Study flowchart stratified by age group.

Post-discharge death is a key contributor to pediatric mortality in sub-Saharan Africa. To address this period’s morbidity and mortality, evidence is needed to inform resource prioritization and policy development. No studies have been conducted in Rwanda, limiting understanding of post-discharge mortality. This study aimed to determine the incidence of and risk factors for post-discharge mortality among children under five admitted with suspected sepsis in Rwanda’s rural and urban healthcare settings. We conducted a prospective, epidemiologic cohort study of post-discharge mortality in children ages 0–60 months admitted for suspected or confirmed infection in two Rwandan hospitals, one rural (Ruhengeri) and one urban (Kigali), from May 2022 to February 2023. We collected clinical, laboratory, and sociodemographic data on admission and follow-up vital statistics at 2-, 4-, and 6-months post-discharge. Of 1218 children enrolled, 115 (9.4%) died, with half in-hospital (n = 57, 4.7%) and half post-discharge (n = 58, 4.7%). Post-discharge mortality was lower in the 6–60-month cohort (n = 30, 3.5%) than in the 0–6-month cohort (10%) and higher in Kigali (n = 37, 10.3%) vs. Ruhengeri (n = 21, 2.7%). Median time to post-discharge death was 38 days (IQR: 16-97.5) in the 0–6-month cohort and 33 days (IQR: 12–76) in the 6–60-month cohort. In the 0–6 months’ cohort, malnutrition (weight-for-age z-score < -3) increased the odds of post-discharge death (aOR 3.31, 95% CI 1.28-8.04), while higher maternal education was protective (aOR 0.15, 95% CI 0.03-0.85). Significant factors in the 6–60-month cohort included an abnormal Blantyre Coma Scale (aOR 3.28, 95% CI 1.47-7.34), travel time to care >;1 hour (aOR 3.54, 95% CI 1.26-9.93), and referral for higher care (aOR 4.13, 95% CI 1.05-16.27). Children aged <2 months within the 0–6 month cohort exhibited the highest cumulative mortality risk. Post-discharge mortality among Rwandan children remains a challenge, requiring interventions like caregiver counselling, follow-up visits, and community health worker monitoring to reduce mortality rates.