Perceptions and attitudes of midwives on respectful maternity care during childbirth: a qualitative study in three district hospitals of Kigali city of Rwanda

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 had 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.

Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study.

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.

Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound.

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. RESPONSIBLE EDITOR Virgilio Mariano Salazar Torres, Karolinska Institute, Sweden.

Prevalence of pregnancy-related complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross-sectional study.

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 delivery-related 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.