Outcomes of neoadjuvant chemotherapy and radical hysterectomy for locally advanced cervical cancer at Kigali University Teaching Hospital, Rwanda: a retrospective descriptive study.

BACKGROUND: Half of countries in Africa lack access to radiation (RT), which is essential for standard treatment of locally advanced cervical cancers. We evaluated outcomes for patients treated with neoadjuvant chemotherapy (NACT) followed by radical hysterectomy in settings where no RT is available. METHODS: We performed a retrospective descriptive study of all patients with FIGO stage IB2-IIA2 and some exceptional stage IIB cases who received NACT and surgery at Kigali University Teaching Hospital in Rwanda. Patients were treated with NACT consisting of carboplatin and paclitaxel once every 3 weeks for 3-4 cycles before radical hysterectomy. We calculated recurrence rates and overall survival (OS) rate was determined by Kaplan-Meier estimates. RESULTS: Between May 2016 and October 2018, 57 patients underwent NACT and 43 (75.4%) were candidates for radical hysterectomy after clinical response assessment. Among the 43 patients who received NACT and surgery, the median age was 56 years, 14% were HIV positive, and FIGO stage distribution was: IB2 (32.6%), IIA1 (7.0%), IIA2 (51.2%) and IIB (9.3%). Thirty-nine (96%) patients received 3 cycles and 4 (4%) received 4 cycles of NACT. Thirty-eight (88.4%) patients underwent radical hysterectomy as planned and 5 (11.6%) had surgery aborted due to grossly metastatic disease. Two patients were lost to follow up after surgery and excluded from survival analysis. For the remaining 41 patients with median follow-up time of 34.4 months, 32 (78%) were alive with no evidence of recurrence, and 8 (20%) were alive with recurrence. One patient died of an unrelated cancer. The 3-year OS rate for the 41 patients who underwent NACT and surgery was 80.8% with a recurrence rate of 20%. CONCLUSIONS: Neoadjuvant chemotherapy with radical hysterectomy is a feasible treatment option for locally advanced cervical cancer in settings with limited access to RT. With an increase in gynecologic oncologists skilled at radical surgery, this approach may be a more widely available alternative treatment option in countries without radiation facilities.

Unravelling the complexity of research capacity strengthening for health professionals in low- and middle-income countries: A concept analysis.

AIMS: Research capacity strengthening (RCS) is crucial in enhancing healthcare outcomes, particularly in low- and middle-income countries (LMICs), which face challenges due to limited resources, unequal access to care and the need for evidence-based decision-making. We seek to move beyond a surface-level understanding of RCS, unearthing the core attributes, the factors that precede its implementation and the transformative outcomes it generates within the LMIC healthcare landscape. DESIGN: This study employs the Walker and Avant approach to concept analysis to comprehensively explore the dimensions and attributes of RCS as it pertains to allied and public health professionals in LMICs, propose empirical referents and suggest an operational definition. DATA SOURCES: Ovid MEDLINE, Embase, CINAHL and Cochrane CENTRAL were searched from inception to 27 July 2023, to identify studies on RCS in LMICs. The Walker and Avant approach to concept analysis was selected because it provides a framework for systematically examining and clarifying the meaning and implications of RCS. This method involves a structured process of defining RCS, identifying its attributes, antecedents, consequences and cases, and ultimately providing a clear understanding of its meaning and implications. Identifying empirical referents offers measurable indicators that researchers and policymakers can use to assess the effectiveness of RCS initiatives in LMICs. CONCLUSION: RCS for health professionals in LMICs involves a sustainable process that equips them with essential research skills, fostering the ability to conduct high-quality research and improve healthcare delivery in resource-constrained settings. IMPLICATIONS: RCS aims to empower health professionals to apply evidence-based practices, reduce disparities and enhance the well-being of populations in LMICs. IMPACT: Ultimately, a concept analysis of RCS empowers us to harness the full potential of research to enhance healthcare delivery, improve patient outcomes and advance the well-being of populations worldwide.

Cervical cancer treatment in Rwanda: Resource-driven adaptations, quality indicators, and patient outcomes.

OBJECTIVE: Most cervical cancer cases and deaths occur in low- and middle-income countries, yet clinical research from these contexts is significantly underrepresented. We aimed to describe the treatment quality, resource-driven adaptations, and outcomes of cervical cancer patients in Rwanda. METHODS: A retrospective cohort study was conducted of all patients with newly diagnosed cervical cancer enrolled between April 2016 and June 2018. Data were abstracted from medical records and analyzed using descriptive statistics, Kaplan Meier methods, and Cox proportional hazards regression. RESULTS: A total of 379 patients were included; median age 54 years, 21% HIV-infected. A majority (55%) had stage III or IV disease. Thirty-four early-stage patients underwent radical hysterectomy. Of 254 patients added to a waiting list for chemoradiation, 114 ultimately received chemoradiation. Of these, 30 (26%) received upfront chemoradiation after median 126 days from diagnosis, and 83 (73%) received carboplatin/paclitaxel while waiting, with a median 56 days from diagnosis to chemotherapy and 207 days to chemoradiation. There was no survival difference between the upfront chemoradiation and prior chemotherapy subgroups. Most chemotherapy recipients (77%) reported improvement in symptoms. Three-year event-free survival was 90% with radical hysterectomy (95% CI 72-97%), 66% with chemoradiation (95% CI 55-75%), and 12% with chemotherapy only (95% CI 6-20%). CONCLUSIONS: Multi-modality treatment of cervical cancer is effective in low resource settings through coordinated care and pragmatic approaches. Our data support a role for temporizing chemotherapy if delays to chemoradiation are anticipated. Sustainable access to gynecologic oncology surgery and expanded access to radiotherapy are urgently needed.

Obstetrics and Gynecology Residents Can Accurately Classify Benign Ovarian Tumors Using the International Ovarian Tumor Analysis Rules.

OBJECTIVES: Recognition of benign versus malignant tumors is essential in gynecologic ultrasound (US). The International Ovarian Tumor Analysis (IOTA) rules have been proposed as part of resident US training. The objective of this study was to examine whether they could be accurately used by obstetrics and gynecology residents in Rwanda. METHODS: Patients undergoing explorative laparotomy for adnexal masses at the University Teaching Hospital of Kigali were included. Before the study, a didactic lecture on the IOTA rules for classifying adnexal masses was performed. Preoperative transabdominal US examinations were performed by residents at different levels of training, who were blinded to the results of prior US examinations. The IOTA classification was compared to the final pathologic diagnosis. RESULTS: There were 72 patients who underwent 116 US examinations. Only 15.5% of US examinations were considered inconclusive. First-year residents (12) correctly diagnosed 18 of 20 masses (90%) as benign and 4 of 4 as malignant. Second-year residents (9) classified 29 of 29 masses correctly. Third-year residents (10) accurately identified 21 of 22 (95.5%) as benign and 5 of 5 as malignant. Fourth-year residents (13) accurately identified 11 of 12 (91.7%) as benign and 6 of 6 as malignant. Therefore, 74 of 78 tumors (94.9%) considered benign by IOTA rules were confirmed by histologic results. Similarly, all 20 tumors classified as malignant were confirmed. Overall, the sensitivities to diagnose benign and malignant tumors by the IOTA rules were 83.3% and 100%, respectively. The positive and negative predictive values were 100% and 94.9%. There were no significant differences noted between residency years. CONCLUSIONS: All levels of Rwandan obstetrics and gynecology residents were able to use the IOTA rules to accurately distinguish benign from malignant tumors.

Point of care ultrasound: does the presence of ascites in severe pre-eclampsia correlate with poor maternal and neonatal outcome?

OBJECTIVE: Ascites in severe pre-eclampsia may impact foetal and maternal outcomes. The objective was to determine the prevalence of ascites in women with severe pre-eclampsia by point of care (POC) ultrasound and to determine whether it correlates with higher perinatal risks. METHODS: Prospective cohort study of patients admitted with severe pre-eclampsia at 2 teaching hospitals in Kigali, Rwanda. Serial POC ultrasound was performed to document ascites. Patients were stratified by the presence of ascites in perinatal period. Maternal demographics and complications were recorded and compared between groups. RESULTS: There were 112 patients with severe pre-eclampsia, and ascites was found in 53.5% (76.7% antepartum, and 23.3% postpartum). Antepartum ascites correlated with an earlier delivery (32.2 ± 0.51 vs. 33.8 ± 0.47 weeks, P = 0.022) as well as lower birthweight (1587.3 ± 77.03 vs. 2011.6 ± 103.5 g, P = 0.002). Antepartum ascites was associated with higher stillbirth rates (P = 0.034) and NICU admission (87.2% vs. 68%, P = 0.034). Maternal hospital stay was increased in the ascites group (P < 0.0001). CONCLUSIONS: Ascites is common in severe pre-eclampsia in Rwanda and maybe a prognosticator for poor outcomes. A larger sample is necessary to determine whether ascites is independently associated with maternal morbidity and mortality and whether documenting its presence aids in the management of the foetus and mother.

OBJECTIF: L'ascite dans la pré-éclampsie sévère peut avoir un impact sur les résultats pour le fœtus et la mère. L'objectif était de déterminer la prévalence de l'ascite chez les femmes présentant une échographie de pré-éclampsie sévère au point des soins et de déterminer si elle corrélait avec des risques périnataux plus élevés. MÉTHODES: Etude de cohorte prospective de patientes admises avec une pré-éclampsie sévère dans deux hôpitaux universitaires de Kigali, au Rwanda. Une échographie au point des soins a été réalisée en série pour documenter l'ascite. Les patientes ont été stratifiées en fonction de la présence d'ascite en période périnatale. Les données démographiques maternelles et les complications ont été enregistrées et comparées entre les groupes. RÉSULTATS: Il y avait 112 patientes atteintes de pré-éclampsie sévère et l'ascite a été trouvé chez 53,5% (76,7% antépartum et 23,3% postpartum). L'ascite antépartum corrélait avec un accouchement antérieur (32,2 ± 0,51 vs 33,8 ± 0,47 semaines, p = 0,022) ainsi qu'avec un poids à la naissance plus faible (1587,3 ± 77,03 vs 2011,6 ± 103,5 g, p = 0,002). L'ascite antépartum était associée à des taux de mortinatalité plus élevés (p = 0,034) et à une admission en USIN-US (87,2% contre 68%, p = 0,034). Le séjour à l'hôpital de la mère était augmenté dans le groupe ascite (p <0,0001). CONCLUSIONS: L'ascite est fréquente dans la pré-éclampsie sévère au Rwanda et peut être un pronostic pour des résultats médiocres. Un échantillon plus important est nécessaire pour déterminer si l'ascite est associée de manière indépendante à la morbidité et à la mortalité maternelles et si la documentation de sa présence facilite la prise en charge du fœtus et de la mère.

Strengthening healthcare delivery in Rwanda: Implementation science training for reproductive health researchers.

BACKGROUND: Addressing the gap between research and practice is crucial for enhancing reproductive healthcare outcomes. In Rwanda and other low- and middle-income countries, bolstering health researchers' implementation science (IS) capacity is essential. We present a pre-post-intervention study assessing the influence of an intensive IS training program on Rwandan reproductive health researchers' perceived IS knowledge and self-efficacy in applying IS in their own research. METHODS: To introduce IS principles, we held a one-day training for a diverse cohort of 25 sexual and reproductive health researchers in Rwanda. The training encompassed modules on IS concepts, methodologies, and practical applications. Pre- and post-training assessments gauged changes in participants' perceived IS knowledge and self-efficacy in applying IS in their own work. RESULTS: The study revealed a significant improvement in self-efficacy related to performing IS related tasks. Researchers reported heightened confidence in designing and implementing evidence-based interventions. In terms of perceived knowledge, participants retained what they learned at 4 months. The training fostered a collaborative learning environment, encouraging participants to exchange ideas and experiences. CONCLUSION: Targeted training in IS appears to enhance reproductive health researchers' capacity to translate research into practice, potentially leading to improved healthcare outcomes in Rwanda. Moving forward, we advocate for the Ministry of Health to establish structures for IS research agenda-setting, particularly for sexual and reproductive health and rights. Ideally, universities, health systems, and research institutions will incorporate IS capacity strengthening into their routine activities. Ongoing training is crucial to reinforce and expand IS knowledge. Our findings are expected to inform future interventions and guide policy development.

Scoping review of qualitative studies investigating reproductive health knowledge, attitudes, and practices among men and women across Rwanda.

BACKGROUND: Research efforts in Rwanda to improve sexual and reproductive health and rights (SRHR) are increasing; however, comprehensive literature reviews on SRHR are limited. This scoping review examines individual and contextual factors shaping knowledge, attitudes, and practices in the domains of: 1) family planning, 2) abortion care, and 3) other SRHR in Rwanda. Recognizing that individual, community, and societal factors influence RH, this review is guided by Bronfenbrenner's Ecological Systems Theory. METHODS: Eligible studies were conducted in Rwanda, included males and/or females of any age, and were published within the past 20 years. Studies reporting views of only healthcare or other professionals were excluded. RESULTS: Thirty-six studies were included. The majority addressed individual and contextual considerations. At the individual level, studies explored knowledge about SRHR problems while at the interpersonal level, the support and attitudes of men and community members for adolescent SRHR were investigated. In terms of healthcare organization, maternal health practices, increased access to family planning programs, and the need for sexually transmitted infection programs was explored. At the social and cultural level, researchers investigated beliefs and traditional gender roles. Regarding public health policy, studies mentioned promoting and increasing funding for SRHR and reducing gender inequities. CONCLUSION: Our findings can inform SRHR research programs, public health campaigns, and policy advances in Rwanda.

Pregnant women's knowledge of obstetrical danger signs: A cross-sectional survey in Kigali, Rwanda.

Maternal mortality remains critically high in low- and middle-income countries (LMIC), particularly in sub-Saharan Africa. Rwanda's leading causes of maternal death include postpartum hemorrhage and obstructed labor. Maternal recognition of obstetrical danger signs is critical for timely access to emergency care to reduce maternal mortality.To assess maternal knowledge of obstetrical danger signs among pregnant women attending antenatal care services in Kigali, Rwanda. We conducted a cross-sectional study between September and December 2018. The outcome of interest was maternal knowledge of ODS during pregnancy, labor and delivery, and the immediate postpartum period. We recruited pregnant women at five health centers, one district hospital, and one referral hospital, and we had them complete a structured questionnaire. Reporting three correct ODS was defined as having good knowledge of ODS. A total of 382 pregnant women responded to the survey. Most women (48.9%) were aged 26-35, and 50.5% had completed secondary or higher education. The knowledge of ODS was 56%, 9%, and 17% during pregnancy, labor and delivery, and postpartum, respectively. Women aged 26 to 35 had two times (OR: 1.80, 95% CI: 1.05, 3.06) higher odds of ODS knowledge during pregnancy than women aged 16 to 25. Attending three antenatal care visits was associated with 2.6 times (OR: 2.59, 95% CI: 1.17, 5.66) higher odds of ODS knowledge during pregnancy than not attending any visit. Longer distances to the nearby health facility were associated with significantly lower knowledge during pregnancy, and Muslim women had substantially higher postpartum ODS knowledge than any other religion. In conclusion, women's knowledge of ODS associated with labor and delivery and postpartum was low. Antenatal care must be encouraged and its content revised to ensure it covers potential late pregnancy complications.

Healthcare provider challenges to early detection of cervical cancer at primary healthcare level in Rwanda.

Our objective was to assess the health facility related factors that cause delays in cervical cancer diagnosis at a primary healthcare level in Rwanda. Healthcare providers in outpatient clinics at 10 health centers in Kigali city and the Eastern province of Rwanda were surveyed. Eighty-five healthcare providers participated; 83.5% were nurses and the remainder were midwives. Only 15 (17.6%) reported prior training on visual inspection with acetic acid (VIA) cervical cancer screening, and they were distributed among 6 of the 10 health centers surveyed. However, 76.5% of respondents reported that at least one person was trained in VIA at their health center. The basic equipment necessary for cervical cancer evaluation was reported to be generally available. Overall, only 31.8% of participants had good basic knowledge level on cervical cancer screening. No association was found between respondents' knowledge about cervical cancer screening and profession, education level, work experience or reported prior training on VIA. There is a gap in the number of primary healthcare providers with the skills to perform pelvic exam and VIA cervical cancer screening at health centers in Rwanda. As health centers are the first point of contact for patients with the healthcare system, there is a need to improve their knowledge and skills in performing cervical cancer screening and detection.

Increased Rwandan Access to Obstetrician-Gynecologists Through a U.S.-Rwanda Academic Training Partnership.

OBJECTIVE: To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012-2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician-gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns. METHODS: We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial operations, R for statistical analysis, zonal statistics for circular distances, and friction surface for travel time analysis. RESULTS: The number of ob-gyns in public hospitals increased from 14 to 49 nationally. Before the program, 18 residents graduated over a 7-year period (two residents per year); 33 graduated by year 5 (six residents per year). Rwandan faculty increased by 45%. In 2011, most providers were in the capital city. Between 2011 and 2016, the proportion of pregnant women living 10 km from an ob-gyn-staffed public hospital increased from 13.0% to 31.6%; within 25 km increased from 28.4% to 82.9%. Travel time analysis from 2011 to 2016 showed 49.1% of Rwandan women within 1 hour of a hospital and 85.6% within 2 hours. In 2016, this coverage increased to 87.5% and 98.3%, respectively. CONCLUSION: In 5 years, the Human Resources for Health Rwanda program improved the number of residency graduates in obstetrics and gynecology and nationwide access to these providers. The program reduced rural-urban disparities in access to ob-gyns.