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Miller H, Rudolfson N, Nkurunziza T, Cherian T, Kayitesi D, Mazimpaka C, Kateera F, Riviello R, Hedt-Gauthier B. Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda. Pan Afr Med J 2023; 46:30. [PMID: 38107338 PMCID: PMC10724031 DOI: 10.11604/pamj.2023.46.30.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2023] Open
Abstract
Introduction timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.
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Affiliation(s)
- Hillary Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
| | - Niclas Rudolfson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Word Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund University, Lund, Sweden
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
| | - Theoneste Nkurunziza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
| | | | | | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
- Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, United States of America
| | - Bethany Hedt-Gauthier
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
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Kassa ZY, Debelo BT, Burayu ET, Azene GK. Caesarean childbirth and associated factors during Covid-19 pandemic at public hospitals in the Sidama region, Southern Ethiopia. ETHICS, MEDICINE AND PUBLIC HEALTH 2022; 24:100840. [PMID: 36065216 PMCID: PMC9433345 DOI: 10.1016/j.jemep.2022.100840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022]
Abstract
Background The increasing number of caesarean births worldwide concerns pregnant women, obstetric service providers, and the country's economy. Unnecessary caesarean childbirth increases childbirth complications and the cost of health care in low-income countries, including Ethiopia. Objective This study aims to assess caesarean birth and associated factors at the Sidama region public hospitals, Southern Ethiopia, 2020. Methods An institution-based cross-sectional study was conducted among 484 women who gave birth at public hospitals in the Sidama region. A multi-stage sampling technique was employed. The data were collected from 1st to 30th of July 2020 by face-to-face interviews using a semi-structured questionnaire (see Table S1: see supplementary materials associated with this article on line), and the wealth index was analysed by principal component analysis. Backward logistic regression used an adjusted odds ratio and a 95% confidence interval to assess the strength and association between the caesarean section and its associated factors. A P-value of < 0.05 was used to declare statistical significance. Result Caesarean childbirth in this study was 34.3%. In this study, partograph monitoring (AOR = 2.23, CI = 1.13, 4.38), previous caesarean birth (AOR = 3.21, CI = 1.28,8.17), having genital cutting/mutilation (AOR = 2.51, CI = 1.14,5.53), intermittent cardiotocography monitoring during childbirth (AOR = 2.3, CI = 1.14, 4.49), absence of companionship during delivery (AOR = 4.97, CI = 2.37, 10.43) and is not remembering the last normal menstrual period (AOR = 3.12, CI = 1.40,6.94) had increased the odds of caesarean birth. Conclusion Studies show that the prevalence of caesarean has alarmingly increased in both developed and developing countries. However, the magnitude of caesarean section differs from country to country and in rural and urban areas; the magnitude of caesarean section in this study is much higher than the WHO recommends threshold. The local health bureau and obstetric care providers should pay attention to the caesarean section and need intervention in partograph plotting, companionship, cardiotocography, and female genital mutilation.
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Affiliation(s)
- Z Y Kassa
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - B T Debelo
- Department of Midwifery, College of Medicine and Health Science, Ambo University, Ambo, Ethiopia
| | - E T Burayu
- Department of Midwifery, College of Health Science, Mettu University, Mettu, Ethiopia
| | - G K Azene
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
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Nkurunziza T, Williams W, Kateera F, Riviello R, Niyigena A, Miranda E, Bikorimana L, Nkurunziza J, Velin L, Goodman AS, Matousek A, Klug SJ, Gaju E, Hedt-Gauthier BL. mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda. BMJ Glob Health 2022; 7:bmjgh-2022-009365. [PMID: 35902205 PMCID: PMC9341172 DOI: 10.1136/bmjgh-2022-009365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda. Methods This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis. Results Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%. Conclusions Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients’ acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.
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Affiliation(s)
- Theoneste Nkurunziza
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda .,Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Wendy Williams
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Robert Riviello
- Center for Surgery and Public Health, Harvard Medical School and Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.,Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Niyigena
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Vascular Surgery, University of Southern California, Los Angeles, California, USA
| | - Laban Bikorimana
- Research Department, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | | | - Lotta Velin
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Andrea S Goodman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex Matousek
- Northwest Heart and Lung Surgical Associates, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Stefanie J Klug
- Epidemiology, Department of Sport and Health Sciences, Technical University of Munich, München, Germany
| | - Erick Gaju
- eHealth Unit, Republic of Rwanda Ministry of Health, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Elias S, Wolde Z, Tantu T, Gunta M, Zewudu D. Determinants of early neonatal outcomes after emergency cesarean delivery at Hawassa University comprehensive specialised hospital, Hawassa, Ethiopia. PLoS One 2022; 17:e0263837. [PMID: 35324921 PMCID: PMC8947390 DOI: 10.1371/journal.pone.0263837] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/27/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Neonatal mortality after cesarean delivery is three folds higher than mortality after vaginal births. Post cesarean early neonatal outcomes are associated with preoperative and intraoperative fetomaternal factors which are preventable in the majority of cases. OBJECTIVE To identify determinants of early neonatal outcomes after emergency cesarean delivery at Hawassa University Comprehensive Specialized Hospital, Hawassa, Southern Ethiopia. METHOD Institution based cross sectional study was conducted on 270 emergency cesarean deliveries. Data were collected by using a pretested questionnaire by trained data collectors. Descriptive analysis was used to see the nature of the characteristics of interests. Pearson chi-square-test was used to check presence of association between independent and outcome variables. Bivariate analysis was used to sort out variables at p values less than 0.05 for multivariate logistic regression. Significance level was obtained using odds ratio with 95% CI and p value < 0.05. RESULTS The prevalence of adverse early neonatal outcome after emergency cesarean delivery was 26.7%. Around 11% of newborns had low (<7) fifth minute Apgar score and more than one-third (34.8%) of them admitted to neonatal intensive care unit for more than 24 hours. Fifteen (5.6%) newborns died within their first seven days of life. Neonates with a preoperative meconium-stained amniotic fluid and low birth weight (< 2500 grams) had greater odds of having adverse early neonatal outcome with (AOR = 6.37; 95% CI: 2.64, 15.34) and (AOR = 14.00; 95% CI: 3.64, 53.84) respectively. CONCLUSION The prevalence of adverse early neonatal outcome is high in this study and meconium-stained amniotic fluid during labor as well as low birth weight were the leading predictors of adverse early neonatal outcome during emergency cesarean delivery.
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Affiliation(s)
- Solomon Elias
- Department of Gynecology and Obstetrics, Final Year Resident in Obstetrics and Gynecology in Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Zenebe Wolde
- Department of Obstetrics and Gynecology in Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Temesgen Tantu
- Department of Obstetrics and Gynecology in Wolkite University College of Medicine and Health Sciences, Wolkite, Ethiopia
| | - Muluken Gunta
- Wolaita Zone Health Department Officer, Wolaita Sodo, Southern Nations, Ethiopia
| | - Dereje Zewudu
- Department of Anesthesia in Wolkite University College of Medicine and Health Sciences, Wolkite, Ethiopia
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Båvenäs E, Möller C, Bhandarkar P, Mulowooza J, Löfgren J. Predictors of immediate neonatal outcome after cesarean section in Uganda. Int J Gynaecol Obstet 2021; 158:101-109. [PMID: 34655232 DOI: 10.1002/ijgo.13986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/07/2021] [Accepted: 10/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda. METHODS Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother's age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed. RESULTS A total of 37 585 cesarean sections were recorded. The indications for cesarean section that led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar scores were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared with general anesthesia, spinal anesthesia was favorable for neonatal outcomes. CONCLUSION Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.
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Affiliation(s)
- Erica Båvenäs
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Prashant Bhandarkar
- WHO Collaborating Centre (WHOCC) for Research in Surgical Needs in LMICs, BARC Hospital, Mumbai, India.,School of Health System Studies, Tata Institute of Social Sciences (TISS), Mumbai, India
| | - Jude Mulowooza
- Makerere University School of Public Health, Kampala, Uganda
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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6
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Abdullahi YY, Assefa N, Roba HS. Magnitude and Determinants of Immediate Adverse Neonatal Outcomes Among Babies Born by Cesarean Section in Public Hospitals in Harari Region, Eastern Ethiopia. RESEARCH AND REPORTS IN NEONATOLOGY 2021. [DOI: 10.2147/rrn.s296534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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7
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Rudolfson N, Gruendl M, Nkurunziza T, Kateera F, Sonderman K, Nihiwacu E, Ramadhan B, Riviello R, Hedt-Gauthier B. Validating the Global Surgery Geographical Accessibility Indicator: Differences in Modeled Versus Patient-Reported Travel Times. World J Surg 2021; 44:2123-2130. [PMID: 32274536 PMCID: PMC7266844 DOI: 10.1007/s00268-020-05480-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Since 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. Methods Our 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. Results The 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). Conclusions To 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. Electronic supplementary material The online version of this article (10.1007/s00268-020-05480-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Niclas Rudolfson
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA. .,World Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Magdalena Gruendl
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Kristin Sonderman
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | | | | | - Robert Riviello
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, USA
| | - Bethany Hedt-Gauthier
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
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8
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Mazimpaka C, Uwitonze E, Cherian T, Hedt-Gauthier B, Kateera F, Riviello R, El-Khatib Z, Sonderman K, Gruendl M, Habiyakare C, Hakizimana S, Kayitesi D, Nkurunziza T. Perioperative Management and Outcomes After Cesarean Section-A Cross-Sectional Study From Rural Rwanda. J Surg Res 2020; 245:390-395. [PMID: 31425881 PMCID: PMC7055241 DOI: 10.1016/j.jss.2019.07.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/30/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cesarean sections (c-sections), the most common surgical procedures performed worldwide, are essential in reducing maternal and neonatal deaths. There is a paucity of research studies on c-section care and outcomes in rural African settings. The objective of this study was to describe demographic characteristics, clinical management, and maternal and neonatal outcomes among women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda. METHODS This retrospective cohort study included all women aged ≥ 18 y residing in KDH catchment area who delivered by c-section at KDH between April 1 and September 30, 2017. Demographic and clinical characteristics of these women and their newborns were collected using patient interviews and medical chart extraction. Descriptive analyses were performed, and frequency and percentages are reported. RESULTS Of the 621 women included in the study, 45.7% (n = 284) were aged 25-34 y; 42.2% (n = 262) were married; 67.5% (n = 419) had primary education; and 75.7% (n = 470) were farmers by occupation. Burundian refugees living in the nearby Mahama Refugee Camp comprised 13.7% (n = 85) of the study population. The most common indication for c-section was having undergone a c-section previously (31.9%, n = 198), followed by acute fetal distress (30.8%, n = 191). Among those with previous c-section as the sole indication for surgery, 85.4% presented as either urgent or emergent cases. Postoperatively, 67.7% spent less than 4 d at the hospital and 96.1% had no postoperative complications before discharge. Approximately 10% (59/572) of neonates were admitted to the neonatal unit, with the most common reason being neonatal infection (59.6%, n = 31). CONCLUSIONS Our study found that previous delivery via c-section was the primary indication for c-section and that most of these cases were emergent or urgent on presentation. This study highlights the need for further research to explore the feasibility, safety, and appropriateness of vaginal birth after cesarean in rural district hospitals in sub-Saharan Africa.
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Affiliation(s)
| | - Eline Uwitonze
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Bethany Hedt-Gauthier
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Fredrick Kateera
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ziad El-Khatib
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Kristin Sonderman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Magdalena Gruendl
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Department of Epidemiology, Technical University Munich, Munich, Germany
| | | | | | - Daniella Kayitesi
- Primary Health Care, Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
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9
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Odhiambo J, Ruhumuriza J, Nkurunziza T, Riviello R, Shrime M, Lin Y, Rusangwa C, Omondi JM, Toma G, Nyirimodoka A, Mpunga T, Hedt-Gauthier BL. Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing. Matern Child Health J 2019; 23:613-622. [PMID: 30600515 DOI: 10.1007/s10995-018-2674-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Jackline Odhiambo
- Partners In Health, 800 Boylston St Suite 300, Boston, MA, 02199, USA.
| | | | | | - Robert Riviello
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Shrime
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Yihan Lin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Jack M Omondi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Ministry of Health, Kigali, Rwanda
| | - Gabriel Toma
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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10
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Increased Rwandan Access to Obstetrician–Gynecologists Through a U.S.–Rwanda Academic Training Partnership. Obstet Gynecol 2019; 134:149-156. [DOI: 10.1097/aog.0000000000003317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Hedt-Gauthier BL, Riviello R, Nkurunziza T, Kateera F. Growing research in global surgery with an eye towards equity. Br J Surg 2019; 106:e151-e155. [DOI: 10.1002/bjs.11066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/12/2018] [Accepted: 10/30/2018] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Global surgery research is often generated through collaborative partnerships between researchers from both low- and middle-income countries (LMICs) and high-income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research.
Methods
This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda.
Results
Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding.
Conclusion
It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement.
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Affiliation(s)
- B L Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Partners In Health/Rwanda, Kigali, Rwanda
| | - R Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - F Kateera
- Partners In Health/Rwanda, Kigali, Rwanda
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Cavallaro FL, Pembe AB, Campbell O, Hanson C, Tripathi V, Wong KL, Radovich E, Benova L. Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time. BMJ Open 2018; 8:e024216. [PMID: 30287614 PMCID: PMC6173245 DOI: 10.1136/bmjopen-2018-024216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing. DESIGN Nationally representative, repeated cross-sectional surveys of women and health facilities. SETTING Tanzania. PARTICIPANTS Women of reproductive age and health facility staff. MAIN OUTCOME MEASURES Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment. RESULTS The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals). CONCLUSIONS Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.
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Affiliation(s)
- Francesca L Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Kerry Lm Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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