Tropical Medicine and International Health

doi:10.1111/tmi.12016

volume 18 no 1 pp 1826 january 2013

Local use of geographic information systems to improve data

utilisation and health services: mapping caesarean section
coverage in rural Rwanda
Leanna Sudhof1, Cheryl Amoroso2, Peter Barebwanuwe2, Fabien Munyaneza2, Adolphe Karamaga3,
Giovanni Zambotti4, Peter Drobac2,5 and Lisa R. Hirschhorn6,7
1
2
3
4
5
6
7

Women and Infants Hospital, Providence, RI, USA

Partners In Health, Rwinkwavu, Rwanda
Ministry of Health, Rwinkwavu, Rwanda
Harvard Center for Geographic Analysis, Cambridge, MA, USA
Division of Global Health Equity, Brigham and Womens Hospital, Boston, MA, USA
Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, MA, USA
Partners In Health, Boston, MA, USA

Abstract

objectives To show the utility of combining routinely collected data with geographic location using
a Geographic Information System (GIS) in order to facilitate a data-driven approach to identifying
potential gaps in access to emergency obstetric care within a rural Rwandan health district.
methods Total expected births in 2009 at sub-district levels were estimated using community health
worker collected population data. Clinical data were extracted from birth registries at eight health
centres (HCs) and the district hospital (DH). C-section rates as a proportion of total expected
births were mapped by cell. Peri-partum foetal mortality rates per facility-based births, as well as the
rate of uterine rupture as an indication for C-section, were compared between areas of low and high
C-section rates.
results The lowest C-section rates were found in the more remote part of the hospital catchment
area. The sector with significantly lower C-section rates had significantly higher facility-based peripartum foetal mortality and incidence of uterine rupture than the sector with the highest C-section
rates (P < 0.034).
conclusions This simple approach for geographic monitoring and evaluation leveraging existing
health service and GIS data facilitated evidence-based decision making and represents a feasible
approach to further strengthen local data-driven decisions for resource allocation and quality
improvement.
keywords geographic information systems, maternal mortality, regional health planning, access to
health care, Rwanda

Introduction
Most maternal morbidity and mortality are preventable,
and yet in 2008, nearly 350 000 women died in pregnancy or childbirth worldwide. Although progress has
been made in reducing maternal mortality, the world will
not achieve the target of Millennium Development Goal
(MDG) 5: a 75% reduction in Maternal Mortality Ratio
(MMR) by 2015 (Hogan et al. 2010). Caesarean section
rates are a commonly used indicator to monitor access
to, and use of, emergency obstetric care, one of the critical components in reducing maternal mortality (WHO
18

et al. 2009). WHO estimates that population rates of

Caesarean sections (C-sections) between 5 and 15%
reflect appropriate access and utilisation (2009). Populations with lower rates potentially represent compromised
access and utilisation, raising the risk of preventable
maternal death.
In Rwanda, where 85% of the population live in rural
areas, significant progress has been made towards achieving MDG 5 (Hogan et al. 2010). The MMR has
decreased from an estimated 1300 deaths per 100 000
live births during the period 20002004, to 487 for the
period 20042010 (Hill et al. 2007; National Institute of

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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

Statistics of Rwanda 2011). Despite this progress, the

Rwandan Health Sector Strategic Plan-II noted that
MDG 5 was proving the most difficult to achieve
(2009), and in response, the Rwandan Ministry of Health
(MOH) has prioritised maternal health.
One priority for countries in sub-Saharan Africa working towards maternal mortality reduction is improving
the use of existing data to improve health systems
(Gething et al. 2007). Local decision makers often lack
the tools to efficiently and effectively use data to identify
gaps and ensure evidence-based decision making and
equitable allocation of limited resources. One tool that
has been increasingly used in sub-Saharan African settings to address this challenge is Geographical Information System(s) (GIS). This work has included the
documentation of the negative impact of distance on service utilisation and identification of areas with low access
to services (Noor et al. 2003; Heard et al. 2004; Feikin
et al. 2009; Cooke et al. 2010). Tanser et al. (2001)
analysed the geographic variability in usage rates of clinics in rural South Africa to identify areas of under-performance. GIS was also used for program monitoring and
visualising progress in coverage of insecticide-treated nets
in malaria-endemic regions between 2000 and 2007
(Noor et al. 2009).
Most GIS use reported in the literature was by groups
with good data management infrastructure and expertise
in the context of research institutions or large initiatives.
In this article, we describe the implementation of a relatively low-cost, community-based approach to integrate
GIS analysis and data use into district-level monitoring
and evaluation in the catchment area of a single district
hospital (DH) in southern Kayonza District. Local decision
makers then used the geographic disaggregation and visualisation of locally available data to identify potential gaps
in access to and utilisation of emergency obstetric care,
providing guidance for evidence-based health resource
allocation to improve equity at a sub-district level.

Methods
Study setting
Since 2005, Partners In Health (PIH) has collaborated
with the Rwandan Ministry of Health to strengthen the
health system in three rural districts. Joint interventions
at the DH, health centre and community level have been
employed to improve financial and social access to health
care, including community health worker initiatives to
accompany pregnant women in obtaining prenatal care
and incentivised grants to the health centres (HCs) to
minimise barriers to care as well as improve the quality

2012 Blackwell Publishing Ltd

of care. In 2009, PIH introduced GIS mapping and analysis as an adjunct to existing monitoring and evaluation
efforts in the uniformly hilly southern region of Kayonza
District to examine geographic access.
The health system in the southern part of Kayonza District includes one DH and eight HCs serving 7.5 administrative sectors, which make up the catchment area of the
DH (see Figure 1). The names of the DH, HCs and sectors were replaced with letter designations, with the HC
and the sector they serve given the same letter. Sectors
included a population of 15 00025 000 people, covering
an average area of 48 km2. Each sector is divided by the
Rwandan government into four or five administrative
cells, each containing 516 villages. Each HC serves one
sector, with the exception of the HC in Sector C, which
serves a single cell in the DH catchment. Clinically, HCs
are staffed by nurses alone, and standard obstetrical services include normal labour and vaginal delivery. Complicated labour and high-risk cases are referred to the DH,
and C-sections are only performed at the DH. Operative
vaginal deliveries (forceps and vacuum) are not performed at the HCs or the DH. One HC in the catchment,
HC (H), does not provide childbirth services because
women deliver at the adjoining DH.
Geographic data collection
To support integration of GIS into routine monitoring and
evaluation, PIH employed a Rwandan Bachelor-level GIS
studies graduate to provide training and support data use
through analysis, interpretation and feedback of results to
programs. The GIS team also included a local high school
graduate program associate who acted as coordinator of
data collection activities, which included mapping at the
village level with community health workers. District-wide
geographic data encoding sector boundaries and roads
were obtained from the Centre for GIS at the National
University of Rwanda, and the National Institute for
Statistics in Rwanda provided geographic data encoding
cell boundaries. Sector and district maps were created with
ArcGIS 9.3.1 software, which was obtained through an
academic partnership with Harvard University. All
analysis was carried out by the local GIS team.
Data collection for facility-based delivery and caesarean
sections
C-section and facility delivery data were manually collected over two months by a medical student and data
officer. Maternity data in paper-based labour registries at
the eight HCs and the DH for the 4583 women who
delivered between 1 January 2009 and 31 December
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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

N
0

10 km

Mukarange

Rwinkwavu
Nyamirama
Rwinkwavu Hospital

Ndego

Ruramira

Kabarondo
Murama
Kabare

Legend
HC Inside DH Catchment
Major Unpaved Rd
Paved Rd
Sector Boundaries
Cells in DH Catchment
Cells Outside Catchment

Figure 1 Map of study area.

2009 were extracted and entered in a secure Excel database. The 104 patients from outside of the DH catchment
were excluded. Data extracted included patient name (for
identification of duplicated entries), age, address, admission date, discharge date, delivery date, APGAR score,
referral status and reason for referral. Indications for prepartum referral of labouring patients documented in HC
registries and indications for C-section documented at the
DH were categorised according to first recorded diagnosis: failure to progress, cephalopelvic disproportion, foetal
distress, repeat Caesarean, malpresentation, uterine rupture, failed induction, placental abnormality and preeclampsia. C-sections with documented reasons that are
not recognised indications for C-section were coded as
elective (voluntary, tubal ligation or normal labour).
Estimating total births
Total expected births were calculated using total population at the cell and sector levels as estimated below and
published crude national birth rates. We used the estimate of Rwanda birth rate of 38.1 births per 1000 population from the US Census Bureau 2009 estimate, which
was the most recent and also consistent with the trend in
birth rates reported in the 2005 and 2007 Rwanda DHS
(US Census Bureau 2009, Institut National de la Statistique du Rwanda (INSR), 2006, Ministry of Health
20

(Rwanda), Macro International, Inc 20072008, 2010).

The last Census in Rwanda was conducted in 2002, with
results only made available at the provincial level to the
authors (Minnesota Population Center 2011). The rapid
increase in Rwandas population since 2002 made the
applicability of that data to estimate births in 2009 a
concern (World Bank 2009). We thus turned to Rwandas robust CHW system, which first began collecting
and reporting population data on households in mid2009. The CHWs (25 per village) submitted monthly
reports, which included the number of inhabitants. HCs
routinely collected monthly CHW reports and aggregated
the data at the sector level. We used CHW-level paper
reports for up to 4 months (August, September, and
December 2009 and January 2010) and aggregated the
total population numbers in these reports by village by
month, before calculating the median monthly village
population for each village. The village-level estimates
were then aggregated to give cell and sector population
number estimates. These population estimates, along with
the estimated national crude birth rate, were used to calculate expected births by cell and sector. To test the variability in the CHW population data, we redid the
calculations using the lowest and highest observations for
each village, and the effect on the cell- and sector-level
C-section rates was marginal, with a less than 5% difference for all but two cells, where the difference was less

2012 Blackwell Publishing Ltd

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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

than 7%. Once the DHS 2010 was available, we again

tested the reliability of the CHW data by calculating
expected births using AfriPop 2010 estimates of women
of child-bearing age, and population distribution and
rural age-specific fertility rates averaged across the 2007
2008 and 2010 DHSs. A paired t-test showed no statistical difference between the two methods (P = 0.5098).

compared across sectors. Chi-squared test or Fisher exact

test were used to compare the sectors with the lowest and
highest C-section rates to the other sectors.
Workshops led by the GIS team were held with Ministry of Health and PIH staff at the district, hospital and
local levels to discuss how GIS data can be used in program monitoring and evaluation as well as quality
improvement activities.

Outcome indicators
The main outcome indicator, C-section rate, was measured using two different denominators: estimated total
births in the HC catchment areas (population-based
C-section coverage rate) and total health facility births
(health facility-based C-section rate) (Table 1). Other
indicators included the hospital-based delivery rate and
facility-based peri-partum foetal mortality rate. Both of
these rates were calculated as a proportion of total documented births by patient cell or sector of residence.
Health facility refers to both the HCs and the DH.
Analyses
Maps were created in ArcGIS 9.3.1, linking C-section coverage rates and facility-based peri-partum foetal mortality
rates to cells, the government-determined sub-sector
administrative boundaries. Distances by road between
each HC and the DH were calculated using the network
analysis extension. Ambulance travel time was estimated
using the calculated distances and an assigned average
speed on the two different types of road, paved road and
major unpaved road. Health facility and population-based
C-section rates, facility-based peri-partum foetal mortality
rates and the rates of C-section for uterine rupture were

Ethical approval
This project was reviewed by the institutional review
boards of Partners Health care in Boston, USA and the
Rwanda National Ethics Committee. Patient data were
aggregated at the village or cell level and were anonymised for analysis and reporting.

Results
HC catchments and distances to DH
Documentation of patient addresses at the HCs allowed
linkage of over 97% of women presenting for delivery at
a health facility to their cell of residence, although one
HC (G) had lower rates of documentation (Table 2).
Most women presenting in labour resided within the
HCs catchment, with the exception of HC (C), where
about 50% of presenting patients lived in neighbouring
sectors. The average age of women that delivered in the
DH catchment ranged between 25.8 and 27.7 by sector.
As shown in Figure 2, distances by road between the
HCs and the DH ranged from 12 km to 32 km, and the
estimated travel times varied from a half hour to two
hours.

Table 1 Definitions of outcome indicators

Population-based C-section coverage rate
(per 100 estimated total births)
C-section rate in health-facility based deliveries
(per 100 health-facility based deliveries)

DH delivery rate
(per 100 health-facility based deliveries)

Facility-based peri-partum fetal mortality rate

(per 100 health-facility based deliveries)

2012 Blackwell Publishing Ltd

Total C-sections at the DH for women residing in a cell/Expected total births for
that cell. This rate is a UN indicator for access to emergency obstetric care
(WHO et al. 2009).
Total C-sections at the DH in women residing in a sector/Total documented
health-facility based deliveries at any health facility in S. Kayonza for women
residing in that sector. This rate shows the percentage of women presenting for
health-facility based deliveries who received a C-section.
Total deliveries that occurred at the DH for women residing in a sector/Total
documented health-facility based deliveries at any health facility in S. Kayonza
for women residing in that sector. This measured the proportion of documented
health-facility based deliveries that occurred at the DH, as a measure of health
facility to health facility access.
Total neonates that were documented to be dead at delivery or to have died in
the first ten minutes of life whose mothers lived in a cell/Total documented
health-facility based deliveries at any health facility in S. Kayonza for women
residing in that cell.

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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

Table 2 Geographic characteristics of women registered in maternity ward registries in S. Kayonza

Health facility
of presentation,
represented by
name of sector

Total patients
in labor registered
at each health facility*

% Patients linked
to cell of residence

Total patients
presenting from assigned
HC catchment

Sector
Sector
Sector
Sector
Sector
Sector
Sector
Sector

429
797
236
384
347
527
419
1340

428
795
235
384
344
525
369
1302

421
777
131
381
331
520
412
NA

A
B
C
D
E
F
G
H (HC+DH)

(99.8)
(99.7)
(99.6)
(100.0)
(99.1)
(99.6)
(88.1)
(97.2)

(98.1)
(97.5)
(55.5)
(99.2)
(95.4)
(98.7)
(98.3)

*Including only patients originating from within DH catchment.

Patients identified as having been referred from one of the seven HCs were excluded.

Based on the CHW data, cell populations ranged from

2 300 to 8 200 people, and sector populations ranged
from 14 000 to 31 000. The calculated expected births in
2009 ranged from 88 to 313 births by cell, and from 551
to 1183 births by sector.
The number of patients presenting in labour from
within the DH catchment ranged from 236 at HC (C) to
1340 at the DH (Table 2). The DH delivery rate was significantly lower for women residing in Sector E
(P < 0.016) and significantly higher for women residing
in Sector B (P < 0.001) than for women living in other
sectors (Table 3).

120
Travel time (min)
Distance (km)

100

80

60

40

20

0
Sector B Sector F Sector A Sector G Sector C Sector D Sector E

Population-based C-section coverage rates by cell

Figure 2 Travel time and distance by road from each HC to the
DH.

The map of population-based C-section coverage rates

(Figure 3) varied from 3.0 to 29.6%. The highest rates

Table 3 Distribution by sector of residence of health-facility (HF) based deliveries and C-sections in S. Kayonza

Sector of
residence

Estimated
total
population

Estimated
total births

Total
documented
HF-based
deliveries

Sector
Sector
Sector
Sector
Sector
Sector
Sector
Sector

31 038
24 953
4437
17 408
14 459
26 213
14 998
23 642

1183
951
169
663
551
999
571
901

544
961
147
502
351
712
468
790

A
B
C*
D
E
F
G
H

Deliveries
at the DH
(% of
HF-based
deliveries)
149
330
24
144
77
188
118
NA

(27.4)
(34.3)
(16.3)
(28.7)
(21.9)
(26.4)
(25.2)

Total C-sections
(% of HF-based
deliveries)

C-section
coverage
rates (per 100
estimated
total births)

Range in
by-cell
C-section
coverage rate

C-sections
for Uterine
Rupture
(% C-sections)

59
112
13
49
24
91
56
145

4.99
11.78
7.69
7.39
4.36
9.11
9.81
16.09

3.08.7
10.116.7
7.7
4.910.2
3.07.0
8.59.6
8.813.0
11.729.6

1
0
0
2
3
3
2
2

(10.8)
(11.7)
(8.8)
(9.8)
(6.8)
(12.8)
(12.0)
(18.4)

(1.6)

(3.8)
(12.5)
(3.3)
(3.6)
(1.4)

*Only one cell in Sector C.

Sectors E and H significantly different from the other sectors (P < 0.001).

22

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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

10 km

Rwinkwavu Hospital

Legend
Paved Rd
Major Unpaved Rd
Minor Unpaved Rd
CS Rate by cell (%Expected)

25
5 10
10 15
15 30
Surrounding Sectors

were in the area directly surrounding the hospital, while

the lowest rates were in the eastern, more remote part of
the DH catchment area. For the lowest C-section rate
(3.0%), the 95% confidence interval extended from 1.5
to 5.6%, barely overlapping the 5% minimum WHOrecommended C-section rate. The 95% confidence
interval for the highest C-section rate (29.6%) in the DH
Sector 22.1 to 38.2% was above the WHOrecommended threshold of 15%.
Health facility-based C-section rates
In comparing the rates of C-sections in all health facilitybased deliveries, Sector E had a significantly lower rate
than other sectors (P < 0.001), and Sector H had a significantly higher rate than other sectors (P < 0.001).
Figure 4 shows the inverse relationship between rate of
C-sections in health facility-based deliveries and travel
time between the HC and DH.

Facility-based birth outcomes

Facility-based peri-partum foetal mortality rates ranged
between 0.4 and 4.6%. Figure 5 suggests the co-existence
of low C-section coverage rates and higher facility-based
peri-partum foetal mortality rates in the eastern DH
catchment. Using sectors of residence rather than cell of

2012 Blackwell Publishing Ltd

C-section coverage

Figure 3 C-section coverage rate (per 100 expected births) by cell of residence with road network.
20
18
16
14
12
10
8
6
4
2
0
0

HC (E)
y = 0.0918x + 16.69
R2 = 0.83847
20

80
40
60
100
Travel Time betweem HC and DH (min)

120

140

Figure 4 C-section rates in facility-based deliveries vs. HC to

DH travel time.

residence due to the low incidence of immediate peri-partum foetal mortality documented in the 2009 birth registries, women living in the catchment area of HC (E) had
a higher facility-based peri-partum foetal mortality rate
compared with women living in other sectors in the DH
catchment (P < 0.034).
Uterine rupture as an indication for C-section indicates
delay in accessing emergency obstetrical care. Differences
in uterine rupture as the indications for C-sections based
on sector of residence were seen between Sector E (3 of
24 C-sections) and Sector H, where all patients automatically deliver at the DH, obviating physical access barriers
to emergency obstetrical care in HC-to-DH referrals
(P = 0.02).
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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

N
0

10 km

Rwinkwavu Hospital

Legend
Paved Rd
Major Unpaved Rd
Fetal Mortality Rate by Cell

0
0.41.0
1.02.0
2.03.0
3.04.0
4.05.0
Surrounding Sectors

Figure 5 Overlay of facility-based peri-partum foetal mortality rates (per 100 facility-based births) and population-based
C-section coverage rates (per 100 estimated births) by cell of residence.

Discussion
We found that a locally implemented, low-resource GIS
program successfully integrated routinely available service
delivery data with available geographic data. Feedback of
results to local decision makers using maps of C-section
data allowed visualisation of C-section rates by cell of
patient residence, linking physical access, and in particular accessibility by ambulance (road density and total
distance from the DH), with high (>15%) and low
(<5%) population-based C-section coverage rates. This
addition of the geographic analysis provided program
managers with the ability to rapidly identify distance as a
modifiable factor associated with lower access.
The use of GIS in the context of program monitoring
also allowed for the geographic overlay of different data
types. Facility-based peri-partum foetal mortality rates
and rates of C-section for uterine rupture added additional evidence suggesting that utilisation of C-sections
for women living in the part of the sub-district furthest
from the DH may have been too low. In developing
countries, uterine rupture is usually the result of prolonged dystocia and can be a marker for delay of accessing emergency obstetric care. Other studies have linked
decreased physical access to health facilities with adverse
outcomes in maternal health and other areas of health
care (OMeara et al. 2009; Pirkle et al. 2010).
24

The local integration of GIS into the review of available data also provided district program managers with
potential evidence for physical access as a cause of
C-section rate variability, in particular in Sector E, where
lower road accessibility and higher calculated travel times
overlapped with the lowest C-section rates. Based on
these findings, program managers were concerned that
there may be an unmet need for access to C-sections in
that area. This information was presented in a workshop
to key DH and program decision makers. As a result,
programmatic decisions based on the available data were
made to address the decreased physical access, and an
additional ambulance was placed in the more remote
HC. In contrast, the unexpectedly high rate of C-sections
for women residing in cells adjacent to the paved road
and DH suggests that this may be an over-utilised mode
of delivery for women with easy access, as reflected in
the higher number of cases coming from these cells where
the indication for C-section was coded as elective (data
not presented here).
The value of GIS data to drive local decision making
and resource allocation has also been seen in rural Indonesia, which documented the use of spatial analytical
skills six months following the training of health officers
(Fisher & Myers 2011). Health officers implemented the
open-source mapping system and used the results for
auditing health infrastructure in two districts, directing

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L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

new staff placement based on the location of existing

midwives, prioritising clinic upgrades and road repairs
based on priority areas, and coordinating transportation
to health facilities for term pregnant women. In Rwanda,
integrating GIS into decision making is already serving as
a platform for further strengthening data use in the
health sector. For example, in the Eastern Province, the
use of geographic data to evaluate and plan programs
has been used to identify areas with particularly high proportions of underweight HIV patients, allowing for focusing of CHW efforts in providing nutritional supplements
and education in those areas most in need (Munyaneza
et al. 2011).

patient factors such as perceived severity of illness, socioeconomic status and perceived quality of care to be significant determinants of the accessing of health care in rural
sub-Saharan African settings (Heard et al. 2004; Kiwanuka et al. 2008; Feikin et al. 2009; Van Hemelrijck et al.
2009). These data were not available as a part of the routinely available health facility data. Patient characteristics
such as parity, age at first birth and birth interval are
important determinants of C-section rates. While we
were not able to include as cofactors, these are unlikely
to vary geographically across sectors within a single
district, and therefore, were unlikely to have had a
significant effect on the geographic relationships found
in this study.

Limitations
Similar to many settings in sub-Saharan Africa, data on
actual total births were outdated and did not reflect the
population movement that occurred in the intervening
7 years. While this may have altered the calculated population-based rates, we constructed the estimate that took
advantage of the CHW village-level monitoring and combined these locally derived population estimates with the
national crude birth rate.
Ascertainment of facility births was limited to health
facilities within the DH catchment area. If patients living
at the periphery of the catchment area presented to other
health facilities, the estimated C-section rate may be artificially low. While this may be a consideration in Sector A,
where a health centre outside the DH catchment is located
nearby, the area with the lowest C-section rate (Sector E)
is remote with no access to alternative facilities.
Neonatal mortality, defined as the rate of infants that
die in the first 28 days of life, is a more valid measure
for adverse birth outcomes than immediate perinatal
mortality (WHO et al. 2009), but this data were unavailable. We were also unable to measure maternal mortality
as an outcome at the sector level due to the low incidence
over the one year of the study.
The driving times from the HCs to DH calculated using
standard speeds on different types of road and distances by
road were not confirmed with actual travel time data under
varying conditions. Given the terrain and lack of paved
roads to the more remote HCs, the travel times were likely
underestimated for routes to those HCs, and the association observed in this study may be more pronounced than
presented here. Measuring actual ambulance travel times
between health facilities and travel times from villages to
the HCs would be important in follow-up studies.
In addition to the geographic barriers identified in the
study, other factors which we were not able to capture
may have affected C-section rates. Studies have shown

2012 Blackwell Publishing Ltd

Conclusion
In conclusion, our use of GIS to combine geographic and
routine clinical data along with the involvement of local
leaders resulted in the integration of GIS as a tool for
program monitoring, data-driven decision making at the
district level and measurement of impact of these decisions in the future. We believe that this low-resourced,
simple geographic monitoring and evaluation system can
increase the effective use of routinely collected data and
help countries improve healthcare access and outcomes at
the local level. Although the use of GIS to assess access
to health services in East Africa is not new, novel aspects
of our approach include the community involvement
from initial conception, the focus on sub-district-level
outcomes and the low technical expertise required to
train staff and perform the data collection and analysis.
Plans are already underway to replicate in other health
service areas and other districts supported by PIH, with
the goal of strengthening the capacity of district health
officials and their partners to use this approach to identify and guide responses to gaps in the delivery of a
specific health service in the communities.
Acknowledgements
The authors thank Deo Rutamu and Paulin Basinga for
their help in acquiring the Rwanda-specific GIS data;
Didi Bertrand Farmer, Denise Uwera and Elias Ngizwenayo for their support in facilitating this work; and Issa
Kamatari for assistance with data collection. Many
thanks also go to Bethany Hedt, Ann Miller and Mary
Kay Smith-Fawzi for their help with design- and analysisrelated questions and to Dana Thomson for her help with
the population estimates. Most of all, we are grateful to
the community health workers and maternity staff in
Kayonza District for their help with data collection and
25

Tropical Medicine and International Health

volume 18 no 1 pp 1826 january 2013

L. Sudhof et al. Local use of GIS mapping to improve rural C-section access

their dedication to reducing maternal mortality for the

women in their communities.
References
Cooke GS, Tanser FC, Barnighausen TW & Newell ML (2010)
Population uptake of antiretroviral treatment through primary
care in rural South Africa. BMC Public Health 10, 585593.
Feikin DR, Nguyen LM, Adazu K et al. (2009) The impact of
distance of residence from a peripheral health facility on
pediatric health utilization in rural western Kenya. Tropical
Medicine and International Health 14, 5461.
Fisher RP & Myers BA (2011) Free and simple GIS as appropriate for health mapping in a low resource setting: a case study
in eastern Indonesia. International Journal of Health Geographics 10, 1525.
Gething PW, Noor AM, Goodman CA et al. (2007) Information
for decision making from imperfect national data: tracking
major changes in health care use in Kenya using geostatistics.
BMC Medicine 5, 3745.
Heard NJ, Larsen U & Hozumi D (2004) Investigating access to
reproductive health services using GIS: proximity to services
and the use of modern contraceptives in Malawi. African
Journal of Reproductive Health 8, 164179.
Hill K, Thomas K, AbouZahr C et al. (2007) Estimates of
maternal mortality worldwide between 1990 and 2005: an
assessment of available data. Lancet 370, 13111319.
Hogan MC, Foreman KJ, Naghavi M et al. (2010) Maternal
mortality for 181 countries, 19802008: a systematic analysis
of progress towards Millennium Development Goal 5. Lancet
375, 16091623.
Kiwanuka SN, Ekirapa EK, Peterson S et al. (2008) Access to
and utilisation of health services for the poor in Uganda: a
systematic review of available evidence. Transactions of the
Royal Society of Tropical Medicine and Hygiene 102,
10671074.
Minnesota Population Center (2011) Integrated Public Use Microdata Series, International: Version 6.1. Available at: www.
international.ipums.org/international (accessed 10 April 2011).
Munyaneza F, Barebwanuwe P, Sudhof L et al. (2011) Using
Geographic Information Systems to Support HIV Care in
Rwanda. Poster session presented at: 6th International Conference for Research and Exchange on HIV and AIDS; Jun 910;
Kigali, Rwanda.
National Institute of Statistics of Rwanda (NISR) [Rwanda],
Ministry of Health (MOH) [Rwanda], and ICF International
(2011). Rwanda Demographic and Health Survey 2010. NISR,
MOH, and ICF International, Calverton, MD, USA.
Institut National de la Statistique du Rwanda (INSR) and ORC
Macro (2006) Rwanda Demographic and Health Survey 2005.
INSR and ORC Macro, Calverton, MD.

Ministry of Health (MOH) [Rwanda], National Institute of

Statistics of Rwanda (NISR), and ICF Macro (2009) Rwanda
Interim Demographic and Health Survey 200708. MOH,
NISR, and ICF Macro, Calverton, MD.
National Institute of Statistics of Rwanda (NISR) [Rwanda],
Ministry of Health (MOH) [Rwanda], and ICF International
(2012) Rwanda Demographic and Health Survey 2010. NISR,
MOH, and ICF International, Calverton, MD.
Noor AM, Zurovac D, Hay SI, Ochola SA & Snow RW (2003)
Defining equity in physical access to clinical services using
geographical information systems as part of malaria planning
and monitoring in Kenya. Tropical Medicine and International
Health 8, 917926.
Noor AM, Mutheu JJ, Tatem AJ, Hay SI & Snow RW (2009)
Insecticide-treated net coverage in Africa: mapping progress in
200007. Lancet 373, 5867.
OMeara WP, Noor A, Gatakaa H, Tsofa B, McKenzie FE &
Marsh K (2009) The impact of primary health care on malaria
morbidity: defining access by disease burden. Tropical Medicine & International Health 14, 2935.
Pirkle CM, Fournier P, Tourigny C, Sangare K & Haddad S
(2010) Emergency obstetrical complications in a rural African
setting (Kayes, Mali): the link between travel time and inhospital maternal mortality. Maternal and Child Health
Journal 15, 10811087.
Rwandan Ministry of Health (2009) Health Sector Strategic
Plan-II. Available at: http://www.usaid.gov/rw/our_work/
for_partners/images/rwandahealthsectorstrategicplanii.pdf
(accessed 9 September 2011).
Tanser F, Hosegood V, Benzler J & Solarsh G (2001) New
approaches to spatially analyse primary health care usage
patterns in rural South Africa. Tropical Medicine and
International Health 6, 826838.
Tatem AJ (2010) AfriPop Demography: Women of Child-Bearing
Age 2010. Available at: http://www.afripop.org/ (accessed 10
September 2012).
US Census Bureau (2009) International DataBase. Available at:
http://www.census.gov/ipc/www/idb/country.php. (accessed 4
April 2011).
Van Hemelrijck MJJ, Lindblade KA, Kubaje A et al. (2009)
Trends observed during a decade of paediatric sick visits to
peripheral health facilities in rural Western Kenya, 1997
2006. Tropical Medicine & International Health 14, 6269.
World Bank (2009) World DataBank; Health Nutrition and
Population Statistics. Available at: http://data.worldbank.org/
country/rwanda (accessed 3 June 2011).
World Health Organization, UNFPA, UNICEF, AMDD (2009)
Monitoring emergency obstetric care: A handbook. Available
at: http://www.unfpa.org/webdav/site/global/shared/documents/
publications/2009/obstetric_monitoring.pdf. (accessed 4 April
2011).

Corresponding Author Leanna Sudhof, Women and Infants Hospital, Providence, RI, USA. Tel.: (401) 274-1122;
Fax: (401) 453-7599; E-mail: LSudhof@wihri.org

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2012 Blackwell Publishing Ltd