Background: Global health is faced by two critical interrelated antibiotic challenges: rising incidence of surgical site infections as access to surgical care increases, and a rapid rise in antibiotic resistance. World Health Organization guidelines state that antibiotic prophylaxis for a caesarean section (C-section) should be administered within two hours prior to the first incision. Adherence to antibiotic prophylaxis is one of the factors consistently shown to affect postoperative infection rates; however, there is evidence of major deviations in antibiotic prescribing during C-section care worldwide.

Objective: This qualitative study aims to better understand the rationale behind surgical antibiotic prophylaxis prescribing practices for women undergoing C-sections at Kirehe District Hospital, including antibiotic choice, timing and duration of administration.

Methods: We conducted semi-structured interviews in Kinyarwanda, French, or English with healthcare providers involved in the provision of C-section care at the district hospital, including physicians (n=14), nurses (n=8), midwives (n=12) and anesthesia technicians (n=4). Interviews were recorded, transcribed verbatim, and translated into English, followed by a thematic analysis to identify emerging themes.

Results: Three key themes were identified concerning deviations from national and international surgical antibiotic prophylaxis guidelines at this Rwandan hospital. First, antibiotic prophylaxis prescription decisions stemmed from a desire to compensate for hygiene-related infection risks. A second theme was the adaptive nature of prescription practices amidst guideline uncertainty based on a local gynecologist encouraging over-prescription.  A third theme concerned systems-based barriers to timely and appropriate pre-operative antibiotic administration, including diffusion of antibiotic administration responsibility.

Discussion: This study provides evidence that opinion leaders, while potential targets for cultivation of an antibiotic stewardship champion, may also perpetuate over-prescription amidst concerns of hygiene-related infection risks. Interventions must acknowledge the role of collective sense-making in the iterative negotiation of context-appropriate hospital prescription practices, facilitating active involvement of all prescribers in protocol and workflow development.