Promotion of early and exclusive breastfeeding in neonatal care units in rural Rwanda: a pre- and post-intervention study

Background

Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding.

Methods

This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October–December 2017 (pre-intervention) and September 2018–March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge.

Results

Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge.

Conclusions

Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.

Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda

Background

Integrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centres. This study examines the cost of organising integrated nurse-driven, physician-supervised chronic care for more severe NCDs at an outpatient specialty clinic associated with a district hospital in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, heart failure and rheumatic heart disease.

Methods

A retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro District Hospital in rural Rwanda. We determined initial start-up and annual operating financial cost of the Butaro district advanced NCD clinic for the fiscal year 2013–2014. Per-patient annual cost by disease category was determined.

Results

A total of US$47 976 in fixed start-up costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300 000 people (US$0.16 per capita). The additional annual operating cost for this clinic was US$68 975 (US$0.23 per capita) to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centres. Labour comprised 54% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient (US$151), followed by heart failure (US$104), driven primarily by medication therapy and laboratory testing.

Conclusions

This is the first study to evaluate the costs of integrated, decentralised chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems.

Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes

SETTING

In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care.

OBJECTIVE

To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda.

DESIGN

We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes.

RESULTS

Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma.

CONCLUSION

Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.

Benign and Malignant Breast Disease at Rwanda's First Public Cancer Referral Center

BACKGROUND

Breast cancer incidence is rising in low- and middle-income countries. Understanding the distribution of breast disease seen in clinical practice in such settings can guide early detection efforts and clinical algorithms, as well as support future monitoring of cancer detection rates and stage.

PATIENTS AND METHODS

We conducted a retrospective medical record review of 353 patients who presented to Butaro Cancer Center of Excellence in Rwanda with an undiagnosed breast concern during the first 18 months of the cancer program.

RESULTS

Eighty-two percent of patients presented with a breast mass. Of these, 55% were diagnosed with breast cancer and 36% were diagnosed with benign disease. Cancer rates were highest among women 50 years and older. Among all patients diagnosed with breast cancer, 20% had stage I or II disease at diagnosis, 46% had locally advanced (stage III) disease, and 31% had metastatic disease.

CONCLUSION

After the launch of Rwanda's first public cancer referral center and breast clinic, cancer detection rates were high among patients presenting with an undiagnosed breast concern. These findings will provide initial data to allow monitoring of changes in the distribution of benign and malignant disease and of cancer stage as cancer awareness and services expand nationally.

IMPLICATIONS FOR PRACTICE

The numbers of cases and deaths from breast cancer are rising in low-income countries. In many of these settings, health care systems to address breast problems and efficiently refer patients with symptoms concerning for cancer are rudimentary. Understanding the distribution of breast disease seen in such settings can guide early detection efforts and clinical algorithms. This study describes the characteristics of patients who came with a breast concern to Rwanda's first public cancer referral center during its first 18 months. More than half of patients with a breast mass were diagnosed with cancer; most had late-stage disease. Monitoring changes in the types of breast disease and cancer stages seen in Rwanda will be critical as breast cancer awareness and services grow.

Treatment of Chronic Myeloid Leukemia in Rural Rwanda: Promising Early Outcomes

Purpose

The burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda.

Methods

We conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death.

Results

Forty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up.

Conclusion

Our experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted.

Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda

BACKGROUND

Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda.

MATERIALS AND METHODS

We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage.

RESULTS

A total of 144 patients were included in our analysis. Median total delay was 15 months, and median patient and system delays were both 5 months. In multivariate analyses, patient and system delays of ≥6 months were significantly associated with more advanced-stage disease. Adjusting for other social, demographic, and clinical characteristics, a low level of education and seeing a traditional healer first were significantly associated with a longer patient delay. Having made ≥5 health facility visits before the diagnosis was significantly associated with a longer system delay. However, being from the same district as one of the two hospitals was associated with a decreased likelihood of system delay.

CONCLUSION

Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings.

IMPLICATIONS FOR PRACTICE

Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patient's first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.