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  • 1.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ntaganira, Joseph
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali ,Rwanda.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study2016In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 21, no 7, p. 895-906Article in journal (Refereed)
    Abstract [en]

    Objective To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Methods Physicians (n=19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. Results Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician protection'. Conclusions There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.

  • 2.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krantz, G.
    Nzayirambaho, M.
    Semasaka Sengoma, J. P.
    Condo, J.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health related quality of life determinants for Rwandan women after delivery2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 436-Article in journal (Other academic)
    Abstract [en]

    Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.

    Key messages:

    • Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.
    • Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
  • 3.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Condo, Jeanine
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study2018In: Journal of Health, Population and Nutrition, ISSN 1606-0997, E-ISSN 2072-1315, Vol. 37, article id 12Article in journal (Refereed)
    Abstract [en]

    Background: Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (113 months) after delivery and socio-economic and demographic factors were explored in Rwanda.

    Methods: In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors.

    Results: Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL.

    Conclusions: ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

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  • 4.
    Hitimana, Regis
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation2019In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 36Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

    METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

    RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

    DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

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  • 5.
    Holmlund, Sofia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, J.
    Edvardsson, K.
    Semasaka Sengoma, J. P.
    Hussein, K.
    Ngarina, M.
    Small, R.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Health professionals' experiences and views of obstetric ultrasound in Rwanda2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 367-Article in journal (Other academic)
    Abstract [en]

    Background: The World Health Organizatiońs new recommendations for antenatal care (ANC) include one ultrasound examination before 24 weeks of gestation. Implementation of ultrasound in ANC in low resource countries has been shown to increase pregnant women’s compliance to ANC visits, and facilitate detection of high-risk pregnancies. The aim of this study was to explore Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Methods: A cross-sectional questionnaire study involving physicians (n = 222), obstetricians (n = 29), nurses (n = 387) and midwives (n = 269) managing pregnant women in RWANDA was performed, as part of the CROss Country Ultrasound Study (CROCUS). Data were collected at 106 health facilities from November 2016 – March 2017.

    Preliminary results: One third of the participants performed ultrasound examinations (32.3%) and the majority on a daily basis (60.1%). The ultrasound examination where most participants reported high level skills was evaluation of the fetal heart rate (69.0%). A majority reported no skills or low level skills (79.9%) for ultrasound examination of the fetal heart, aorta and pulmonary artery. A majority (65.0%) reported that lack of ultrasound training of the ultrasound operator sometimes led to suboptimal pregnancy management. Almost all participants (91.3%) agreed that ANC would be improved if midwives were qualified to perform basic ultrasound examinations.

    Conclusions: The vast majority of health professionals in the study believed that maternity care can be improved if midwives learn to perform basic ultrasound examinations. Additional training of physicians performing obstetric ultrasound was also suggested to increase the quality of obstetric ultrasound surveillance and to further improve maternal and fetal health outcomes.

    Key messages:

    • Physicians managing pregnant women need more training in obstetric ultrasound.
    • Midwives need to be educated in performing obstetric ultrasounds.
  • 6.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, Joseph
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Lan, Pham Thi
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Kidanto, Hussein Lesio
    Ngarina, Matilda
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study2018In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 12, article id e0208387Article in journal (Refereed)
    Abstract [en]

    Objectives: Implementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women’s compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Methods: A cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387).

    Results: Obstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations.

    Conclusions: Barriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.

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  • 7.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, Joseph
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. La Trobe Univ, Judith Lumley Ctr, Melbourne, Vic, Australia.
    Lan, Pham Thi
    Sengoma, Jean Paul Semasaka
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Univ Rwanda, Coll Med & Hlth Sci, Sch Publ Hlth, Kigali, Rwanda.
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1350451Article in journal (Refereed)
    Abstract [en]

    Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed.

    Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

    Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS).

    Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed.

    Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda.

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  • 8.
    Mogren, Ingrid
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Ntaganira, Joseph
    School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Holmlund, Sophia
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Small, Rhonda
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia; Department of Women’s and Children’s and Reproductive Health, Karolinska Institutet, Stockholm, Sweden.
    Pham Thi, Lan
    Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Viet Nam.
    Kidanto, Hussein Lesio
    Medical College, East Africa Aga Khan University, Dar es Salaam, Tanzania.
    Ngarina, Matilda
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Bergström, Cecilia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Edvardsson, Kristina
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Maternal health care professionals’ experiences and views on the use of obstetric ultrasound in Rwanda: A cross-sectional study2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 789Article in journal (Refereed)
    Abstract [en]

    Background: This study, undertaken in Rwanda, aimed to investigate health professionals’ experiences and views on the following topics: current clinical guidelines for ultrasound from second trimester at the clinic, regional and national levels, and adherence to clinical guidelines; medically indicated ultrasound examinations; non-medical use of ultrasound including ultrasounds on maternal request; commercialisation of ultrasound; the value of ultrasound in relation to other clinical examinations in pregnancy; and ultrasound and medicalisation of pregnancy.

    Methods: A cross-sectional design was adopted. Health professionals providing antenatal care and delivery services to pregnant women in 108 health facilities were invited to complete a survey, which was developed based on the results of earlier qualitative studies undertaken as part of the CROss Country Ultrasound Study (CROCUS).

    Results: Nine hundred and seven health professionals participated: obstetricians/gynecologists (3.2%,) other physicians (24.5%), midwives (29.7%) and nurses (42.7%). Few physicians reported the existence of clinical guidelines at clinic, regional or national levels in Rwanda, and guidelines were moderately adhered to. Three obstetric ultrasound examinations were considered medically indicated in an uncomplicated pregnancy. Most participants (73.0%) were positive about obstetric ultrasound examinations on maternal request. Commercialisation was not considered a problem, and the majority (88.5%) agreed that ultrasound had contributed to medicalisation of pregnancy.

    Conclusions: Findings indicate that clinical guidelines for the use of obstetric ultrasound are limited in Rwanda. Non-medically indicated obstetric ultrasound was not considered a current problem at any level of the healthcare system. The positive attitude to obstetric ultrasound examinations on maternal request may contribute to further burden on a maternal health care system with limited resources. It is essential that limited obstetric ultrasound resources are allocated where they are most beneficial, and clearly stated medical indications would likely facilitate this.

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  • 9.
    Semasaka, Jean Paul S.
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Munyanshongore, Cyprien
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 340Article in journal (Refereed)
    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.

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  • 10.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda.
    Pregnancy and delivery-related complications in Rwanda: prevalence, associated risk factors, health economic impact, and maternal experiences2018Doctoral 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.

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  • 11.
    Semasaka Sengoma, Jean Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    University of Gothenburg.
    Nzayirambaho, Manasse
    University of Rwanda.
    Munyanshongore, Cyprien
    University of Rwanda.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    “Not taken seriously”: A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 2, article id e0212001Article in journal (Refereed)
    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.

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  • 12.
    Semasaka Sengoma, Jean Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. La Trobe University.
    Krantz, Gunilla
    University of Gothenburg.
    Nzayirambaho, Manasse
    University of Rwanda.
    Munyanshongore, Cyprien
    University of Rwanda.
    Hitimana, Regis
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of Rwanda.
    Edvardsson, Kristina
    La Trobe University.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pulkki-Brännström, Anni-Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Estimation of the economic costs of pregnancy and delivery-related complications in RwandaManuscript (preprint) (Other academic)
  • 13.
    Sengoma, Jean Paul Semasaka
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Munyanshongore, Cyprien
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    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 study2017In: BMJ Open, E-ISSN 2044-6055, Vol. 7, no 7, article id e015015Article in journal (Refereed)
    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.

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  • 14.
    Uwamahoro, Valentine
    et al.
    University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ndagijimana, Albert
    University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
    Humuza, James
    University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda.
    Perceptions and attitudes of midwives on respectful maternity care during childbirth: a qualitative study in three district hospitals of Kigali City of Rwanda2023In: Pan African Medical Journal, E-ISSN 1937-8688, Vol. 46, article id 110Article in journal (Refereed)
    Abstract [en]

    Introduction: Respectful Maternity Care (RMC) is "a universal human right for every childbearing woman". In Rwanda, few studies conducted on RMC assessed how women perceive care provided during childbirth, yet little is known about providers' perspectives. We investigated the perceptions and attitudes of midwives towards the provision of RMC to complement women's viewpoints.

    Methods: this qualitative study used individual in-depth interviews in Kinyarwanda language. A purposive sampling method was used to reach out to twenty-eight midwives from three district hospitals in Kigali City. Transcribed interviews were translated into English and thematic content analysis was performed using Atlas Ti, version 7. The University of Rwanda College of Medicine and Health Sciences Institutional Review Board (Ref: 363/CHMS/IRB/2019) ethically approved this study before data collection.

    Results: the majority of participants revealed that they have knowledge on RMC and perceive that they provide maternal health care based on women´s rights. Positive attitudes towards providing RMC were reported by midwives, however, a considerable number of participants reported the existence of abusive practices. The majority of midwives reported facing many challenges affecting their ability to provide respectful maternal care.

    Conclusion: midwives understand the seven rights of women and have a positive attitude towards providing RMC. However, abusive practices still exist while providing RMC with considerable challenges, including overload and lack of labour monitoring materials. The adjustment of the ratio of midwives to clients and the availability of essential materials in labour monitoring is recommended to improve the quality of healthcare received by women during childbirth.

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