The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

Abstract

Background The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. Objective This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. Methods A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. Results The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). Conclusions Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. Trial Registration ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399

Telemedicine for Surgical Site Infection Diagnosis in Rural Rwanda: Concordance and Accuracy of Image Reviews

“…These studies yielded sensitivities of 70% and 72% and specificities of 100% [36,37]. While attractive for their performance qualities, and with others in SSA using such phone-based follow-up [38], we have previously found that interventions that call women for follow-up miss 38% of eligible patients in our setting [39] and that women who were less educated and with lower incomes, and therefore more vulnerable, are significantly less likely to be reached. From a health equity perspective, our team deems it unacceptable to put forward a program which further disenfranchises the most vulnerable.…”

Prevalence of post‐caesarean section surgical site infections in Rwanda: A systematic review and meta‐analysis

“…This systematic review and meta‐analysis included 17 studies with total participants of 8, 082 individuals. The study with the highest number of participants had 889 participants 13 while the study with the smallest number of participants had 93 participants. 14 The average number of participants from all 17 studies is 457 individuals.…”

“…The included studies were published from 2014 to 2023. A total of 10 studies were conducted at Kirehe District Hospital, 1 , 9 , 13 , 15 , 16 , 17 , 18 , 19 , 20 , 21 two studies at University Teaching Hospital of Kigali, 10 , 22 and one study at University Teaching Hospital of Butare, 23 Kibungo District Hospital, 24 Ruhengeri Referral Hospital, 25 Kabgayi Hospital 14 and Bushenge Provincial Hospital each. 26 Nine studies were cohort studies, 1 , 9 , 15 , 16 , 17 , 19 , 20 , 21 , 24 six were randomized controlled trials 10 , 13 , 18 , 22 , 25 , 26 and two were cross‐sectional studies.…”

Prevalence and outcomes of pediatric surgical conditions at Connaught Hospital in Freetown: a retrospective study

“…Digital health can be another way in which CHWs can improve surgical outcomes, especially during postoperative care 33. Previous studies have provided evidence that CHWs are able to correctly diagnose surgical site infections using an app-based questionnaire and pictures of the incision site in LMICs 34 35. These interventions could help avoid poor surgical outcomes.…”