Maternal health care professionals' experiences and views on the use of obstetric ultrasound in Rwanda: A cross-sectional study.

BACKGROUND: This study, undertaken in Rwanda, aimed to investigate health professionals' experiences and views on the following topics: current clinical guidelines for ultrasound from second trimester at the clinic, regional and national levels, and adherence to clinical guidelines; medically indicated ultrasound examinations; non-medical use of ultrasound including ultrasounds on maternal request; commercialisation of ultrasound; the value of ultrasound in relation to other clinical examinations in pregnancy; and ultrasound and medicalisation of pregnancy. METHODS: A cross-sectional design was adopted. Health professionals providing antenatal care and delivery services to pregnant women in 108 health facilities were invited to complete a survey, which was developed based on the results of earlier qualitative studies undertaken as part of the CROss Country Ultrasound Study (CROCUS). RESULTS: Nine hundred and seven health professionals participated: obstetricians/gynecologists (3.2%,) other physicians (24.5%), midwives (29.7%) and nurses (42.7%). Few physicians reported the existence of clinical guidelines at clinic, regional or national levels in Rwanda, and guidelines were moderately adhered to. Three obstetric ultrasound examinations were considered medically indicated in an uncomplicated pregnancy. Most participants (73.0%) were positive about obstetric ultrasound examinations on maternal request. Commercialisation was not considered a problem, and the majority (88.5%) agreed that ultrasound had contributed to medicalisation of pregnancy. CONCLUSIONS: Findings indicate that clinical guidelines for the use of obstetric ultrasound are limited in Rwanda. Non-medically indicated obstetric ultrasound was not considered a current problem at any level of the healthcare system. The positive attitude to obstetric ultrasound examinations on maternal request may contribute to further burden on a maternal health care system with limited resources. It is essential that limited obstetric ultrasound resources are allocated where they are most beneficial, and clearly stated medical indications would likely facilitate this.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation.

OBJECTIVES: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. METHODS: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). RESULTS: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. DISCUSSION: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study.

BACKGROUND: Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (1-13 months) after delivery and socio-economic and demographic factors were explored in Rwanda. METHODS: In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors. RESULTS: Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL. CONCLUSIONS: ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study.

OBJECTIVE: To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. METHODS: Physicians (n = 19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. RESULTS: Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician 'protection'. CONCLUSIONS: There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.