3%) asymptomatic women presented for screening exam, whereas 126 (84%) were symptomatic. Among symptomatic patients, more than one-third had never had a speculum exam prior to referral (n = 43). Twenty-two (14.7%) women were VIA positive, and 8 (5.3%) had lesions suspicious for cancer, while 120 (80%) were found to be VIA negative. Among women undergoing biopsy (n = 30), 11 were normal (36.7%), 5 cases showed CIN 1 (16.6%), 4 cases showed CIN 2 (13.3%), 2 cases showed CIN 3 (6.7%) and 8 were confirmed cervical cancers (26.7%). In Rwanda, VIA is the current method for cervical cancer screening. In this study, few asymptomatic patients presented for cervical cancer screening. Increasing knowledge about cervical cancer screening and expanding access are key elements to improving cervical cancer control in Rwanda.

Objectives: Rwanda was the first country in Africa to introduce the human papillomavirus (HPV) vaccine. This was achieved through multi-year school-based campaigns. Our study evaluated the impact of the HPV vaccine introduction on the country's immunisation programme and health system., Methods: Thirty key informants were interviewed at national and district levels, and in participating schools. Twenty-seven health facilities completed a questionnaire exploring the effects of the new vaccine introduction on six health system building blocks, as defined by the World Health Organization. Routine service activity data were collected during a 90-day period around the introduction., Results: Routine vaccination activities were not disrupted during the delivery, likely due to a strong Expanded Program on Immunization, appropriate planning and a well-resourced operation. Opportunities were seized to co-deliver other interventions targeted at children and adolescents, such as health promotion. Collaboration with the Ministry of Education was strengthened at national level. Although there were some temporary increases in staff workload, no major negative effects were reported., Conclusion: Despite its delivery through school-based campaigns, the HPV vaccine integrated well into the immunisation programme and health system. The introduction had no major negative effects. Some opportunities were seized to expand services and collaborations., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: To explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss')., Design: A study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda., Findings: All informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy., Conclusions: 'Near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications, Implications for Practice: These findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: We aimed to explore the impacts of new vaccine introductions on immunization programmes and health systems in low- and middle-income countries., Methods: We conducted case studies of seven vaccine introductions in six countries (Cameroon, PCV;Ethiopia, PCV; Guatemala, rotavirus; Kenya, PCV; Mali, Meningitis A; Mali, PCV; Rwanda, HPV). Inter-views were conducted with 261 national, regional and district key informants and questionnaires were completed with staff from 196 health facilities. Routine data from districts and health facilities were gathered on vaccination and antenatal service use. Data collection and analysis were structured around the World Health Organisation health system building blocks., Findings: The new vaccines were viewed positively and seemed to integrate well into existing health systems. The introductions were found to have had no impact on many elements within the building blocks framework. Despite many key informants and facility respondents perceiving that the new vaccine introductions had increased coverage of other vaccines, the routine data showed no change. Positive effects perceived included enhanced credibility of the immunisation programme and strengthened health workers' skills through training. Negative effects reported included an increase in workload and stock outs of the new vaccine, which created a perception in the community that all vaccines were out of stock in a facility. Most effects were found within the vaccination programmes; very few were reported on the broader health systems. Effects were primarily reported to be temporary, around the time of introduction only., Conclusion: Although the new vaccine introductions were viewed as intrinsically positive, on the whole there was no evidence that they had any major impact, positive or negative, on the broader health systems.

Objective: timely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals., Design: health facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis., Setting: interviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda., Participants: 17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care., Measurements and Findings: inductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits., Key Conclusions: qualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews., Implications for Practice: study findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To measure maternal and fetal hemodynamics during acute malaria in pregnancy., Methods: Time courses of maternal heart rate (MHR), maternal blood pressure (BP), and fetal heart rate (FHR) were performed until 56 days after initiation of anti-malarial treatment with artemether-lumefantrine. Women with malaria were hospitalized for at least 3 days until recovery., Results: Mean baseline characteristics of pregnant women with malaria (n=38) versus pregnant women without malaria (n=39) were as follows: gestational age (28.8 vs 24.6 weeks; P=0.006); maximum FHR (165.3 vs 158.3 beats per minute [bpm]; P=0.054); minimum FHR (137.6 vs 128.7 bpm; P=0.016); mean BP (74.7 vs 80.9 mm Hg; P=0.001); pulse pressure (40.3 vs 42.1mm Hg; P=0.300); and MHR (107.4 vs 81.3 bpm; P<0.001). The geometric mean parasite count was 13 795 per μL. Complete time courses were collected from a subgroup of participants. For women with malaria, maternal body temperature and BP normalized within 24 hours and after 72 hours, respectively. The MHR among pregnant women without malaria showed a physiologic increase during pregnancy of approximately 7 bpm between days 0 and 56. The mean FHR among women with malaria normalized after 72 hours., Conclusion: Acute malaria induces maternal and fetal hemodynamic changes., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the knowledge, attitudes, and practices of obstetric care providers (OCPs) in Bugesera District, Rwanda, crucial to the delivery of safe motherhood services., Methods: A quantitative descriptive survey in Kinyarwanda targeting all OCPs in the district was implemented in November 2010 to determine demographic characteristics, safe motherhood knowledge, obstetric practices, and attitudes toward additional training., Results: The study captured 87% of OCPs, of whom 137 of 168 (82%) were A2 level nurses. Most expressed a need to improve their knowledge (60.6%) and skills confidence (72.2%) in safe motherhood. The mean percentage of correct answers of 50 questions assessing overall knowledge was 46.4%; sections on normal labor (39.3% correct) and obstetric complications (37.1% correct) were the weakest. Fundal pressure during vaginal delivery was practiced by 60.8%, and only 15.9% of providers practiced active management of the third stage of labor for all deliveries. Providers supported additional training, and 89.3% expressed willingness to participate in a 2-day workshop even if it were their day off., Conclusion: The study has identified a need to improve safe motherhood knowledge and practices of OCPs in the Bugesera District of Rwanda. OCPs support additional training as an intervention to reduce maternal mortality., (Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)