Telemedicine to improve the diagnosis of surgical site infections post-cesarean delivery in rural Rwanda

Harvard Medical School, Boston MA

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Abstract

Project Summary/Abstract Improved access to cesarean delivery in sub-Saharan Africa has led to new challenges, particularly an increase in surgical site infections (SSIs). An estimated 7-12% of women who have cesarean sections in the region develop SSIs, often after they are discharged from hospitals. Distance and financial barriers can prevent or delay them returning for care, and this can lead to increased maternal morbidity and mortality. Recent expansion of broadband cellular network coverage in sub-Saharan Africa provides an opportunity to explore whether these problems can be solved using telemedicine to follow-up with women remotely, accurately diagnose SSIs, and link those at risk of SSIs back to care. We propose a mHealth-CHW Photo-Enhanced Screening (mC-PES) intervention for SSI monitoring in rural Rwanda. Community health workers will visit women approximately 10 days after surgery, administer a validated three-question clinical assessment, take a photo of the wound, and transmit this information to a general practitioner who will provide an SSI diagnosis in real time. Patients diagnosed with an SSI will be referred to a hospital for care. Our goal is to assess the feasibility, acceptability, and diagnostic efficacy of the mC-PES intervention. The prospective intervention will include a cohort of 421 women receiving cesarean sections. We will evaluate the study's feasibility by assessing the percent of a certain set of implementation measures that are successfully completed. To determine how acceptable mC-PES is to patients and providers, we will interview 15 enrolled mothers, 14 hospital general practitioners, and 15 community health workers and use a Framework Analysis to analyze the data. Finally, to evaluate diagnostic efficacy, we will compare SSI diagnoses women that receive via the mC-PES interventions to that resulting from physical examinations by general practitioners, which we consider the gold standard. We will also assess the diagnostic accuracy using wound photos and SSI diagnoses, for 521 women whose data we previously collected as part of an ongoing study. The results from this study will inform postoperative follow-up for women delivering via cesarean section in rural areas of Africa. Further, the study will provide insight on whether mHealth and telemedicine interventions could be used for a broader range of clinical follow-up in sub-Saharan Africa.