Screen, Notify, See, and Treat: Initial Results of Cervical Cancer Screening and Treatment in Rwanda.

PURPOSE: To describe the first year results of Rwanda's Screen, Notify, See, and Treat cervical cancer screening program, including challenges encountered and revisions made to improve service delivery. METHODS: Through public radio broadcasts, meetings of local leaders, church networks, and local women's groups, public awareness of cervical cancer screening opportunities was increased and community health workers were enlisted to recruit and inform eligible women of the locations and dates on which services would be available. Screening was performed using human papillomavirus (HPV) DNA testing technology, followed by visual inspection with acetic acid (VIA), and cryotherapy, biopsy, and surgical treatment for those who tested HPV-positive. These services were provided by five district hospitals and 15 health centers to HIV-negative women of age 35-45 and HIV-positive women of age 30-50. Service utilization data were collected from the program's initiation in September 2013 to October 2014. RESULTS: Of 7,520 cervical samples tested, 874 (11.6%) screened HPV-positive, leading 780 (89%) patients to undergo VIA. Cervical lesions were found in 204 patients (26.2%) during VIA; of these, 151 were treated with cryoablation and 15 were referred for biopsies. Eight patients underwent complete hysterectomy to treat advanced cervical cancer. Challenges to service delivery included recruitment of eligible patients, patient loss to follow-up, maintaining HIV status confidentiality, and efficient use of consumable resources. CONCLUSION: Providing cervical cancer screening services through public health facilities is a feasible and valuable component of comprehensive women's health care in resource-limited settings. Special caution is warranted in ensuring proper adherence to follow-up and maintaining patient confidentiality.

Group antenatal care versus standard antenatal care and effect on mean gestational age at birth in Rwanda: protocol for a cluster randomized controlled trial.

Background: Group antenatal care has demonstrated promise as a service delivery model that may result in improved outcomes compared to standard antenatal care in socio-demographic populations at disparately high risk for poor perinatal outcomes. Intrigued by results from the United States showing lower preterm birth rates among high-risk women who participate in group antenatal care, partners working together as the Preterm Birth Initiative - Rwanda designed a trial to assess the impact of group antenatal care on gestational age at birth. Methods: This study is a pair-matched cluster randomized controlled trial with four arms. Pairs randomized to group or standard care were further matched with other pairs into quadruples, within which one pair was assigned to implement basic obstetric ultrasound at the health center and early pregnancy testing at the community. At facilities randomized to group care, this will follow the opt-out model of service delivery and individual visits will always be available for those who need or prefer them. The primary outcome of interest is mean gestational age at birth among women who presented for antenatal care before 24 completed weeks of pregnancy and attended more than one antenatal care visit. Secondary outcomes of interest include attendance at antenatal and postnatal care, preterm birth rates, satisfaction of mothers and providers, and feasibility. A convenience sample of women will be recruited to participate in a longitudinal survey in which they will report such indicators as self-reported health-related behaviors and depressive symptoms. Providers will be surveyed about satisfaction and stress. Discussion: This is the largest cluster randomized controlled trial of group antenatal and postnatal care ever conducted, and the first in a low- or middle-income country to examine the effect of this model on gestational age at birth. Trial registration: This study is registered on ClinicalTrials.gov as NCT03154177 May 16, 2017.

Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data.

BACKGROUND: Sustained investments in Rwanda's health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies. METHODS: This is a cross-sectional study of 9002 births to 6328 women age 15-49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0-11 months, and 12-59 months. Analyses were performed in Stata v12, adjusting for complex sample design. RESULTS: Of 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3-4 births in the past 5 years (OR = 3.97) compared to 1-2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1-4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25-50 months (OR = 0.67) compared to 9-24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both). CONCLUSIONS: In the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda's next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

Missed Opportunities in Neonatal Deaths in Rwanda: Applying the Three Delays Model in a Cross-Sectional Analysis of Neonatal Death.

Objective Administered in a timely manner, current evidence-based interventions could reduce neonatal deaths from infections, intrapartum injuries and complications due to prematurity. The three delays model (delay in seeking care, in arriving at a health facility, and in receiving adequate care), which has been applied to understanding maternal deaths, may be useful for understanding neonatal deaths. We assess the main causes of neonatal deaths in Rwanda and their associated delays. Methods Using a cross-sectional study design, we evaluated data from 2012 from 40 facilities in which babies were delivered. Audit committees in each facility reviewed each neonatal death in the facility and reported finding to the Ministry of Health using structured questionnaires. Information from questionnaires were centralized in an electronic database. At the end of 2012, records from 40 health facilities across Rwanda's five provinces (mainly district hospitals) were available in the database and were used for this analysis. Results Of the 1324 neonates, the major causes of death were: asphyxia and its complications (36.7%), lower respiratory tract infections (LRTI) (22.5%), and prematurity (22.4%). At least one delay was experienced by nearly three-quarters of neonates: Maternal Delay in Seeking Care 22.1%, Maternal Delay in Arrival to Care 11.2%, Maternal Delay in Adequate Care 14.2%, Neonatal Delay in Seeking Care 8.1%, Neonatal Delay in Arrival to Care 9.3%, and Neonatal Delay in Adequate Care 29.1%. Neonates with each of the main causes of death had statistically significantly increased odds of experiencing Maternal Delay in Seeking Care. Asphyxia deaths had increased odds of experiencing all three Maternal Delays. LRTI deaths had increased odds of all three Neonatal Delays. Conclusion Delays for women in seeking obstetrical care is a critical factor associated with the main causes of neonatal death in Rwanda. Improving obstetrical care quality could reduce neonatal deaths due to asphyxia. Likewise, reducing all three delays could reduce neonatal deaths due to LRTI.

Making Abortion Safer in Rwanda: Operationalization of the Penal Code of 2012 to Expand Legal Exemptions and Challenges.

Penal code was revised in Rwanda in 2012 allowing legal termination of pregnancy resulting from rape, incest, forced marriage, or on medical grounds. An evaluation was conducted to assess women's access to abortion services as part of an ongoing program to operationalize the new exemptions for legal abortion. Data was collected from eight district hospitals; seven gender-based violence (GBV) centers and six intermediate courts. Three focus group discussions and 22 in-depth interviews were conducted with key informants. At hospitals, of the 2,644 uterine evacuation records (July 2012-June 2014), and 312 monitoring cases (August-December 2014), majority of all uterine evacuations (97% and 85% respectively, for the two periods) were for obstetric conditions, and induced abortion on medical grounds accounted for 2% vs. 15% respectively. Medical abortion was the prominent method of uterine evacuation. At the GBV centers, 3,763 records were identified retrospectively; 273 women were pregnant. Since the legal reform there was only one abortion for a pregnancy resulting from rape. Abortion stigma and court order requirement are major barriers to access services. The operationalization program has made significant contributions to make abortion safer in Rwanda but this evaluation demonstrates that further work is required to reach the goal of providing safe abortion services to all eligible women. Addressing abortion stigma at the community, organizational and structural levels; further strengthening of service provision; and streamlining legal requirements to protect particularly young women from sexual violence and making abortion a realistic option for GBV victims are some of the important next steps.

Use of administrative records to assess pneumococcal conjugate vaccine impact on pediatric meningitis and pneumonia hospitalizations in Rwanda.

BACKGROUND: Ongoing surveillance is critical to assessing pneumococcal conjugate vaccine (PCV) impact over time. However, robust prospective studies are difficult to implement in resource-poor settings. We evaluated retrospective use of routinely collected data to estimate PCV impact in Rwanda. METHODS: We collected data from admission registers at five district hospitals on children age <5yearsadmitted for suspected meningitis and pneumonia during 2002-2012. We obtained clinical and laboratory data on meningitis from sentinel surveillance at the national reference hospital in Kigali. We developed multivariable logistic regression models to estimate PCV effectiveness (VE) against severe pneumonia and probable bacterial meningitis and Poisson models to estimate absolute rate reductions. Haemophilus influenzae type b vaccine was introduced in January 2002, PCV7 in April 2009 and PCV13 in August 2011. RESULTS: At the district hospitals, the severe pneumonia and suspected meningitis hospitalization rates decreased by 70/100,000 and 11/100,000 children for 2012 compared to baseline, respectively. VE against severe pneumonia calculated from logistic regression was 54% (95% CI 42-63%). In Kigali, from 2002 to 2012, annual suspected meningitis cases decreased from 170 pre-PCV7 to 40 post-PCV13 and confirmed pneumococcal meningitis cases from 7 to 0. VE against probable bacterial meningitis was 42% (95% CI -4% to 68%). CONCLUSION: In a resource-poor African setting, analysis of district hospital admission logbooks and routine sentinel surveillance data produced results consistent with more sophisticated impact studies conducted elsewhere. Our findings support applying this methodology in other settings and confirm the benefits of PCV in Rwanda.

Human papillomavirus infection in Rwanda at the moment of implementation of a national HPV vaccination programme.

BACKGROUND: Cervical cancer is the most common female cancer in Rwanda that, in 2011, became the first African country to implement a national vaccination programme against human papillomavirus (HPV). METHODS: To provide a robust baseline for future evaluations of vaccine effectiveness, cervical cell specimens were obtained from 2508 women aged 18-69 years from the general population in Kigali, Rwanda, during 2013/14. 20 % of women were HIV-positive. Samples were used for liquid-based cytology and HPV testing (44 types) with GP5+/6+ PCR. RESULTS: HPV prevalence was 34 %, being highest (54 %) in women ≤19 years and decreasing to 20 % at age ≥50. Prevalence of high risk (HR) HPV and cytological abnormalities was 22 and 11 % respectively (including 2 % with high-grade squamous intraepithelial lesions, HSIL) decreasing with age. Age-standardised prevalence of HR HPV was 22 % (or 19 % among HIV-negative women), and HPV16 was the most common type. Prevalence of HPV and cytological abnormalities were significantly higher in HIV-positive than HIV-negative women, and the difference increased with age. Other significant risk factors for HPV positivity in multivariate analyses were high lifetime number of sexual partners, receiving cash for sex, and being a farmer. 40 % of women with HSIL were infected with HPV16/18 and there was no significant difference between HIV-positive and HIV-negative women. CONCLUSIONS: This study confirms Rwanda to be a setting of high prevalence of HPV and cervical disease that is worsened by HIV. These data will serve as a robust baseline for future evaluations of HPV vaccine programme effectiveness.

Effectiveness of Pentavalent Rotavirus Vaccine Under Conditions of Routine Use in Rwanda.

BACKGROUND: Rotavirus vaccine efficacy is lower in low-income countries than in high-income countries. Rwanda was one of the first low-income countries in sub-Saharan Africa to introduce rotavirus vaccine into its national immunization program. We sought to evaluate rotavirus vaccine effectiveness (VE) in this setting. METHODS: VE was assessed using a case-control design. Cases and test-negative controls were children who presented with a diarrheal illness to 1 of 8 sentinel district hospitals and 10 associated health centers and had a stool specimen that tested positive (cases) or negative (controls) for rotavirus by enzyme immunoassay. Due to high vaccine coverage almost immediately after vaccine introduction, the analysis was restricted to children 7-18 weeks of age at time of rotavirus vaccine introduction. VE was calculated as (1 - odds ratio) × 100, where the odds ratio was the adjusted odds ratio for the rotavirus vaccination rate among case-patients compared with controls. RESULTS: Forty-eight rotavirus-positive and 152 rotavirus-negative children were enrolled. Rotavirus-positive children were significantly less likely to have received rotavirus vaccine (33/44 [73%] unvaccinated) compared with rotavirus-negative children (81/136 [59%] unvaccinated) (P= .002). A full 3-dose series was 75% (95% confidence interval [CI], 31%-91%) effective against rotavirus gastroenteritis requiring hospitalization or a health center visit and was 65% (95% CI, -80% to 93%) in children 6-11 months of age and 81% (95% CI, 25%-95%) in children ≥12 months of age. CONCLUSIONS: Rotavirus vaccine is effective in preventing rotavirus disease in Rwandan children who began their rotavirus vaccine series from 7 to 18 weeks of age. Protection from vaccination was sustained after the first year of life.

Urine testing to monitor the impact of HPV vaccination in Bhutan and Rwanda.

Bhutan (2010) and Rwanda (2011) were the first countries in Asia and Africa to introduce national, primarily school-based, human papillomavirus (HPV) vaccination programmes. These target 12 year-old girls and initially included catch-up campaigns (13-18 year-olds in Bhutan and ninth school grade in Rwanda). In 2013, to obtain the earliest indicators of vaccine effectiveness, we performed two school-based HPV urine surveys; 973 female students (median age: 19 years, 5th-95th percentile: 18-22) were recruited in Bhutan and 912 (19 years, 17-20) in Rwanda. Participants self-collected a first-void urine sample using a validated protocol. HPV prevalence was obtained using two PCR assays that differ in sensitivity and type spectrum, namely GP5+/GP6+ and E7-MPG. 92% students in Bhutan and 43% in Rwanda reported to have been vaccinated (median vaccination age = 16, 5th-95th: 14-18). HPV positivity in urine was significantly associated with sexual activity measures. In Rwanda, HPV6/11/16/18 prevalence was lower in vaccinated than in unvaccinated students (prevalence ratio, PR = 0.12, 95% confidence interval, CI: 0.03-0.51 by GP5+/GP6+, and 0.45, CI: 0.23-0.90 by E7-MPG). For E7-MPG, cross-protection against 10 high-risk types phylogenetically related to HPV16 or 18 was of borderline significance (PR = 0.68; 95% CI: 0.45-1.01). In Bhutan, HPV6/11/16/18 prevalence by GP5+/GP6+ was lower in vaccinated than in unvaccinated students but CIs were broad. In conclusion, our study supports the feasibility of urine surveys to monitor HPV vaccination and quantifies the effectiveness of the quadrivalent vaccine in women vaccinated after pre-adolescence. Future similar surveys should detect increases in vaccine effectiveness if vaccination of 12 year-olds continues.

The Economic Burden Attributable to a Child's Inpatient Admission for Diarrheal Disease in Rwanda.

BACKGROUND: Diarrhea is one of the leading causes of childhood morbidity and mortality. Hospitalization for diarrhea can pose a significant burden to health systems and households. The objective of this study was to estimate the economic burden attributable to hospitalization for diarrhea among children less than five years old in Rwanda. These data can be used by decision-makers to assess the impact of interventions that reduce diarrhea morbidity, including rotavirus vaccine introduction. METHODS: This was a prospective costing study where medical records and hospital bills for children admitted with diarrhea at three hospitals were collected to estimate resource use and costs. Hospital length of stay was calculated from medical records. Costs incurred during the hospitalization were abstracted from the hospital bills. Interviews with the child's caregivers provided data to estimate household costs which included transport costs and lost income. The portion of medical costs borne by insurance and household were reported separately. Annual economic burden before and after rotavirus vaccine introduction was estimated by multiplying the reported number of diarrhea hospitalizations in public health centers and district hospitals by the estimated economic burden per hospitalization. All costs are presented in 2014 US$. RESULTS: Costs for 203 children were analyzed. Approximately 93% of the children had health insurance coverage. Average hospital length of stay was 5.3 ± 3.9 days. Average medical costs for each child for the illness resulting in a hospitalization were $44.22 ± $23.74 and the total economic burden was $101, of which 65% was borne by the household. For households in the lowest income quintile, the household costs were 110% of their monthly income. The annual economic burden to Rwanda attributable to diarrhea hospitalizations ranged from $1.3 million to $1.7 million before rotavirus vaccine introduction. CONCLUSION: Households often bear the largest share of the economic burden attributable to diarrhea hospitalization and the burden can be substantial, especially for households in the lowest income quintile.

Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis.

BACKGROUND: In May, 2012, Rwanda became the first low-income African country to introduce pentavalent rotavirus vaccine into its routine national immunisation programme. Although the potential health benefits of rotavirus vaccination are huge in low-income African countries that account for more than half the global deaths from rotavirus, concerns remain about the performance of oral rotavirus vaccines in these challenging settings. METHODS: We conducted a time-series analysis to examine trends in admissions to hospital for non-bloody diarrhoea in children younger than 5 years in Rwanda between Jan 1, 2009, and Dec 31, 2014, using monthly discharge data from the Health Management Information System. Additionally, we reviewed the registries in the paediatric wards at six hospitals from 2009 to 2014 and abstracted the number of total admissions and admissions for diarrhoea in children younger than 5 years by admission month and age group. We studied trends in admissions specific to rotavirus at one hospital that had undertaken active rotavirus surveillance from 2011 to 2014. We assessed changes in rotavirus epidemiology by use of data from eight active surveillance hospitals. FINDINGS: Compared with the 2009-11 prevaccine baseline, hospital admissions for non-bloody diarrhoea captured by the Health Management Information System fell by 17-29% from a pre-vaccine median of 4051 to 2881 in 2013 and 3371 in 2014, admissions for acute gastroenteritis captured in paediatric ward registries decreased by 48-49%, and admissions specific to rotavirus captured by active surveillance fell by 61-70%. The greatest effect was recorded in children age-eligible to be vaccinated, but we noted a decrease in the proportion of children with diarrhoea testing positive for rotavirus in almost every age group. INTERPRETATION: The number of admissions to hospital for diarrhoea and rotavirus in Rwanda fell substantially after rotavirus vaccine implementation, including among older children age-ineligible for vaccination, suggesting indirect protection through reduced transmission of rotavirus. These data highlight the benefits of routine vaccination against rotavirus in low-income settings. FUNDING: Gavi, the Vaccine Alliance and the Government of Rwanda.

Maternal death audit in Rwanda 2009-2013: a nationwide facility-based retrospective cohort study.

OBJECTIVE: Presenting the results of 5 years of implementing health facility-based maternal death audits in Rwanda, showing maternal death classification, identification of substandard (care) factors that have contributed to death, and conclusive recommendations for quality improvements in maternal and obstetric care. DESIGN: Nationwide facility-based retrospective cohort study. SETTINGS: All cases of maternal death audited by district hospital-based audit teams between January 2009 and December 2013 were reviewed. Maternal deaths that were not subjected to a local audit are not part of the cohort. POPULATION: 987 audited cases of maternal death. MAIN OUTCOME MEASURES: Characteristics of deceased women, timing of onset of complications, place of death, parity, gravida, antenatal clinic attendance, reported cause of death, service factors and individual factors identified by committees as having contributed to death, and recommendations made by audit teams. RESULTS: 987 cases were audited, representing 93.1% of all maternal deaths reported through the national health management information system over the 5-year period. Almost 3 quarters of the deaths (71.6%) occurred at district hospitals. In 44.9% of these cases, death occurred in the post-partum period. Seventy per cent were due to direct causes, with post-partum haemorrhage as the leading cause (22.7%), followed by obstructed labour (12.3%). Indirect causes accounted for 25.7% of maternal deaths, with malaria as the leading cause (7.5%). Health system failures were identified as the main responsible factor for the majority of cases (61.0%); in 30.3% of the cases, the main factor was patient or community related. CONCLUSIONS: The facility-based maternal death audit approach has helped hospital teams to identify direct and indirect causes of death, and their contributing factors, and to make recommendations for actions that would reduce the risk of reoccurrence. Rwanda can complement maternal death audits with other strategies, in particular confidential enquiries and near-miss audits, so as to inform corrective measures.

Successive introduction of four new vaccines in Rwanda: High coverage and rapid scale up of Rwanda's expanded immunization program from 2009 to 2013.

As the pace of vaccine uptake accelerates globally, there is a need to document low-income country experiences with vaccine introductions. Over the course of five years, the government of Rwanda rolled out vaccines against pneumococcus, human papillomavirus, rotavirus, and measles & rubella, achieving over 90% coverage for each. To carry out these rollouts, Rwanda's Ministry of Health engaged in careful review of disease burden information and extensive, cross-sectoral planning at least one year before introducing each vaccine. Rwanda's local leaders, development partners, civil society organizations and widespread community health worker network were mobilized to support communication efforts. Community health workers were also used to confirm target population size. Support from Gavi, UNICEF and WHO was used in combination with government funds to promote country ownership and collaboration. Vaccination was also combined with additional community-based health interventions. Other countries considering rapid consecutive or simultaneous rollouts of new vaccines may consider lessons from Rwanda's experience while tailoring the strategies used to local context.

A cost comparison of introducing and delivering pneumococcal, rotavirus and human papillomavirus vaccines in Rwanda.

BACKGROUND: Detailed cost evaluations of delivery of new vaccines such as pneumococcal conjugate, human papillomavirus (HPV), and rotavirus vaccines in low and middle-income countries are scarce. This paper differs from others by comparing the costs of introducing multiple vaccines in a single country and then assessing the financial and economic impact at the time and implications for the future. The objective of the analysis was to understand the introduction and delivery cost per dose or per child of the three new vaccines in Rwanda to inform domestic and external financial resource mobilization. METHODS: Start-up, recurrent, and capital costs from a government perspective were collected in 2012. Since pneumococcal conjugate and HPV vaccines had already been introduced, cost data for those vaccines were collected retrospectively while prospective (projected) costing was done for rotavirus vaccine. RESULTS: The financial unit cost per fully immunized child (or girl for HPV vaccine) of delivering 3 doses of each vaccine (without costs related to vaccine procurement) was $0.37 for rotavirus (RotaTeq(®)) vaccine, $0.54 for pneumococcal (Prevnar(®)) vaccine in pre-filled syringes, and $10.23 for HPV (Gardasil (®)) vaccine. The financial delivery costs of Prevnar(®) and RotaTeq(®) were similar since both were delivered using existing health system infrastructure to deliver infant vaccines at health centers. The total financial cost of delivering Gardasil(®) was higher than those of the two infant vaccines due to greater resource requirements associated with creating a new vaccine delivery system in for a new target population of 12-year-old girls who have not previously been served by the existing routine infant immunization program. CONCLUSION: The analysis indicates that service delivery strategies have an important influence on costs of introducing new vaccines and costs per girl reached with HPV vaccine are higher than the other two vaccines because of its delivery strategy. Documented information on financial commitments for new vaccines, particularly from government sources, is a useful input into country policy dialogue on sustainable financing and co-financing of new vaccines, as well as for policy decisions by donors such as Gavi, the Vaccine Alliance.

Capacity building for oncology programmes in sub-Saharan Africa: the Rwanda experience.

Despite an estimated 456,000 deaths caused by cancer in sub-Saharan Africa in 2012 and a cancer burden that is predicted to double by 2030, the region accounts for only 0·3% of worldwide medical expenditure for cancer. Challenges to cancer care in sub-Saharan Africa include a shortage of clinicians and training programmes, weak healthcare infrastructure, and inadequate supplies. Since 2011, Rwanda has developed a national cancer programme by designing comprehensive, integrated frameworks of care, building local human resource capacity through partnerships, and delivering equitable, rights-based care. In the 2 years since the inauguration of Rwanda's first cancer centre, more than 2500 patients have been enrolled, including patients from every district in Rwanda. Based on Rwanda's national cancer programme development, we suggest principles that could guide other nations in the development of similar cancer programmes.

A facility birth can be the time to start family planning: postpartum intrauterine device experiences from six countries.

Initiation of family planning at the time of birth is opportune, since few women in low-resource settings who give birth in a facility return for further care. Postpartum family planning (PPFP) and postpartum intrauterine device (PPIUD) services were integrated into maternal care in six low- and middle-income countries, applying an insertion technique developed in Paraguay. Facilities with high delivery volume were selected to integrate PPFP/PPIUD services into routine care. Effective PPFP/PPIUD integration requires training and mentoring those providers assisting women at the time of birth. Ongoing monitoring generated data for advocacy. The percentages of PPIUD acceptors ranged from 2.3% of women counseled in Pakistan to 5.8% in the Philippines. Rates of complications among women returning for follow-up were low. Expulsion rates were 3.7% in Pakistan, 3.6% in Ethiopia, and 1.7% in Guinea and the Philippines. Infection rates did not exceed 1.3%, and three countries recorded no cases. Offering PPFP/PPIUD at birth improves access to contraception.

Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District.

BACKGROUND: While Rwanda has achieved impressive gains in contraceptive coverage, unmet need for family planning is high, and barriers to accessing quality reproductive health services remain. Few studies in Rwanda have qualitatively investigated factors that contribute to family planning use, barriers to care, and quality of services from the community perspective. METHODS: We undertook a qualitative study of community perceptions of reproductive health and family planning in Rwanda's southern Kayonza district, which has the country's highest total fertility rate. From October 2011 to December 2012, we conducted interviews with randomly selected male and female community members (n = 96), community health workers (n = 48), and health facility nurses (n = 15), representing all 8 health centers' catchment areas in the overall catchment area of the district's Rwinkwavu Hospital. We then carried out a directed content analysis to identify key themes and triangulate findings across methods and informant groups. RESULTS: Key themes emerged across interviews surrounding: (1) fertility beliefs: participants recognized the benefits of family planning but often desired larger families for cultural and historical reasons; (2) social pressures and gender roles: young and unmarried women faced significant stigma and husbands exerted decision-making power, but many husbands did not have a good understanding of family planning because they perceived it as a woman's matter; (3) barriers to accessing high-quality services: out-of-pocket costs, stock-outs, limited method choice, and long waiting times but short consultations at facilities were common complaints; (4) side effects: poor management and rumors and fears of side effects affected contraceptive use. These themes recurred throughout many participant narratives and influenced reproductive health decision making, including enrollment and retention in family planning programs. CONCLUSIONS: As Rwanda continues to refine its family planning policies and programs, it will be critical to address community perceptions around fertility and desired family size, health worker shortages, and stock-outs, as well as to engage men and boys, improve training and mentorship of health workers to provide quality services, and clarify and enforce national policies about payment for services at the local level.

The health system cost of post-abortion care in Rwanda.

Based on research conducted in 2012, we estimate the cost to the Rwandan health-care system of providing post-abortion care (PAC) due to unsafe abortions, a subject of policy importance not studied before at the national level. Thirty-nine public and private health facilities representing three levels of health care were randomly selected for data collection from key care providers and administrators for all five regions. Using an ingredients approach to costing, data were gathered on drugs, supplies, material, personnel time and hospitalization. Additionally, direct non-medical costs such as overhead and capital costs were also measured. We found that the average annual PAC cost per client, across five types of abortion complications, was $93. The total cost of PAC nationally was estimated to be $1.7 million per year, 49% of which was expended on direct non-medical costs. Satisfying all demands for PAC would raise the national cost to $2.5 million per year. PAC comprises a significant share of total expenditure in reproductive health in Rwanda. Investing more resources in provision of contraceptive services to prevent unwanted or mistimed pregnancies would likely reduce health systems costs.

Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda.

OBJECTIVE: Integrated Management of Childhood Illness (IMCI) is the leading clinical protocol designed to decrease under-five mortality globally. However, impact is threatened by gaps in IMCI quality of care (QOC). In 2010, Partners In Health and the Rwanda Ministry of Health implemented a nurse mentorship intervention Mentoring and Enhanced Supervision at Health Centres (MESH) in two rural districts. This study measures change in QOC following the addition of MESH to didactic training. DESIGN: Prepost intervention study of change in QOC after 12 months of MESH support measured by case observation using a standardised checklist. Study sample was children age 2 months to 5 years presenting on the days of data collection (292 baseline, 413 endpoint). SETTING: 21 rural health centres in Rwanda. OUTCOMES: Primary outcome was a validated index of key IMCI assessments. Secondary outcomes included assessment, classification and treatment indicators, and QOC variability across providers. A mixed-effects regression model of the index was created. RESULTS: In multivariate analyses, the index significantly improved in southern Kayonza (ß-coefficient 0.17, 95% CI 0.12 to 0.22) and Kirehe (ß-coefficient 0.29, 95% CI 0.23 to 0.34) districts. Children seen by IMCI-trained nurses increased from 83.2% to 100% (p<0.001) and use of IMCI case recording forms improved from 65.9% to 97.1% (p<0.001). Correct classification improved (56.0% to 91.5%, p<0.001), as did correct treatment (78.3% to 98.2%, p<0.001). Variability in QOC decreased (intracluster correlation coefficient 0.613-0.346). CONCLUSIONS: MESH was associated with significant improvements in all domains of IMCI quality. MESH could be an innovative strategy to improve IMCI implementation in resource-limited settings working to decrease under-five mortality.