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Pregnancy and delivery-related complications in Rwanda: prevalence, associated risk factors, health economic impact, and maternal experiences
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda.ORCID iD: 0000-0001-8166-4527
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Every year more than 1.5 million women suffer from pregnancy and delivery-related complications (PDCs) during pregnancy and childbirth worldwide, and these women are a vulnerable population for lifelong consequences, somatically, psychologically and financially. Following the establishment of Millennium Development Goal no 5, which targeted a reduction of 75% of the maternal mortality ratio from 1990 to 2015, many efforts were made to reduce maternal mortality worldwide. In low-income countries saving a pregnant woman’s life requires a focused medical intervention so that near-miss cases of death are considered as obstetric success and thus postpartum follow-up may be neglected. In Rwanda, maternal mortality is estimated to 210 per 100,000 live births and main obstetric complications are hypertensive disorders during pregnancy, obstructive/prolonged labour, post-partum haemorrhage (PPH) and sepsis/infections. However, the specific prevalence of PDCs as well as their consequences to the woman and her family is currently relatively unknown.

Aims: The overall aim of this thesis was to determine the prevalence of PDCs and their associated risk factors and to investigate delivered women’s experiences of PDCs, the consequences of these complications on postpartum health and family situation, and to estimate the societal economic costs of pregnancy, delivery and postpartum-related problems.

Subjects and methods: A population-based cross-sectional study including 921 women who gave birth within the past 13 months prior to time of data collection (Paper I) and a health facility-based study including 817 women that were at discharge time (Paper II) were conducted in the Northern Province of Rwanda and Kigali City. Fifteen women who experienced PDCs were interviewed through individual in-depth qualitative interviews (Paper III). A micro costing approach to collect health facility data and household costs including opportunity cost, transport and food cost was conducted to estimate the societal economic cost of PDCs (Paper I-V). Descriptive statistics, Chi-Square, bi- and multivariable logistic regression, Cox regression, and health economic analysis were applied for quantitative data analyses (Papers I, II and IV). Qualitative manifest and latent content analysis was used for qualitative data analyses (Paper III).

Results: Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were estimated to 15.0%, 4.9%, 2.4%, and 3.7%, respectively (Paper I). In total, 56.4% of the participants were transferred and the majority were transferred from health centres to district hospitals, with caesarean section (CS) as the main reason for transfer. Almost three-quarters of the women started labour spontaneously; 5% had induced labour and 28.4% of all pregnant women were delivered by CS (Paper II). Pre-eclampsia/eclampsia, PPH, and caesarean section (CS) due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively (Paper II). Risk factors for CS due to prolonged labour or dystocia were poverty, nulliparity, and residence far from health facility (Paper II). The prevalence of poor-self rated health (poor-SRH) for participants who gave birth within the past 14 months prior to time of data collection was 32.2% at one day postpartum, 7.8% at one month, and 11.7% at time of the interview (Paper I). Most participants who had experienced PDCs reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications (Paper III). Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems (Paper III). PDCs negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity (Paper III). The estimated total societal cost of a normal uncomplicated vaginal delivery was 107 United States dollars (USD). The incremental cost of a vaginal delivery followed by PPH was 55 USD. The incremental cost of prolonged, dystocic or obstructed labour resulting in a CS was 146 USD. The incremental cost of pre-eclampsia with vaginal delivery and pre-eclampsia with CS were 289 and 339 USD, respectively. The major cost categories of the estimated costs for each mode of delivery were staff, the hospitalisation rooms, and household expenditures (Paper IV).

Conclusions: A high prevalence of poor self-rated health status was reported in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. The estimated prevalences of specific pregnancy and delivery-related complications were relatively low, probably in part due to underestimation. Rwandan women experiencing PDCs are facing many challenges and problems during pregnancy, delivery and postpartum period. The costs of PDCs were calculated to be very high in comparison to the net median monthly wage in Rwanda. In addition, the Rwandan health system presents weaknesses in relation to the prevention of PDCs. Above all, there is an insufficient postpartum health care provision and community support to women experiencing PDCs. The results from this thesis call for interventions, to improve the postpartum health care services and call for the community sensitisation for the increased support to women who face difficult living circumstances because they have experienced severe pregnancy and delivery-related complications.

Place, publisher, year, edition, pages
Umeå: Umeå University, Department of Clinical Sciences Obstetrics and Gynecology , 2018. , p. 67
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1973
Keywords [en]
Pregnancy and delivery-related complications, cross-sectional study, qualitative method, costing study, health economics, epidemiology, self-rated health status, pregnancy, childbirth, postpartum, Rwanda, prevalence, experiences
National Category
Obstetrics, Gynecology and Reproductive Medicine Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-152496ISBN: 978-91-7601-923-8 (print)OAI: oai:DiVA.org:umu-152496DiVA, id: diva2:1254132
Public defence
2018-11-02, Bergasalen, Målpunkt Q, Plan 0, Norrlands univeristetsjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2018-10-11 Created: 2018-10-08 Last updated: 2018-10-10Bibliographically approved
List of papers
1. Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study
Open this publication in new window or tab >>Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study
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2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 340Article in journal (Refereed) Published
Abstract [en]

Background: Self-rated health status (SRH) can be used as a predictor of morbidity and mortality. Postpartum self-rated health has been used to estimate maternal morbidity and postpartum problems. Reproductive history factors are associated with poor self-rated health postpartum. This study investigated prevalence of self-reported health problems during first, second, and third trimesters of pregnancy, delivery, and postpartum. In addition, this study investigated SRH in Rwandan women up to 13 months from partus. Methods: This population-based, cross-sectional study collected data in 2014 using structured interviews (N = 921). Univariable analysis was used to identify variables that were associated with poor self-rated health status (poor-SRH). Logistic regression analyses were performed to identify factors associated with poor-SRH at one day, one week, and one month postpartum and at the time of the interview. Results: Mean time between latest delivery and the time of interview was 7.1 months. Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were 15.0, 4.9, 2.4, and 3.7 %, respectively. The prevalence of poor-SRH was 32.2 % at one day postpartum, 7.8 % at one month, and 11.7 % at time of the interview. Hypertension during pregnancy and significant postpartum haemorrhage were associated with poor-SRH at one day and one week postpartum. Severe bleeding during pregnancy and labour were associated with poor-SRH at one week and one month postpartum. Infection and anaemia during pregnancy were associated with poor-SRH at one month postpartum and at the time of interview. The Kaplan-Meier curves illustrate restitution of health for most women during the study period. Conclusions: This population-based study reports a high prevalence of poor SRH status among Rwandan women in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. These factors may be prevented or reduced by providing more frequent and specific attention during pregnancy and by providing timely measures that address complications during delivery, including adequate postpartum care.

Keywords
Self-rated health status, Pregnancy, Rwanda, Reproductive history, Cross-sectional study, Pregnancy-related complications
National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-129839 (URN)10.1186/s12884-016-1138-y (DOI)000387606600001 ()27821082 (PubMedID)
Available from: 2017-01-16 Created: 2017-01-09 Last updated: 2018-10-08Bibliographically approved
2. Prevalence of pregnancy-related complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross-sectional study
Open this publication in new window or tab >>Prevalence of pregnancy-related complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross-sectional study
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2017 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 7, article id e015015Article in journal (Refereed) Published
Abstract [en]

Objectives: This study estimated health facility-based prevalence for pre-eclampsia/eclampsia, postpartum haemorrhage and caesarean section (CS) due to prolonged labour/dystocia. The background characteristics of Rwandan pregnant women, the course of labour and the level of healthcare were investigated in relation to pregnancy and delivery outcomes. Methods: This is health facility-based study and data were collected in 2014-2015 through structured interviews and medical records (n=817) in Kigali and Northern Province, Rwanda. Frequencies and prevalence were used to describe participants' background factors, labour and deliveryrelated characteristics. Bivariable and multivariable logistic regression models were performed for different background factors and pregnancy/delivery outcomes. Results: Pre-eclampsia/eclampsia, postpartum haemorrhage and CS due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively. In total, 56.4% of the participants were transferred from facilities with low levels to those with higher levels of healthcare, and the majority were transferred from health centres to district hospitals, with CS as the main reason for transfer. Participants who arrived at the health facility with cervical dilation grade of <= 3 cm spent more hours in maternity ward than those who arrived with cervical dilatation grade of <= 4 cm. Risk factors for CS due to prolonged labour or dystocia were poor households, nulliparity and residence far from health facility. Conclusions: The estimated health facility-based prevalence of pregnancy-related complications was relatively low in this sample from Rwanda. CS was the main reason for the transfer of pregnant women from health centres to district hospitals. Upgrading the capacity of health centres in the management of pregnant women in Rwanda may improve maternal and fetal health.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2017
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-141836 (URN)10.1136/bmjopen-2016-015015 (DOI)000410203700063 ()
Available from: 2017-11-15 Created: 2017-11-15 Last updated: 2018-10-08Bibliographically approved
3. “Not taken seriously”: A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications
Open this publication in new window or tab >>“Not taken seriously”: A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications
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2019 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 2, article id e0212001Article in journal (Refereed) Published
Abstract [en]

Background: There is limited knowledge on the women’s experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women’s experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation.

Methods: Data were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13–24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis.

Results: Most participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies.

Conclusions: The findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women’s individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.

Place, publisher, year, edition, pages
Public Library of Science, 2019
Keywords
Interviews, pregnancy, delivery, postpartum, experiences, complications, Rwanda, qualitative method, content analysis
National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:umu:diva-152493 (URN)10.1371/journal.pone.0212001 (DOI)000458761300067 ()30759136 (PubMedID)
Note

Originally included in thesis in manuscript form

Available from: 2018-10-08 Created: 2018-10-08 Last updated: 2019-03-26Bibliographically approved
4. Estimation of the economic costs of pregnancy and delivery-related complications in Rwanda
Open this publication in new window or tab >>Estimation of the economic costs of pregnancy and delivery-related complications in Rwanda
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(English)Manuscript (preprint) (Other academic)
Keywords
Hospital, pregnancy, pregnancy complication, delivery complication, cost
National Category
Obstetrics, Gynecology and Reproductive Medicine Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-152495 (URN)
Available from: 2018-10-08 Created: 2018-10-08 Last updated: 2018-10-09

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