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Case review of perinatal deaths with application of a three delays analysis at hospitals in Kigali, Rwanda
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).
(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 [en]
Perinatal audit, three delays model, urban hospitals, Rwanda
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-259480OAI: oai:DiVA.org:uu-259480DiVA: diva2:844333
Available from: 2015-08-05 Created: 2015-08-05 Last updated: 2015-09-04
In thesis
1. Child survival in Rwanda: Challenges and potential for improvement: Population- and hospital-based studies
Open this publication in new window or tab >>Child survival in Rwanda: Challenges and potential for improvement: Population- and hospital-based studies
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.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1122
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
urn:nbn:se:uu:diva-259476 (URN)978-91-554-9288-5 (ISBN)
Public defence
2015-09-23, Rosensalen, Barnsjukhuset Akademiska sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
Available from: 2015-09-01 Created: 2015-08-05 Last updated: 2015-10-01

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