Rural District Hospital In Rwanda Research Articles

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda.

Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Enablers and barriers to post-discharge follow-up among women who have undergone a caesarean section: experiences from a prospective cohort in rural Rwanda

BackgroundCaesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda.MethodsWomen aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return.ResultsOf 586 study participants, the majority (62.6%) were between 21–30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43–37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07–38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03–0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50).ConclusionmHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.

Implementation of a Pediatric Early Warning Score to Improve Communication and Nursing Empowerment in a Rural District Hospital in Rwanda.

Pediatric early warning (PEW) scores represent a "track-and-trigger system" that identifies clinical deterioration in a patient's condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses' knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses' feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. Implementation of PEW scores increased nurses' technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.

Presentation of Pediatric Unintentional Injuries at Rural Hospitals in Rwanda: A Retrospective Study.

Background:Injuries are a leading cause of mortality among children globally, with children in low- and middle-income countries more likely to die if injured compared to children in high-income countries. Timely and high-quality care are essential to reduce injury-related morbidity and mortality.Objectives:This study describes patterns, management, and outcomes of children 0–15 years presenting with unintentional injuries at three district hospitals in rural Rwanda between January 1 and December 31, 2017.Methods:Using a retrospective cross-sectional study design, we assessed the demographic and clinical characteristics, care provided, and outcomes of the children using data extracted from patient medical charts. We describe the patient population using frequencies and proportions as well as median and interquartile ranges.Findings:Of the 449 injured children who sought care at the three rural district hospitals, 66.2% (n = 297) were boys. The main causes of injury were falls (n = 261, 58.1%), burns (n = 101, 22.5%), and road traffic injuries (n = 67, 14.9%). Burns were the most common injury among children aged 0–5 years while falls were the leading injury type among the 5–15 years age group. Vital signs were inconsistently completed ranging between 23.8–89.1% of vital sign items. Of the injured children, 37.0% (n = 166) received surgery at the district hospital, general practitioners performed 80.9% (n = 114) of surgeries, 87.4% (n = 145) of operated patients received no anesthesia, and 69.3% (n = 311) were admitted to the district hospital, while 2.7% (n = 12) were transferred to tertiary facilities for higher-level care.Conclusions:The presentation of child injuries—namely falls, burns, and road traffic accidents—is similar to what has been reported in other sub-Saharan African countries. However, more needs to be done to improve the completion and documentation of vital signs and increase availability of surgical specialists. Finally, targeted strategies to prevent burns and motorcycle-related injuries are recommended prevention interventions for this rural population.

Treatment of Hodgkin Lymphoma With ABVD Chemotherapy in Rural Rwanda: A Model for Cancer Care Delivery Implementation.

PURPOSEHodgkin lymphoma (HL) is highly curable in high-income countries (HICs), yet many patients around the world do not have access to therapy. In 2012, cancer care was established at a rural district hospital in Rwanda through international collaboration, and a treatment protocol using doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiotherapy was implemented.METHODSWe conducted a retrospective cohort study of all patients with confirmed HL seen at Butaro Hospital from 2012 to 2018 to evaluate quality indicators and clinical outcomes.RESULTSEighty-five patients were included (median age, 16.8 years; interquartile range, 11.0-30.5 years). Ten (12%) were HIV positive. Most had B symptoms (70%) and advanced stage (56%) on examination and limited imaging. Of 21 specimens evaluated for Epstein-Barr virus, 14 (67%) were positive. Median time from biopsy to treatment was 6.0 weeks. Of 73 patients who started ABVD, 54 (74%) completed 6 cycles; the leading reasons for discontinuation were treatment abandonment and death. Median dose intensity of ABVD was 92%. Of 77 evaluable patients, 33 (43%) are in clinical remission, 27 (36%) are deceased, and 17 (22%) were lost to follow-up; 3-year survival estimate is 63% (95% CI, 50% to 74%). Poorer performance status, advanced stage, B symptoms, anemia, dose intensity < 85%, and treatment discontinuation were associated with worse survival.CONCLUSIONTreating HL with standard chemotherapy in a low-resource setting is feasible. Most patients who completed treatment experienced a clinically significant remission with this approach. Late presentation, treatment abandonment, and loss to follow-up contribute to the discrepancy in survival compared with HICs. A strikingly younger age distribution in our cohort compared with HICs suggests biologic differences and warrants further investigation.

Implementation of a Pediatric Early Warning Score (PEWS) as a Tool for Improving Communication and Nursing Empowerment in a Rural District Hospital in Rwanda

Program Goals: Pediatric Early Warning Scores (PEWS) are a “track and trigger system” (Leonard, e11), identifying clinical deterioration as early as eleven hours preceding a sentinel event (Akre, e763). Prior to implementation, nurses reported feeling unprepared to advocate for their patients; lacking both the vocabulary and agency to highlight deteriorating patients to physicians. Primarily evaluated in high-income countries, we implemented PEWS in a rural, district hospital in Rwanda; a novel protocol in this setting. Our primary aims were to: 1. Utilize the PEWS tool to improve communication between nurses and …

Implementation of a Pediatric Early Warning Score (PEWS) as a Tool for Improving Communication and Nursing Empowerment in a Rural District Hospital in Rwanda

Implementation of a Pediatric Early Warning Score (PEWS) as a Tool for Improving Communication and Nursing Empowerment in a Rural District Hospital in Rwanda

Parents as carers on a neonatal unit: Qualitative study of parental and staff perceptions in a low-income setting

AimTo determine parents' experiences on a neonatal unit in a low-income country, how they and staff perceive the role of parents and if parents' role as primary carers could be extended. BackgroundA busy, rural district hospital in Rwanda. Rwandan neonatal mortality is falling, but achieving Sustainable Development Goal target is hampered by trained staff shortage. MethodsQualitative thematic content analysis of semi-structured interviews with 12 parents and 16 staff. ResultsParental concerns were around their baby's survival, stress and discharge. They were satisfied with their baby's care but feared their baby may die. Mothers described stress from remaining in hospital throughout baby's stay, providing all non-technical care including tube or breast feeds day and night, followed by kangaroo mother care until discharge. They expressed loneliness from lack of visitors, difficulty finding food and somewhere to sleep, financial worries, concern about family at home, and were desperate to be discharged. Staff focused on shortage of nurses limiting technical care, ability to educate parents and provide follow-up. Neither groups thought parents' role could be extended. ConclusionStaff, including senior management, were mainly focused on increasing nursing numbers. Parents' concerns were psychosocial and about coping emotionally with their baby's care and practical concerns about inpatient facilities, particularly lack of food and accommodation and absence from home. Staff preoccupation with nurse numbers made them concentrate on medical care, but parental issues identified are more likely to be provided by experienced mothers, allied health professionals, mothers' groups or community health workers.

Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient-Reported Travel Times

BackgroundSince long travel times to reach health facilities are associated with worse outcomes, geographic accessibility is one of the six core global surgery indicators; this corresponds to the second of the “Three Delays Framework,” namely “delay in reaching a health facility.” Most attempts to estimate this indicator have been based on geographical information systems (GIS) algorithms. The aim of our study was to compare GIS derived estimates to self-reported travel times for patients traveling to a district hospital in rural Rwanda for emergency obstetric care.MethodsOur study includes 664 women who traveled to undergo a Cesarean delivery in Kirehe, Rwanda. We compared self-reported travel time from home to the hospital (excluding waiting time) with GIS estimated travel times, which were computed using the World Health Organization tool AccessMod, using linear regression.ResultsThe majority of patients used multiple modes of transportation (walking = 48.5%, public transport = 74.2%, private transport = 2.9%, and ambulance 70.6%). Self-reported times were longer than GIS estimates by a factor of 1.49 (95% CI 1.40–1.57). Concordance was higher when the GIS model took into account that all patients in Rwanda are referred via their health center (β = 1.12; 95% CI 1.05–1.18).ConclusionsTo our knowledge, in this largest to date GIS validation study for geographical access to healthcare in low- and middle-income countries, a standard GIS model was found to significantly underestimate real travel time, which likely is in part because it does not model the actual route patients are travelling. Therefore, previous studies of 2-h access to surgery will need to be interpreted with caution, and future studies should take local travelling conditions into account.

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda.

Background:In rural sub-Saharan Africa, access to care for severe non-communicable diseases (NCDs) is limited due to myriad delivery challenges. We describe the implementation, patient characteristics, and retention rate of an integrated NCD clinic inclusive of cancer services at a district hospital in rural Rwanda.Methods:In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014. We report descriptive statistics of patient characteristics and retention.Results:Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hypertension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%.Conclusions:The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.

A Machine Learning-Based Triage Tool for Children With Acute Infection in a Low Resource Setting.

To deploy machine learning tools (random forests) to develop a model that reliably predicts hospital mortality in children with acute infections residing in low- and middle-income countries, using age and other variables collected at hospital admission. Post hoc analysis of a single-center, prospective, before-and-after feasibility trial. Rural district hospital in Rwanda, a low-income country in Sub-Sahara Africa. Infants and children greater than 28 days and less than 18 years of life hospitalized because of an acute infection. None. Age, vital signs (heart rate, respiratory rate, and temperature) capillary refill time, altered mental state collected at hospital admission, as well as survival status at hospital discharge were extracted from the trial database. This information was collected for 1,579 adult and pediatric patients admitted to a regional referral hospital with an acute infection in rural Rwanda. Nine-hundred forty-nine children were included in this analysis. We predicted survival in study subjects using random forests, a machine learning algorithm. Five prediction models, all including age plus two to five other variables, were tested. Three distinct optimization criteria of the algorithm were then compared. The in-hospital mortality was 1.5% (n = 14). All five models could predict in-hospital mortality with an area under the receiver operating characteristic curve ranging between 0.69 and 0.8. The model including age, respiratory rate, capillary refill time, altered mental state exhibited the highest predictive value area under the receiver operating characteristic curve 0.8 (95% CI, 0.78-0.8) with the lowest possible number of variables. A machine learning-based algorithm could reliably predict hospital mortality in a Sub-Sahara African population of 949 children with an acute infection using easily collected information at admission which includes age, respiratory rate, capillary refill time, and altered mental state. Future studies need to evaluate and strengthen this algorithm in larger pediatric populations, both in high- and low-/middle-income countries.

Report on the Treatment of Hodgkin Lymphoma with ABVD Chemotherapy at Two Rural District Hospitals in Rwanda

Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high-resource settings, there are few reports of HL treatment in low-resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy-confirmed HL seen at Butaro and Rwinkwavu hospitals between October 2009 and June 2018. Data were extracted from clinical charts and analyzed using descriptive statistics and Kaplan-Meier logrank testing. Results: Ninety HL patients were seen at Butaro (n=85) and Rwinkwavu (n=5); 58% male, median age 16 (IQR 10.6-30.5) with 54% under age 18. Eleven (12%) were HIV positive. Mean duration of presenting symptoms at the time of intake was 54 weeks; 70% had B symptoms. Nodular sclerosis was the predominant histological subtype (47%) followed by mixed cellularity (28%). Of 24 biopsy specimens evaluated for EBV, 14 (58%) were positive, 10 (42%) negative. Most patients were staged with chest x-ray (81%); fewer had abdominal ultrasound (34%), CT (21%), or bone marrow biopsy (20%). Resulting Ann Arbor stages were I (17%), II (28%), III (32%), IV (20%), and undetermined (3%). Median time from initial biopsy to first dose of ABVD was 6.1 weeks (IQR 3.6-11.9). Of 76 patients who started ABVD, 56 (74%) completed all 6 cycles; the leading reasons for discontinuation were loss to follow up (n=9) and death (n=7). Median time to completion of the 24-week ABVD regimen was 26.1 weeks; 51 patients (67%) experienced at least one treatment delay. Neutropenia, social factors, and infection were the most common reasons for delays. Dose reductions were rare. Mean dose intensity over 6 cycles was 87.2% calculated per Owadally, et al. 2010; &lt;86% in 40% of patients, 86-97% in 32%, and &gt;97% in 28%. Of the 76 patients started on ABVD, 34 (45%) are in clinical remission, 21 (28%) are deceased, 2 (3%) referred to palliative care, and 19 (25%) are lost to follow up at a median interval of 48 months from intake. Univariate analysis demonstrates that stage III-IV (p=0.0000), ECOG performance status 2-4 (p=0.0004), hemoglobin &lt;10.5 g/dL (p=0.01), WBC &gt; 15,000 mm3 (p=0.05), B symptoms (p=0.004), and extranodal disease (0.0004) were associated with worse survival. Conclusions: We observed a strikingly younger age distribution in our cohort compared to the classic bimodal distribution reported in high income countries, suggesting biologic differences that warrant further investigation. Treating HL with standard chemotherapy in a low-resource setting through international partnership is feasible, and nearly half of patients who complete treatment may experience a clinically significant remission with this approach. Late presentation, treatment delays, and loss to follow up are among major reasons to explain the discrepancy in survival compared to high income countries. Further efforts should tackle these identified barriers to achieve better survival outcomes. Figure Disclosures No relevant conflicts of interest to declare.

Patient, clinician and logistic barriers to blood pressure control among adult hypertensives in rural district hospitals in Rwanda: a cross-sectional study

BackgroundHypertension management in rural, resource-poor settings is difficult. Detailed understanding of patient, clinician and logistic factors which pose barriers to effective blood pressure control could enable strategies to improve control to be implemented.MethodsThis cross-sectional, multifactorial, observational study was conducted at four rural Rwandan district hospitals, examining patient, clinician and logistic factors. Questionnaires were administered to consenting adult outpatient hypertensive patients, obtaining information on sociodemographic factors, past management for hypertension, and adherence (by Morisky Medication Adherence 8-item Scale (MMAS-8). Treating clinicians identified local difficulties in providing hypertension management from a standard World Health Organisation list and nominated their preferred treatment regimens. Blood pressure measurements and other clinical data were collected during the study visit and used to determine blood pressure control, according to goals from JNC-8 guidelines. Medication availability and cost at each hospital’s pharmacy were reviewed as logistic barriers to treatment.ResultsThe 112 participating patients were 80% female, with only 41% having completed primary education. Self-reported adherence by the MMAS-8 was high in 77% (86/112) and significantly associated) with literacy, lack of medication side effects and the particular hospital and pharmacy attended (all p < 0.05). However, of 89 patients with blood pressure data, only 26 (29%) had achieved goal blood pressure. No patient factor were statistically associated with poor blood pressure control. Among 30 participating clinicians, deficiencies in knowledge were evident; 43% (13/30) and 37% (11/30) chose a loop diuretic as their prescribed medication and as an ideal medication, respectively, for a newly diagnosed hypertensive patient without comorbidities, counter to JNC 8 recommendations, and 50% (15/30) identified clinician non-adherence to hypertension guidelines as a barrier. In the pharmacies, common anti-hypertensive medications were affordably available (> 6 out of 8 examined medications available in all pharmacies, cost <US$0.50 per month); however, clinicians perceived medication cost and availability to be barriers to care.ConclusionsClinician-based factors are a major barrier to blood pressure control in rural district hospitals in Rwanda, and blood pressure control overall was poor. Patient and logistic barriers to blood pressure were not evident in this study.

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

BackgroundIntegrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centres. This study examines the...

Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies

ObjectivesWe sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1–5 years by analysing verbal and social autopsies (VSA). Factors in the home,...

Cost of Integrated Chronic Care for Severe Noncommunicable Diseases at District Hospitals in Rural Sub-Saharan Africa

Background: Integrated clinical strategies to address noncommunicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention of behavioral risk factors and treatment of common conditions at primary health centers. This study examines the cost of decentralizing integrated nurse-driven, physician-supervised chronic care for more severe NCDs to outpatient specialty clinics associated with district hospitals in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, and heart failure. Methods: A retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro district hospital in rural Rwanda. We determined initial startup and annual operating cost of the Butaro district advanced NCD clinic for the fiscal year 2013-2014. Per-patient annual cost by disease category were determined. Findings: A total of $51,444 U.S. dollars (USD) in startup costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300,000 people ($0.2 per capita). The annual operating cost for this clinic was $68,040 USD ($0.3 per capita) to manage a 632-patient cohort and provide training, supervision, and mentorship to primary health centers. Labor comprised 53% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient ($151 USD), followed by heart failure ($104 USD), driven primarily by medication therapy and laboratory testing. Interpretation: This is the first study to evaluate the costs of integrated, decentralized chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems. Funding Statement: The authors declare: None. Declaration of Interests: The authors declare: None. Ethics Approval Statement: Ethical approval was obtained by the Rwanda National Ethics Committee and Institutional Review Board of Brigham and Women’s Hospital.

Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda.

BackgroundThere are few prospective studies of outcomes following surgery in rural district hospitals in sub-Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical-site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda.MethodsAdult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection.ResultsOf 729 women who had a caesarean section, 620 were eligible for follow-up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI.ConclusionThe prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub-Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Nurse-Driven Echocardiography and Management of Heart Failure at District Hospitals in Rural Rwanda.

Nurse-Driven Echocardiography and Management of Heart Failure at District Hospitals in Rural Rwanda.

A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants

BackgroundDespite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards.MethodsWe retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher’s exact or Wilcoxon rank-sum tests at the α = 0.05 significance level.ResultsA total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates (n = 965/1168) and 93.4% (n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% (n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days.ConclusionsOur results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries.