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Child survival in Rwanda: Challenges and potential for improvement: Population- and hospital-based studies
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

After the 1994 genocide and collapse of the health system, Rwanda initiated major social and health reforms in order to reduce child mortality and health inequities in accordance with the Millennium Development Goals. The aim of this thesis was to assess trends in under-five mortality (U5M) and equity in child survival, to study social barriers for improved perinatal and neonatal survival, and to evaluate Helping Babies Breathe (HBB), a newborn resuscitation program.

In paper I we analysed trends and social inequities in child mortality 1990−2010, using data from national Demographic and Health Surveys conducted in 2000, 2005, and 2010. The following papers were based on hospital studies in the capital of Rwanda. In paper II we explored social inequities in perinatal mortality. Using a perinatal audit approach, paper III assessed factors related to the three delays, which preceded perinatal deaths, and estimates were made of potentially avoidable deaths. Paper IV evaluated knowledge and skills gained and retained by health workers after training in HBB.

Under-five mortality declined from the peak of 238 deaths per 1000 live births (95% CI 226 to 251) in 1994 to 65 deaths per 1000 live births (95% CI 61 to 70) in 2010 and concurred with decreased social gaps in child and neonatal survival between rural and urban areas and household wealth groups. Children born to women with no education still had significantly higher under-five mortality. Neonatal mortality also decreased but at a slower rate as compared to infant and U5M. Maternal rural residence or having no health insurance were linked to increased risk of perinatal death. Neither maternal education nor household wealth was associated with perinatal mortality risks. Lack of recognition of pregnancy danger signs and intrapartum-related suboptimal care were major contributors to perinatal deaths, whereof one half was estimated to be potentially avoidable. Knowledge significantly improved after training in HBB. This knowledge was sustained for at least 3 months following training whereas practical skills had declined.

These results highlight the need for strengthening coverage of lifesaving interventions giving priority to underserved groups for improved child survival at community as well as at hospital levels.  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 84 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1122
Keyword [en]
Trends, social differentials, child mortality, perinatal mortality, perinatal audit, three delays model, training healthcare workers, Helping Babies Breathe, urban hospitals, Kigali, Rwanda
National Category
Medical and Health Sciences
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-259476ISBN: 978-91-554-9288-5 (print)OAI: oai:DiVA.org:uu-259476DiVA: diva2:844322
Public defence
2015-09-23, Rosensalen, Barnsjukhuset Akademiska sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-09-01 Created: 2015-08-05 Last updated: 2015-10-01
List of papers
1. Trends and social differentials in child mortality inRwanda 1990–2010: results from three demographicand health surveys
Open this publication in new window or tab >>Trends and social differentials in child mortality inRwanda 1990–2010: results from three demographicand health surveys
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2015 (English)In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 69, no 9, 834-840 p.Article in journal (Refereed) Published
Abstract [en]

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

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-251290 (URN)10.1136/jech-2014-204657 (DOI)000359388800004 ()
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-04-14 Created: 2015-04-14 Last updated: 2017-12-04Bibliographically approved
2. Social equity in perinatal survival: a case-control study at hospitals in Kigali, Rwanda
Open this publication in new window or tab >>Social equity in perinatal survival: a case-control study at hospitals in Kigali, Rwanda
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2015 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 104, no 12, 1233-1240 p.Article in journal (Refereed) Published
Abstract [en]

AIM:

Rwanda has invested heavily in improving maternal and child health, but knowledge is limited regarding social equity in perinatal survival. We analysed whether perinatal mortality risks differed between social groups in hospitals in the country's capital.

METHODS:

A case-control study was carried out on singleton births aged at least 22 weeks of gestation and born in district or tertiary referral hospitals in Kigali from July 2013 to May 2014. Perinatal deaths were recorded as they occurred, with the next two surviving neonates born in the same hospital selected as controls. Conditional logistic regression was used to determine social determinants of perinatal death after adjustments for potential confounders.

RESULTS:

We analysed 234 perinatal deaths and 468 controls. Rural residence was linked to an increased risk of perinatal death (OR = 3.31, 95% CI 1.43-7.61), but maternal education or household asset score levels were not. Having no health insurance (OR = 2.11, 95% CI 0.91-4.89) was associated with an increased risk of perinatal death, compared to having community health insurance.

CONCLUSION:

Living in a rural area and having no health insurance were associated with an increased risk of perinatal mortality rates in the Rwandan capital, but maternal education and household assets were not.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-251587 (URN)10.1111/apa.12951 (DOI)000367536000019 ()25640733 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2015-04-21 Created: 2015-04-21 Last updated: 2017-12-04Bibliographically approved
3. Case review of perinatal deaths with application of a three delays analysis at hospitals in Kigali, Rwanda
Open this publication in new window or tab >>Case review of perinatal deaths with application of a three delays analysis at hospitals in Kigali, Rwanda
(English)Manuscript (preprint) (Other academic)
Abstract [en]

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

Keyword
Perinatal audit, three delays model, urban hospitals, Rwanda
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-259480 (URN)
Available from: 2015-08-05 Created: 2015-08-05 Last updated: 2015-09-04
4. Evaluating helping babies breathe: Training for healthcare workers at hospitals in Rwanda
Open this publication in new window or tab >>Evaluating helping babies breathe: Training for healthcare workers at hospitals in Rwanda
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2013 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 102, no 1, e34-e38 p.Article in journal (Refereed) Published
Abstract [en]

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

Keyword
Education, Healthcare workers, Helping Babies Breathe, Hospital, Rwanda
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-192028 (URN)10.1111/apa.12034 (DOI)000312313200017 ()
Available from: 2013-01-21 Created: 2013-01-15 Last updated: 2017-12-06Bibliographically approved

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