A total of 639 women were included in the study, with 511 (80.0%) having follow up at all three time points, 548 (85.8%) with follow up at two time points, and 602 (94.2%) with at least one follows up. Most women were between 20 and 34 years old (n = 477, 74.6%), with 56 (8.8%) under 20 years and 106 (16.6) over 34 years (Table 1). The majority of women lived with a partner (n = 536, 83.9%). Most (n = 543, 85%) were farmers and the median self-reported annual household income was US$1,624 ($1,133, $2,675), with 72 participants (11.3%) belonging to the lowest rank of Ubudehe categories. The median travel time from the woman’s home to the health center was 30 minutes (IQR: 15, 60) and 40 minutes (IQR: 5, 60) from health center to the hospital. Primipara accounted for 40.4% (n = 258) of women, and 264 women (41.4%) had one or two previous births. Approximately 30% of women (n = 188) had a prior c-section delivery.
Table 1
Demographic and clinical characteristics of women delivering via c-section at Kirehe District Hospital
Variable name | Frequency (n) | Percentage (%) |
N | 639 | 100% |
DEMOGRAPHIC CHARACTERISTICS |
Age, in years | | |
< 20 | 56 | 8.8% |
20–24 | 191 | 29.9% |
25–29 | 175 | 27.4% |
30–34 | 111 | 17.4% |
>=35 | 106 | 16.6% |
Parity | | |
0 | 258 | 40.4% |
1–2 | 264 | 41.4% |
3–4 | 73 | 11.4% |
> 4 | 43 | 6.7% |
Marital Status | | |
Single, separated, divorced/widow | 103 | 16.1% |
Legally married | 237 | 37.1% |
Cohabitating (common marriage) | 299 | 46.8% |
Level of education | | |
Less than primary | 60 | 9.4% |
Completed primary | 431 | 67.5% |
Completed secondary or more | 148 | 23.1% |
Has health insurance | 636 | 99.5% |
Ubudehe categories | | |
Ubudehe 1 | 72 | 11.3% |
Ubudehe 2 | 334 | 52.4% |
Ubudehe 3&4 | 231 | 36.3% |
Occupation | | |
Farmer | 543 | 85.0% |
Employed (self, government, etc.) | 74 | 11.6% |
Unemployed (including housewives and students) | 22 | 3.4% |
Travel time in minutes, HC to hospital, Median (IQR) | 30 | (15,60) |
Travel time in minutes, HC to hospital, Median (IQR) | 40 | (5,60) |
Annual Income in USD, Median (IQR) ⱡ | $1,624 | ($1,133, $2675) |
CLINICAL CHARACTERISTICS |
Had previous c-section | 188 | 29.56% |
Reasons for surgery (N = 630) | | |
Fetal factors, no maternal factors | 213 | 33.8% |
Maternal factors, no neonatal factors | 177 | 28.1% |
Previous c-section only | 140 | 22.2% |
Maternal and fetal factors | 100 | 15.9% |
Any intraoperative complication | | |
Yes | 12 | 1.9% |
Not documented | 627 | 98.1% |
Duration of c-section surgery (in minutes) (N = 623) | | |
<=30 | 189 | 30.3% |
(30–45] | 290 | 46.5% |
(45–60] | 79 | 12.68% |
> 60 | 65 | 10.43% |
Length of hospital stay post-c-section, in days (N = 601) | | |
<=3 days | 240 | 39.9% |
> 3 days | 361 | 60.1% |
Surgical c-section categories | | |
Emergent | 38 | 6.0% |
Urgent | 562 | 88.1% |
Elective | 38 | 6.0% |
Neonatal outcomes at discharge (N = 631) | | |
Alive and discharged | 553 | 87.6% |
Alive and admitted to NICU | 63 | 10.0% |
Died | 15 | 2.4% |
* Defined by any of the following: prior uterine scar, obstructed labor, contracted pelvis, hypertension, fever, hemorrhage, uterine rupture, placental abnormality |
**Defined by any of the following: Fetal distress, mal presentation, malposition, macrosomia, multiple pregnancies, cord prolapse, intrauterine growth restriction ⱡ Converted using Rwanda purchasing power parity (PPP) for 2018 |
Nearly all women (n = 600, 94.1%) had an urgent or emergency surgery. The indication for c-section was: fetal factors only (n = 213, 33.8%), maternal factors only (n = 177, 28.1%), prior c-section (n = 140, 22%) and combined fetal and maternal factors (n = 100, 15.9%). Nearly half of all women (n = 290, 46.5%) had surgery length ranging between 30 to 45 minutes, 189 (30.3%) had a surgery length of less than 30 minutes, and 65 (10.4%) had a surgery length of greater than an hour. Over 60% (n = 361) of participants had a hospital stay greater than three days (Table 1)
Table 2 summarizes the five dimensions of functional status of patients at POD 3, POD 11 and POD 30. The majority of women were able to move independently at the time of hospital discharge (83.3%, n = 518 of 622) at POD 11 (84.7%, n = 499 of 589) and at POD30 (91.0%, n = 500 of 549). Participants reported the lowest level of functionality in the dimension assessing ability to perform usual activities, with 50.8% (n = 316 of 622) of women reporting total inability to perform usual activities at hospital discharge and 15.6% (n = 86 of 551) at POD 30. At POD 30, 68.6% (n = 368 of 551) women reported needing help to perform usual activities, 48.6% (268 of 551) reported poor or very poor overall health status, and 80 14.5% (n = 80 of 551) reported needing help to self-care. The overall functional status was poor for 54.0% (n = 333 of 617) and 26.8% (n = 147 of 548) of women at POD 3 and POD 30, respectively. Of the 147 women with poor functional status documented at POD 30, 78 (53%) had reported poor functional status at POD 3, while 79 (47%) had good functional status at POD 3 and deteriorated over the following month.
Table 2
Description of dimensions used to define functional status of women at Kirehe district Hospital
| At discharge | POD11 | POD30 |
DIMENSION OF FUNCTION | n | % | n | % | n | % |
Mobility/ Ability to move | N = 622 | N = 589 | N = 549 |
I cannot move | 1 | 0.2% | 0 | 0.0% | 2 | 0.4% |
I need some help to move | 30 | 4.8% | 9 | 1.5% | 28 | 5.1% |
I need very little help to move | 73 | 11.7% | 81 | 13.8% | 19 | 3.5% |
I can move independently | 518 | 83.3% | 499 | 84.7% | 500 | 91.0% |
Level of Energy | N = 622 | N = 590 | N = 551 |
Very low | 11 | 1.8% | 12 | 2.1% | 21 | 3.8% |
Low | 175 | 28.1% | 114 | 19.3% | 107 | 19.4% |
Moderate | 421 | 67.7% | 412 | 69.8% | 364 | 66.1% |
High | 15 | 2.4% | 52 | 8.8% | 59 | 10.7% |
Ability to perform usual activities | N = 622 | N = 588 | N = 551 |
I cannot perform activities | 316 | 50.8% | 145 | 24.7% | 86 | 15.6% |
I need some help to perform activities | 229 | 36.8% | 165 | 28.1% | 139 | 25.2% |
I need little help performing activities | 63 | 10.1% | 148 | 25.2% | 239 | 43.4% |
I don't need help | 14 | 2.3% | 130 | 22.1% | 87 | 15.8% |
Ability to self-care | N = 620 | N = 590 | N = 550 |
I cannot care for myself | 11 | 1.8% | 1 | 0.2% | 8 | 1.5% |
I need some help to care for myself | 63 | 10.2% | 14 | 2.4% | 48 | 8.7% |
I need little help care for myself | 151 | 24.3% | 82 | 13.9% | 32 | 5.8% |
I don't need help to care for myself | 395 | 63.7% | 493 | 83.6% | 462 | 84.0% |
Overall health status | N = 623 | N = 590 | N = 551 |
Very poor | 3 | 0.5% | 3 | 0.5% | 3 | 0.5% |
Poor | 394 | 63.2% | 228 | 38.6% | 265 | 48.1% |
Good | 218 | 35.0% | 341 | 57.8% | 242 | 43.9% |
Very Good | 8 | 1.3% | 18 | 3.1% | 41 | 7.4% |
MAIN OUTCOME | | | | | | |
Overall Functional Status * | N = 617 | N = 587 | N = 548 |
Poor | 333 | 54.0% | 152 | 25.9% | 147 | 26.8% |
Good | 284 | 46.0% | 435 | 74.1% | 401 | 73.2% |
*Overall function status is a composite variable created by combining the above individual domains; scores 1–4 are generated and dichotomized into poor function status :1–2, good function satus:3–4, inclusive |
Women who stayed in the hospital longer than three days after delivery were more likely to report poor functional status at POD 30 compared to those who stayed three days or fewer (p = 0.024, Table 3). Those with a poor functional status had a significantly lower monthly income [poor functional status: $37.6, IQR: ($28.3, $62.4); good functional status: $45.4, IQR: ($30.3, $70.6); p = 0.04)].
Table 3
Bivariate analysis of characteristics associated with poor functional status at POD30
Variable name | | Poor function at pod30 | P-value* |
| N | n | % | |
Number with poor functional outcome, overall | 548 | 147 | 26.8% | |
DEMOGRAPHIC CHARACTERISTICS |
Age, in years | | | | 0.25 |
< 20 | 43 | 7 | 16.3% | |
20–24 | 158 | 43 | 27.2% | |
25–29 | 153 | 36 | 23.5% | |
30–34 | 99 | 31 | 31.3% | |
>=35 | 95 | 30 | 31.6% | |
Parity (N = 547) | | | | 0.43 |
0 | 217 | 51 | 23.5% | |
1–2 | 229 | 64 | 28.0% | |
3–4 | 63 | 19 | 30.2% | |
> 4 | 38 | 13 | 34.2% | |
Marital Status | | | | 0.80 |
Single, separated, divorced/widow | 80 | 19 | 23.8% | |
Legally married | 231 | 58 | 27.5% | |
Cohabitating (common marriage) | 255 | 70 | 27.5% | |
Level of education | | | | 0.13 |
Less than primary | 54 | 13 | 24.1% | |
Completed primary | 359 | 106 | 29.5% | |
Completed secondary or more | 135 | 28 | 20.7% | |
Has health insurance | | | | 0.18 |
No | 3 | 2 | 66.7% | |
Yes | 545 | 145 | 26.1% | |
Ubudehe categories | | | | 0.47 |
Ubudehe 1 | 55 | 11 | 20.0% | |
Ubudehe 2 | 289 | 80 | 27.7% | |
Ubudehe 3&4 | 202 | 56 | 27.7% | |
Occupation | | | | 0.09 |
Farmer | 463 | 129 | 27.9% | |
Employed (self, government, etc.) | 67 | 17 | 25.4% | |
Unemployed | 18 | 1 | 5.6% | |
Travel time in minutes, home to health center, Median (IQR)(N = 579) | | | | 0.18 |
Among those with poor function | 134 | 30 | (15,60) | |
Among those with good function | 361 | 30 | (15,60) | |
Travel time in minutes, HC to hospital, Median (IQR)(N = 579) | | | | 0.10 |
Among those with poor function | 134 | 45 | (10,60) | |
Among those with good function | 360 | 37.5 | (5,60) | |
Monthly Income in USD, Median (IQR) | | | | |
Among those with poor function | 147 | 37.6 | (28.3,62.4) | 0.05 |
Among those with good function | 370 | 45.4 | (30.3,72.8) | |
CLINICAL CHARACTERISTICS | | | |
Had previous c-section (N = 636) | 162 | 43 | 29.45% | 0.95 |
Reasons for surgery (N = 630) | | | | 0.28 |
Fetal factors, no maternal factors | 182 | 52 | 35.5% | |
Maternal factors, no neonatal factors | 154 | 33 | 22.6% | |
Previous c-section only | 119 | 33 | 22.6% | |
Maternal and fetal factors | 87 | 28 | 19.2% | |
Duration of c-section surgery (in minutes) | 534 | | | 0.07 |
<=30 | 163 | 33 | 20.2% | |
(30–45] | 247 | 78 | 31.6% | |
(45–60) | 70 | 20 | 28.6% | |
> 60 | 54 | 12 | 22.2% | |
Any intraoperative complication | | | | 0.10 |
Not reported | 538 | 142 | 26.4% | |
Yes | 10 | 5 | 50% | |
Length of hospital stay, in days | 534 | | | 0.024 |
<=3 days | 163 | 33 | 20.3% | |
> 3 days | 371 | 110 | 29.7% | |
Surgical c-section categories | 547 | | | 0.74 |
Emergent | 32 | 9 | 28.1% | |
Urgent | 481 | 127 | 26.4% | |
Elective | 34 | 11 | 32.4% | |
Neonatal outcomes at discharge | 542 | | | 0.31 |
Alive and discharged | 487 | 127 | 26.1% | |
Alive and admitted to NICU | 41 | 15 | 36.6% | |
Died | 14 | 3 | 21.4% | |
In the final reduced model (Table 4), surgery duration, intraoperative complications, and income remained the only significant factors. Patients whose surgery duration ranged between 30 to 45 minutes had 85% increased odds of reporting poor functional status at POD 30 compared to those with surgery duration of less than 30 minutes (aOR = 1.85, 95% CI: 1.15, 2.95). Women with any documented intraoperative complications had 3.12 times higher odds of poor function compared to women without complications (aOR = 4.12, 95% CI: 1.09, 15.57). For every US$100 increase in monthly income, there was a 38% decrease in the odds of reporting poor functional status at POD 30 (aOR = 0.62, 95% CI: 0.40, 0.96).
Table 4
Multivariate analysis of characteristics independently associated with poor functional status at POD30
| Full Model | Reduced Model |
Variable name | OR | 95% CI | p-value | OR | 95% CI | p-value |
Level of education | | | | | | |
Less than primary | Ref | | | | | |
Completed primary | 1.3 | (0.64, 2.72) | 0.44 | | | |
Completed secondary or more | 0.9 | (0.38, 2.11) | 0.80 | | | |
Has health insurance | | | | | | |
No | Ref | | | | | |
Yes | 0.19 | (0.02,2.19) | 0.18 | | | |
Occupation | | | | | | |
Farmer | Ref | | | | | |
Employed (self, gov., etc) | 1.2 | (0.60,2.50) | 0.58 | | | |
Unemployed | 0.28 | (0.03,2.21) | 0.23 | | | |
Travel time in minutes, home to health center, Median (IQR)(N = 579) | 0.99 | (0.95, 1.04) | 0.87 | | | |
Travel time in minutes, HC to hospital, Median (IQR)(N = 579) | 1.02 | (0.99,1.04) | 0.21 | | | |
Monthly Income in USD, Median (IQR) | 0.67 | (0.42,1,06) | 0.10 | 0.62 | (0.40,0.96) | 0.033 |
Any intraoperative complication | | | | | | |
Not reported | Ref | | | | | |
Yes | 5.39 | (1.29,22.53) | 0.021 | 4.12 | (1.09,25.57) | 0.037 |
Duration of c-section surgery (in minutes) | | | | | | |
<=30 | Ref | | | | | |
(30–45] | 1.7 | (1.05,2.80) | 0.03 | 1.85 | (1.15,2.95) | 0.01 |
(45–60) | 1.5 | (0.76,2.91) | 0.242 | 1.56 | (0.82,2.99) | 0.18 |
> 60 | 0.80 | (0.35,1.82) | 0.60 | 0.92 | (0.42,2.03) | 0.84 |
Length of hospital stay, in days | | | | | | |
<=3 days | Ref | | | | | |
> 3 days | 0.76 | (0.50,1.15) | 0.20 | | | |