Background Despite reaching Millennium Development Goal (MDG) 3, the maternal mortality rate (MMR) is still high in Rwanda. Most deaths occur after transfer of patients with obstetric complications from district hospitals (DHs) to referral hospitals; timely detection and management may improve these outcomes. The RI and MEOWS tool has been designed to predict morbidity and decrease delay of transfer. Our study aimed: 1) to determine if the use of the RI and MEOWS tool is feasible in DHs in Rwanda and 2) to determine the role of the RI and MEOWS tool in predicting morbidity. Methods A cross-sectional study enrolled parturient admitted to 4 district hospitals during the study period from April to July 2019. Data was collected on completeness rate (feasibility) to RI and MEOWS tool, and prediction of morbidity (hemorrhage, infection, and pre-eclampsia). Results Among 478 RI and MEOWS forms used, 75.9% forms were fully completed suggesting adequate feasibility. In addition, the RI and MEOWS tool showed to predict morbidity with a sensitivity of 28.9%, a specificity of 93.5%, a PPV of 36.1%, a NPV of 91.1%, an accuracy of 86.2%, and a relative risk of 4.1 (95% Confidential Interval (CI), 2.4–7.1). When asked about challenges faced during use of the RI and MEOWS tool, most of the respondents reported that the tool was long, the staff to patient ratio was low, the English language was a barrier, and the printed forms were sometimes unavailable. Conclusion The RI and MEOWS tool is a feasible in the DHs of Rwanda. In addition, having moderate or high scores on the RI and MEOWS tool predict morbidity. After consideration of local context, this tool can be considered for scale up to other DHs in Rwanda or other low resources settings. Trial registration This is not a clinical trial rather a quality improvement project. It will be registered retrospectively.

Background: Despite reaching Millennium Development Goal (MDG) 3, the maternal mortality rate (MMR) is still high in Rwanda. Most deaths occur after transfer of patients with obstetric complications from district hospitals (DHs) to referral hospitals; timely detection and management may improve these outcomes. The RI and MEOWS tool has been designed to predict morbidity and decrease delay of transfer. Our study aimed: 1) to determine if the use of the RI and MEOWS tool is feasible and acceptable in DHs in Rwanda and 2) to determine the role of the RI and MEOWS tool in predicting morbidity.Methods: A cross-sectional study enrolled parturient admitted to 4 district hospitals during the study period from April to July 2019. Data was collected on compliance rate to RI and MEOWS tool, acceptability, and prediction of morbidity (hemorrhage, infection, and pre-eclampsia).Results: Among 798 parturient enrolled in this study, the mean age was 20.3 years (Sd=6.8), most of them had insurance (95%), the mean of length of stay was 3.1 days (Sd=2.08), and the morbidity rate was 10.3%. The RI and MEOWS tool compliance rate was 76.3 and acceptability rate among 22 respondents was 90.9%. The RI and MEOWS tool had accuracy of 14.29%, P value <0.001, relative risk of 0.277 42 (0.1718-0.4487), sensitivity of 73.68%, specificity of 93.86%, positive predictive value of 11.57%, and negative predictive value of 41.67% .Conclusion: RI and MEOWS tool is a feasible and acceptable in the DHs of Rwanda. In addition, having moderate or high scores on the RI and MEOWS tool predict morbidity. After consideration of local context, this tool can be considered for scale up to other district hospitals in Rwanda or other low resources settings.