The WHO Maternal Near Miss (MNM) approach was developed to evaluate and improve quality of obstetric care worldwide. This study aimed to study the incidence of MNM and quality of care at a district hospital in rural Rwanda by applying this approach. A facility based, prospective cohort study conducted at a district hospital in rural Rwanda between June 2013 and December 2014. Subjects were followed from time of admission to discharge or death. In 3979 deliveries, 3827 singletons and 152 twins pairs were born. Among the 4131 neonates, there were 3994 live births and 137 stillbirths. Ninety-nine women suffered severe maternal outcome (SMO): 86 maternal near misses and 13 deaths. This adds up to a maternal near miss ratio of 21.5 per 1000 live births (95 % CI 17.3-26.5), a maternal mortality ratio of 325 per 100 000 live births (95 % CI 181–543) and a mortality index of 13.1 % (95 % CI 7.3–21.9). Hemorrhage (n = 49, 57 %) and hypertensive disorders (n = 27, 31.4 %) were the commonest MNM conditions. Eclampsia (n = 4/13; 30.7 %) was the leading cause of maternal mortality, while sepsis/peritonitis following cesarean section (n = 2/6; 33.3 %) had the highest mortality index. Seventy-seven out of 99 SMO cases (77.9 %) were referred from other facilities with critical conditions and 28 out of 99 SMO cases (28.3 %) were admitted into the Intensive Care Unit. Several indicators such as administration of oxytocin, magnesium sulfate and antibiotics were found to be suboptimal. MNM is common at district level in Rwanda. The MNM approach enabled us to identify shortfalls in clinical practice and the referral system.

With an aim to prevent adverse pregnancy outcomes, ‘birth preparedness and complication readiness’ (BP/CR) promotes timely access to skilled maternal and neonatal services. Objective of this study was to assess implementation of BP/CR among pregnant women admitted with obstetric emergencies in rural Rwanda. A cross-sectional study among pregnant women who were referred to Ruhengeri hospital between July and November 2015. The ‘Safe Motherhood questionnaire’ as developed by Jhpiego’s Maternal and Neonatal Health Program was used to collect data. Women were asked to mention key danger signs and respond as to whether they had identified: (A) skilled birth attendant, (B) location to give birth, (C) mode of transport, (D) money to cover health care expenditure. Women who answered ‘yes’ to three or four items were labeled ‘well prepared’. Multivariate logistic regression analysis was conducted to compare the ‘well prepared’ and ‘less prepared’. With regard to complication readiness, out of 350 women, 296 (84.6%), 271 (77.4%) and 288 (82.3%) could mention at least one key danger sign during pregnancy, labor and postpartum respectively, but only 23 (6.6%) could mention three or more key danger signs during all three periods. With regard to birth preparedness, 46 (13.1%) women had identified a skilled birth attendant, 68 (19.4%) birth location, 76 (21.7%) mode of transport, and 306 (87.4%) had saved money for health care costs. Seventy-eight women (22.3%) were ‘well prepared’, associated factors being first time pregnancy (adjusted Odds Ratio (aOR) = 3.2; 95% CI; 1.2–5.8), knowledge of at least two danger signs (aOR = 2.8; 95% CI; 1.7–3.9) and having been assisted by a community health worker at the antenatal clinic (aOR = 2.2, 95% CI; 1.3–3.7). Knowledge of obstetric danger signs was suboptimal and birth preparedness low. We recommend review of practices regarding health promotion in antenatal care, taking care not to exclude multiparous women from messages related to birth preparedness, and do promote use of community health workers to enhance effectiveness of BP/CR.

INTRODUCTION: birth preparedness and complication readiness (BP/CR) promotes timely access to skilled maternal and neonatal services, active preparation and decision-making for seeking health care to prevent any adverse outcomes. The aim was to assess level of male partner (MP) involvement in the birth plan, the attitude of the women towards maternal care and factors associated with BP/CR among obstetric referrals in rural Rwanda. METHODS: this was a cross-sectional study among 350 pregnant women who were admitted as referrals at Ruhengeri hospital, between July 2015 and November 2015. Data was collected on socio-demographics, level of MP?s participation in maternal health care and domestic activities, women?s attitude towards involvement of men in maternal care and BP/CR. Any woman who arranged to have a birth companion, made a plan of where to deliver from, received health education on pregnancy and childbirth complications, saved money in case of pregnancy complication and had attended antenatal care (ANC) at least 4 times, was deemed as having made a birth plan. RESULTS: the mean age was 27.7 years, while mean age of the spouse was 31.3 years. Majority of the women (n=193; 55.1%) and their spouse (n=208; 59.4%) had completed primary education. Men?s role was found to be mainly in the area of financial support. The level of men ANC attendance was low (n=103; 29.4%), while 78 (22.3%) women were accompanied to the labor ward. However, there was a strong opposition to the physical presence of MP in the labor room (n=178; 50.9%). The main reason cited by women opposing MP presence is that it is against their culture for a man to witness the delivery of a baby. On multivariable analysis, maternal education level of secondary or higher adjusted odds ratio [AOR] 1.4 95% CI (1.8-2.6), formal occupation of spouse, AOR 2.4 95% CI (1.4-4.2) and personnel checked during ANC being community health worker AOR 2.2, 95% CI; (1.3?3.7) were associated with being well prepared. CONCLUSION: male involvement in pregnancy and antenatal care is low. To increase men involvement in birth plan addressing cultural barriers and refraining care-givers and health facility policies towards family delivery is paramount.

Offering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda. Audit of women’s records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014. Out of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n = 23, 7.7%) compared with women who had an ERCS (n = 5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2–5.4). There was no difference in neonatal admissions between women who underwent ToL (n = 64/297; 21.5%) and those who delivered by ERCS (n = 35/138; 25.4%: aOR 0.8; CI 0.5–1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n = 40, 13.4%) compared to those who delivered by ERCS (n = 15, 10.9%: aOR 1.9; CI 1.6–3.6). Perinatal mortality was similar among infants whose mothers had ToL (n = 8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n = 4; 29/1000 ERCSs). A considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL.

Birth preparedness and complication readiness (BP/CR) comprise a strategy to make women plan for birth and encourage them to seek professional care in order to reduce poor pregnancy outcome. We aimed to understand the facilitators and barriers to BP/CR among community health workers (CHWs) and community members in rural Rwanda. Eight focus group discussions were conducted with 88 participants comprising of CHWs, elderly women aged 45–68 and men aged 18–59, as well as two key informant interviews in Musanze district, Rwanda, between November and December 2015. Qualitative data were digitally recorded, transcribed verbatim and analysed using content analysis. Participants perceived the importance of family assistance, medical insurance and attending antenatal care (ANC) to facilitate BP/CR and enhance professional care at birth. CHWs reinforced BP/CR messages by SMS alerts and during community gatherings. ‘Ubudehe (collective action to combat poverty)’ was known as a tool to identify the poorest families in need of government aid to pay for medical care. Disrespect and abuse of women during labor by health workers were perceived as important barriers to access professional care, as well as conflicting health policies such as user fees for ANC and family planning services, and imposing fines on women giving birth outside health facilities. CHWs, ANC and medical insurance are perceived to be important facilitators of BP/CR. Respectful care is paramount for improved maternal health. There is a need for addressing inconsistent health policies hindering the intention to access professional care.

Most maternal and perinatal deaths could be prevented through timely access to skilled birth attendants. Women should access appropriate obstetric care during pregnancy, labor, and puerperium. Maternity waiting homes (MWHs) permit access to emergency obstetric care when labor starts. This study compared maternal and perinatal outcomes among MWH users and non-users through a retrospective cohort study. Data were collected through obstetric chart reviews and analyzed using STATA version 15. Of the 8144 deliveries reported between 2015 and 2019, 1305 women had high-risk pregnancies and were included in the study. MWH users had more spontaneous vaginal deliveries compared to non-users (38.6% versus 16.8%) and less cesarean sections (57.7% versus 76.7%). Maternal morbidities such as postpartum hemorrhage occurred less frequently among users than non-users (2.13% versus 5.64%). Four women died among non-users while there was no death among users. Non-users had more stillbirths than users (7.68% versus 0.91%). The MWH may have contributed to the observed differences in outcomes. However, many women with high risk pregnancies did not use the MWH, indicating a probable gap in awareness, usefulness, or their inability to stay due to other responsibilities at home. Use of MWHs at scale could improve maternal and perinatal outcomes in Rwanda.