Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis.

BACKGROUND: Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals. METHODS: Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model. RESULTS: Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths. CONCLUSIONS: Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival

Detectable Viral Load in Late Pregnancy among Women in the Rwanda Option B+ PMTCT Program: Enrollment Results from the Kabeho Study.

There are limited viral load (VL) data available from programs implementing Option B+, lifelong antiretroviral treatment (ART) to all HIV-positive pregnant and postpartum women, in resource-limited settings. Extent of viral suppression from a prevention of mother-to-child transmission of HIV program in Rwanda was assessed among women enrolled in the Kigali Antiretroviral and Breastfeeding Assessment for the Elimination of HIV (Kabeho) Study. ARV drug resistance testing was conducted on women with VL\u3e2000 copies/ml. In April 2013-January 2014, 608 pregnant or early postpartum HIV-positive women were enrolled in 14 facilities. Factors associated with detectable enrollment VL (\u3e20 copies/ml) were examined using generalized estimating equations. The most common antiretroviral regimen (56.7%, 344/607) was tenofovir/lamivudine/efavirenz. Median ART duration was 13.5 months (IQR 3.0-48.8); 76.1% of women were on ART at first antenatal visit. Half of women (315/603) had undetectable RNA-PCR VL and 84.6% (510) had36 months compared to those on ART 4-36 months (72/191, 37.7% versus 56/187, 29.9%), though the difference was not significant. The odds of having detectable enrollment VL decreased significantly as duration on ART at enrollment increased (AOR = 0.99, 95% CI: 0.9857, 0.9998, p = 0.043). There was a higher likelihood of detectable VL for women with lower gravidity (AOR = 0.90, 95% CI: 0.84, 0.97, p = 0.0039), no education (AOR = 2.25, (95% CI: 1.37, 3.70, p = 0.0004), nondisclosure to partner (AOR = 1.97, 95% CI: 1.21, 3.21, p = 0.0063) and side effects (AOR = 2.63, 95% CI: 1.72, 4.03, p36 months with genotyping available. Most women were receiving ART at first antenatal visit, with relatively high viral suppression rates. Shorter ART duration was associated with higher VL, with a concerning increasing trend for higher viremia and drug resistance among women on ART for \u3e3 years

Trends and social differentials in child mortality in Rwanda 1990–2010: results from three demographic and health surveys

Background: Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. Methods: We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15–49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mother's educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. Results: Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005–2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. Conclusions: Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths

Transitioning to Country Ownership of HIV Programs in Rwanda

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs

Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda.

AIM: To evaluate the educational effectiveness of the Helping Babies Breathe programme. METHODS: Knowledge of trainees from two district hospitals and one tertiary referral hospital was evaluated before and after training in 2010. A postcourse practical skills evaluation was performed on a Neonatalie Newborn Simulator. Participants underwent a re-evaluation after 3 months. RESULTS: One hundred eighteen trainees completed the course. The percentages of correct answers on a written test significantly increased from 77 ± 15% to 91 ± 9% (p < 0.01) after training. The mean score obtained on a postcourse skill evaluation was 89 ± 9%; 64% of the trainees achieved passing scores. Retesting 3 months later showed that knowledge remained at the same level, while practical skills decreased to 83 ± 16%, and the pass rate dropped significantly to 43% (p < 0.01). CONCLUSION: Healthcare workers who participate in a Helping Babies Breathe programme can significantly improve their knowledge. While such knowledge is retained for at least 3 months, skills dropped to unsatisfactory levels in that period of time, indicating the need for retraining in the interim or the acquisition of practical experience by such healthcare workers

Social equity in perinatal survival : a case-control study at hospitals in Kigali, Rwanda

AIM: Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital. METHODS: A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders. RESULTS: We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance. CONCLUSION: Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not

Additional file 1: of Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis

Case study A. (DOC 22 kb

Additional file 2: of Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis

Case study B. (DOC 22 kb

Kabeho Study Cohort Screening and Enrollment Diagram.

<p>Kabeho Study Cohort Screening and Enrollment Diagram.</p