Open Access Research Prevalence of pregnancy-related BMJ Open: first published as 10.1136/bmjopen-2016-015015 on 9 July 2017. Downloaded from complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross- sectional study Jean Paul Semasaka Sengoma,1,2 Gunilla Krantz,3 Manasse Nzayirambaho,2 Cyprien Munyanshongore,2 Kristina Edvardsson,1,4 Ingrid Mogren1 To cite: Semasaka Sengoma JP, ABSTRACT Strengths and limitations of this study Krantz G, Nzayirambaho M, et al. Objectives This study estimated health facility-based Prevalence of pregnancy-related prevalence for pre-eclampsia/eclampsia, postpartum complications and course of ► All the women eligible consented to participate in haemorrhage and caesarean section (CS) due to prolonged labour of surviving women the study. labour/dystocia. The background characteristics of Rwandan who gave birth in selected ► Female professional interviewers with nursing and health facilities in Rwanda: a pregnant women, the course of labour and the level of midwifery background who were not working at the health facility-based, cross- healthcare were investigated in relation to pregnancy and selected health facilities were employed to make the sectional study. BMJ Open delivery outcomes. pregnant women feel comfortable while responding 2017;7:e015015. doi:10.1136/ Methods This is health facility-based study and data were to questions. bmjopen-2016-015015 collected in 2014–2015 through structured interviews and ► There may also be under-reporting of cases medical records (n=817) in Kigali and Northern Province, ► Prepublication history for and physicians’ diagnosis of pregnancy-related this paper is available online. Rwanda. Frequencies and prevalence were used to describe complications because of not following the pre- To view these files please visit participants’ background factors, labour and delivery- established guidelines. This can happen due to the journal online (http:// dx. doi. related characteristics. Bivariable and multivariable logistic insufficient knowledge or misinterpretation or http://bmjopen.bmj.com/ org/ 10. 1136/ bmjopen- 2016- regression models were performed for different background lack of time due to heavy workloads and lack 015015). factors and pregnancy/delivery outcomes. of the equipment necessary for management of Results Pre-eclampsia/eclampsia, postpartum haemorrhage complicated pregnancies. Received 4 November 2016 and CS due to prolonged labour/dystocia represented 1%, Revised 19 April 2017 ► Due to a lack of knowledge in seasonal variation of 2.7% and 5.4% of all participants, respectively. In total, Accepted 10 May 2017 the investigated pregnancy-related complications in 56.4% of the participants were transferred from facilities Rwanda, the study design did not take into account with low levels to those with higher levels of healthcare, a possible seasonal variation in outcomes. This may and the majority were transferred from health centres to be a potential limitation, because the outcomes on October 1, 2021 by guest. Protected copyright. district hospitals, with CS as the main reason for transfer. during the study period may not be representative Participants who arrived at the health facility with cervical of a whole year. dilation grade of ≤3 cm spent more hours in maternity ► The study design focused on women who survived ward than those who arrived with cervical dilatation grade pregnancy and childbirth and did not take into of ≥4 cm. Risk factors for CS due to prolonged labour or account women who had died from pregnancy- dystocia were poor households, nulliparity and residence far related complications. This may have resulted in from health facility. minor underestimation of cases. 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 In 2013, about 300 000 maternal deaths hospitals. Upgrading the capacity of health centres in the occurred worldwide, and every year more management of pregnant women in Rwanda may improve than one and half million women suffer For numbered affiliations see maternal and fetal health. from pregnancy-related complications end of article. during pregnancy and delivery.2 3 The most BACKGROUND common pregnancy-related complications Correspondence to Dr Jean Paul Semasaka Some pregnancies end tragically with are maternal haemorrhage, maternal sepsis, Sengoma; jeanpaul. semasaka. maternal and/or fetal/child death or cause abortion, hypertensive disorders (pre-ec- sengoma@ umu. se severe maternal and/or child impairment.1 lampsia, eclampsia and pregnancy-induced Semasaka Sengoma JP, et al. BMJ Open 2017;7:e015015. doi:10.1136/bmjopen-2016-015015 1 Open Access hypertension) and obstructed labour.4 5 Maternal haem- AIMS BMJ Open: first published as 10.1136/bmjopen-2016-015015 on 9 July 2017. Downloaded from orrhage is the leading cause of maternal mortality, The study’s overall aim was to determine the hospi- representing 33.9% of all maternal deaths in Africa. tal-based prevalence of pregnancy-related complications The prevalence of post-partum haemorrhage (PPH) in (pre-eclampsia/eclampsia, postpartum haemorrhage and the world is approximately 6%.5 In Uganda, between prolonged labour or obstructed labour or dystocia labour 2013 and 2014, the incidence of PPH was 9%, while resulting in a caesarean section (CS) and to describe the the prevalence of maternal haemorrhage was estimated course of labour and the background characteristics of to be around 19.3% in Rwandan referral hospitals.5–7 women giving birth in selected Rwandan health facilities. According to the WHO, hypertensive disorders during Specific aims were: pregnancy account for 9% of maternal mortality in ► to estimate the hospital-based prevalence of (1) Africa and Asia.5 8 Pre-eclampsia, characterised by pre-eclampsia and eclampsia, (2) postpartum hypertension and proteinuria, complicates 3%–5% of haemorrhage and (3) prolonged labour or obstructed pregnancies worldwide.8 Pre-eclampsia can develop into labour or dystocia labour resulting in a CS; eclampsia, characterised by the seizures that may be fatal ► to describe the course of labour from the time of for both mother and fetus.9 In 2013, the prevalence of arrival at a health facility until delivery and the pre-eclampsia/eclampsia in the East African region (ie, characteristics related to the course of labour and Democratic Republic of Congo, Kenya and Uganda) was delivery in relation to the level of healthcare; 1.02%, 2.27% and 1.15%, respectively.10 ► to describe background characteristics of women who Prolonged labour or obstructed labour occurs when the give birth in Rwandan health facilities and to describe fetus does not progress into the birth canal despite strong these characteristics’ associations with pregnancy uterine contractions.11 Obstructed labour represents outcomes. 8% of maternal deaths globally.1 In 2010, the incidence of obstructed labour was around 12.2% in Ethiopia and METHODS 12 13 3.7% in Rwanda in 2011. The study setting During the last decade, Rwanda has made significant 14 The Rwandan public health system is composed of health improvements in maternal health. In 2015, Rwanda posts, health centres, district hospitals, military hospitals, reported a maternal mortality ratio of 210 per 100 000 provincial hospitals and referral hospitals.20 A health live births and is one of few African countries that has centre, which provides the lowest level of healthcare managed to fulfil the fifth Millennium Development Goal to pregnant women, is where pregnant women with an of reducing maternal mortality by over 75% between 1990 15 16 uncomplicated pregnancy receive healthcare. Compli- and 2015. A few studies have investigated abortion and cated cases are referred to higher levels of healthcare, postabortion care, antenatal care (ANC), use of commu- such as district, provincial and referral hospitals.21 Health nity health workers and rapidSMS to promote ANC and http://bmjopen.bmj.com/ 14 17 18 centres are mainly staffed by A2 nurses (registered nurses childbirth attendance in Rwanda. However, the with secondary levels of education).22 Private healthcare literature is limited on the course of labour and pregnan- is available in Kigali and other large cities in the form cy-related complications. of private dispensaries, private clinics and private hospi- This study aims to fill the knowledge gap in this area tals. Only the large private hospitals provide assisted and to serve as documentation for policymakers. delivery.20 This study was conducted in the City of Kigali Rwanda’s national guidelines on the management of and Northern Province of Rwanda. It involved eight some obstetric and gynaecological common cases are very health centres, seven district hospitals, one provincial on October 1, 2021 by guest. Protected copyright. similar to those of the WHO and thus also similar to those hospital, one referral hospital and one private hospital. used in many other countries. In these guidelines, pre-ec- This study used self-reported data from postpartum lampsia is defined as blood pressure of ≥140/90/90 mm women and data from medical records. Hg after 20 weeks of gestation plus proteinuria of 300 mg 19 This study used diagnoses made by physicians as per 24 hours or >2+ on a urine dipstick. Furthermore, noted in patients’ medical records. The diagnoses were