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Abstract Background Diarrhea, defined as three or more loose stool per day, is a major cause of child mortality. Exploring its spatial distribution, prevalence, and influencing factors is crucial for public health decision and targeted interventions. This study aimed to investigate these aspects using 2019 Rwanda demographic health survey data. Method A total 7,978 (weighted) under-five children were included in this study. Spatial clustering (hotspots areas) were mapped using ArcGIS and SaTscan software. A multilevel logistic regression model was fitted to assessed factors associated with diarrhea, reporting significance at p

Abstract Background Nurses and midwives are at the forefront of the provision of Emergency Obstetric and Neonatal Care (EmONC) and Continuous Professional Development (CPD) is crucial to provide them with competencies they need to provide quality services. This research aimed to assess uptake and accessibility of midwives and nurses to CPD and determine their knowledge and skills gaps in key competencies of EmONC to inform the CPD programming. Methods The study applied a quantitative, cross-sectional, and descriptive research methodology. Using a random selection, forty (40) health facilities (HFs) were selected out of 445 HFs that performed at least 20 deliveries per month from July 1st, 2020 to June 30th, 2021 in Rwanda. Questionnaires were used to collect data on updates of CPD, knowledge on EmONC and delivery methods to accessCPD. Data was analyzed using IBM SPSS statistics 27 software. Results Nurses and midwives are required by the Rwandan midwifery regulatory body to complete at least 60 CPD credits before license renewal. However, the study findings revealed that most health care providers (HCPs) have not been trained on EmONC after graduation from their formal education. Results indicated that HCPs who had acquired less than 60 CPD credits related to EmONC training were 79.9% overall, 56.3% in hospitals, 82.2% at health centres and 100% at the health post levels. This resulted in skills and knowledge gaps in management of Pre/Eclampsia, Postpartum Hemorrhage and essential newborn care. The most common method to access CPD credits included workshops (43.6%) and online training (34.5%). Majority of HCPs noted that it was difficult to achieve the required CPD credits (57.0%). Conclusion The findings from this study revealed a low uptake of critical EmONC training by nurses and midwives in the form of CPD. The study suggests a need to integrate EmONC into the health workforce capacity building plan at all levels and to make such training systematic and available in multiple and easily accessible formats. Implication on nursing and midwifery policy Findings will inform the revision of policies and strategies to improve CPD towards accelerating capacity for the reduction of preventable maternal and perinatal deaths as well as reducing maternal disabilities in Rwanda.

IntroductionOne of the targets for the third sustainable development goals is to reduce worldwide maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030. To address issues affecting women and the newborns during childbirth and postnatal period, concerted efforts from governments and their stakeholders are crucial to maximize the use of technology to enhance frontline health professionals' skills to provide the emergency obstetric and newborn care (EmONC). However, no study has garnered nurses' and midwives' perspectives regarding the application of technology-enhanced learning approach to provide on-the-job Continuous Professional Development (CPD) and factors that may influence the application of this training approach in the Rwandan context.MethodsThe study collected data from nurses and midwives from forty (40) public health facilities in remote areas nationwide. The study applied a qualitative descriptive design to explore and describe nurses' and midwives' perspectives on the feasibility and acceptability of technology enhanced learning approaches such as e-learning, phone-based remote training, and other online methods to provide trainings in EmONC. Two focus group discussions with EmONC mentors, two with nurses and midwives were conducted. Twelve key informant interviews were conducted. Participants were selected purposively. In total, 54 individuals were included in this study. A thematic approach was used to analyse data.ResultsNurses and midwives highlighted the need to provide refresher trainings about the management of pre-eclampsia. Most of the EmONC trainings are still provided face-to-face and the use of technology enhanced learning approaches have not yet been embraced in delivering EmONC CPDs for nurses and midwives in remote areas. Nurses and midwives found the first developed prototype of smartphone app training of the EmONC acceptable as it met the midwives' expectations in terms of the knowledge and skills' gap in EmONC.ConclusionAlthough the newly developed application was found acceptable, further research involving practical sessions by nurses and midwives using the developed application is needed to garner views about the ease of use of the application, relevance of the EmONC uploaded content on the app, and needed improvements on the app to address their needs in EmONC.

Abstract Background Prematurity is still the leading cause of global neonatal mortality, Rwanda included, even though advanced medical technology has improved survival. Initial hospitalization of premature babies (PBs) is associated with high costs which have an impact on Rwanda’s health budget. In Rwanda, these costs are not known, while knowing them would allow better planning, hence the purpose and motivation for this research. Methods This was a prospective cost of illness study using a prevalence approach conducted in 5 hospitals (University Teaching Hospital of Butare, Gisenyi, Masaka, Muhima, and Ruhengeri). It included PBs admitted from June to July 2021 followed up prospectively to determine the medical direct costs (MDC) by enumerating the cost of all inputs. Descriptive analyses and ordinary least squares regression were used to illustrate factors associated with and predictive of mean cost. The significance level was set at p

Abstract Background The shortage of health care providers (HCPs) and inequity in their distribution along with the lack of sufficient and equal professional development opportunities in low-income countries contribute to the high mortality and morbidity of women and newborns. Strengthening skills and building the capacity of all HCPs involved in Maternal and Newborn Health (MNH) is essential to ensuring that mothers and newborns receive the required care in the period around birth. The Training, Support, and Access Model (TSAM) project identified onsite mentorship at primary care Health Centers (HCs) as an approach that could help reduce mortality and morbidity through capacity building of HCPs in Rwanda. This paper presents the results and lessons learnt through the design and implementation of a mentorship model and highlights some implications for future research. Methods The design phase started with an assessment of the status of training in HCs to inform the selection of Hospital-Based Mentors (HBMs). These HBMs took different courses to become mentors. A clear process was established for engaging all stakeholders and to ensure ownership of the model. Then the HBMs conducted monthly visits to all 68 TSAM assigned HCs for 18 months and were extended later in 43 HCs of South. Upon completion of 6 visits, mentees were requested to assist their peers who are not participating in the mentoring programme through a process of peer mentoring to ensure sustainability after the project ends. Results The onsite mentorship in HCs by the HBMs led to equal training of HCPs across all HCs regardless of the location of the HC. Research on this mentorship showed that the training improved the knowledge and self-efficacy of HCPs in managing postpartum haemorrhage (PPH) and newborn resuscitation. The lessons learned include that well trained midwives can conduct successful mentorships at lower levels in the healthcare system. The key challenge was the inconsistency of mentees due to a shortage of HCPs at the HC level. Conclusions The initiation of onsite mentorship in HCs by HBMs with the support of the district health leaders resulted in consistent and equal mentoring at all HCs including those located in remote areas.

Abstract Background There are a number of factors that may contribute to high mortality and morbidity of women and newborns in low-income countries. These include a shortage of competent health care providers (HCP) and a lack of sufficient continuous professional development (CPD) opportunities. Strengthening the skills and building the capacity of HCP involved in the provision of maternal, newborn and child health (MNCH) is essential to ensure quality care for mothers, newborns and children. To address this challenge in Rwanda, mentorship of HCPs was identified as an approach that could help build capacity, improve the provision of care and accelerate the reduction in maternal and neonatal mortality and morbidity. In this paper, we describe the development and implementation of a novel mentorship model named Four plus One (4+ 1) for MNCH in Rwanda. Methods The mentorship model built on the basis of inter-professional collaboration (IPC) was developed in early 2017 through consultations with different key actors. The design phase included refresher courses in specific skills and training course on mentoring. Field visits were conducted in 10 hospitals from June 2017 to February 2020. Hospital management teams (MT) were involved in the development and implementation of this mentorship model to ensure ownership of the program. Results Upon completion of planned visits to each hospital, a total of 218 HCPs were involved in the process. Reports prepared by mentors upon each mentorship visit and compiled by Training Support and Access Model (TSAM) for MNCH’CPD team, highlighted the mothers and newborns who were saved by both mentors and mentees. Also, different logbooks of mentees showed how the capacity of staff was strengthened, thereby suggesting effectiveness of the model. Through different mentorship coordination meetings, the model was much appreciated by the MTs of hospitals, especially the IPC component of the model and confirmed the program ‘effectiveness. Conclusion The initiation of a mentorship model built on IPC together with the involvement of the leadership of the hospital may be the cause effect of reduction of specific mortality and improve MNCH in low resource settings even when there are a limited number of specialists in the health facilities.

Abstract Background Nurses and midwives are a critical part of the healthcare team and make up the largest section of health professionals. Leadership styles are believed to be an important determinant of job satisfaction and retention making effective leadership within nursing and midwifery crucial to health systems success. In Rwanda, there are gaps in knowledge of managerial leadership styles of nurses and midwives and the influence of these styles on job satisfaction and retention for nurses and midwives who report to them, as well as their influence on the provision of health services. This study describes the managerial leadership styles adopted by nurses/midwives and examines the relationship between managerial leadership styles and job satisfaction, intention to stay, and service provision. Methods The Path-Goal Leadership questionnaire was adopted and used to collect data on leadership styles while other questionnaires with high validity and reliability were used to collect data on job satisfaction, intention to stay and service provision. The study involved 162 full-time nurses and midwives practicing in 5 selected hospitals with a minimum of 6 months of experience working with their current direct managers. Regression analysis was used to draw conclusions on relationships between variables. Results Nurses and midwives managers were more inclined to the directive leadership style followed by a supportive leadership style, and the participative leadership style. The nurse and midwife’s managerial leadership styles together significantly explained 38, 10 and 23% of the variance in job satisfaction, intention to stay and service provision, respectively. Conclusion The findings of this study indicate that managerial leadership styles play a substantial role in enhancing job satisfaction, intention to stay and service provision. The implication for nursing and midwifery management There is a need to develop a comprehensive formal professional continuous development course on leadership styles and ensure that all nurses and midwives managers benefit from this course prior to or immediately after being appointed as a manager. Having such a course may even prepare future leaders for their role early in their career. Effective leadership in nursing and midwifery should be enhanced at all levels to improve the job satisfaction of nurses and midwives, address the issue of retention in their respective health facilities and strengthen service provision.

Objectives To identify mentors’ perspectives on strengths and weaknesses of the Training, Support and Access Model for Maternal, Newborn and Child Health (TSAM-MNCH) clinical mentorship programme in Rwandan district hospitals. Understanding the perspectives of mentors involved in this programme can aid in the improvement of its implementation.Design The study used a qualitative approach with in-depth interviews.Setting Mentors of TSAM-MNCH clinical mentorship programme mentoring health professionals at district hospitals of Rwanda.Participants 14 TSAM mentors who had at least completed six mentorship visits on a regular basis in three selected district hospitals.Results Mentors’ accounts demonstrated an appreciation of the two mentoring structures which are interprofessional collaboration and training. These structures are highlighted as the strengths of the mentoring programme and they play a significant role in the successful implementation of the mentorship model. Inconsistency of mentoring activities and lack of resources emerged as major weaknesses of the clinical mentorship programme which could hinder the effectiveness of the mentoring scheme.Conclusion The findings of this study highlight the strengths and weaknesses perceived by mentors of the TSAM-MNCH clinical mentorship programme, providing insights that can be used to improve its implementation. The study represents unique TSAM-MNCH structural settings, but its findings shed light on Rwandan health system issues that need to be further addressed to ensure better quality of care for mothers, newborns and children.