Cervical Cancer Screening by Midwives in the Kara Region of Northern Togo: Knowledge, Attitudes and Practices ()
1. Introduction
Cervical cancer is a common and deadly cancer of women. With an estimated global prevalence of 2.3 million women with cervical cancer and 528,000 annual new cases, or 266,000 deaths each year, cervical cancer is the second most common cancer affecting women worldwide [1]. In contrast to developed countries characterized by the progressive decline of cervical cancer, the constant and alarming progression of this cancer is observed in Africa south of the Sahara [2]. According to WHO, 90% of cervical cancer-related deaths will occur in sub- Saharan Africa by 2030 [3]. Thus, it occupies the first place with a consistently high mortality, making it a serious public health problem [4]. Fortunately, these deaths are preventable because cervical cancer is one of the most preventable and treatable cancers if detected early enough and treated properly [5]. Therefore, cervical cancer benefits from the possibility of primary prevention through vaccination, but especially from early detection of pre-cancerous lesions that may evolve into invasive cancer, which is often a sign of the disease in our African contexts.
In Togo, cervical cancer is the second most common cancer in women after breast cancer [6]. Cervical cancer screening is a major public health issue and requires good knowledge on the part of health personnel, in this case midwives, who are in constant contact with women. To date in the Kara region, no study on the real knowledge of midwives on cervical cancer screening exists. This study was therefore conducted to assess their knowledge, attitude and practice of cervical cancer screening.
2. Population and Method
This was a descriptive cross-sectional study, from January 2020 to June 2020. Midwives practising in different hospitals and health centres of the Kara region in northern Togo constituted the study population. All midwives who gave their consent and agreed to complete the survey form were included in the study. Midwives who did not consent to participate in the study and those who were absent during the study period were not included. An anonymous self-administered questionnaire validated after a pre-test on 10 midwives from another region was used to collect data. The questionnaire was an anonymous written structured with semi- closed and open questions, self-administered and returned by all respondents. We were interested in the following variables: general knowledge of cervical cancer, knowledge of cervical cancer screening, attitude towards cervical cancer and screening practice. Stata version 13 and Excel were used for data processing and analysis.
3. Results
3.1. Sociodemographic
Fifty midwives participated in the study. The average age was 32.46 ± 3.2 years with extremes of 23 and 50 years. In 92% of cases, their professional experience did not exceed 10 years of practice.
3.2. Knowledge about Cervical Cancer
Table 1 below shows the distribution of midwives according to their knowledge of cervical cancer.
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Table 1. Distribution of midwives according to their knowledge of cervical cancer.
3.3. Attitude about Cervical Cancer Screening
Ninety-six percent of midwives felt that cervical cancer is preventable. Twenty-four percent believed that cervical cancer is not fatal if detected early. They all agreed to routinely offer cervical cancer screening to any woman attending a gynecology or obstetrics department. They all expressed the need for a national cervical cancer control program that would allow for free screening and management of pre-cancerous lesions. All midwives expressed the need to be trained in the screening and management of pre-cancerous lesions.
3.4. Pratices about Cervical Cancer Screening
Of the 50 midwives, none had yet performed a screening test as part of their gynecological follow-up. Only one midwife reported performing VIA/VILI on a patient once.
4. Discussion
The anatomical position of the cervix offers a laudable advantage in the detection of precancerous lesions and the prevention of cervical cancer through thorough knowledge and regular practice of screening. In our environment, where there are few specialists in this field, midwives, who are in the first line of contact with women, have a crucial role to play in the prevention and control of cervical cancer. We therefore conducted this study among midwives to assess their knowledge and practices on the subject. As the data were collected on the basis of a self-administered questionnaire, the bias would be the possibility of misrepresentation of reality. However, despite the fact that our respondents had less than 10 years of professional experience, the data collected seems satisfactory.
4.1. Knowledge
All midwives are aware of cervical cancer. Oncogenic HPV infections were identified in 74% of cases as causing cervical cancer. Our results are similar to those obtained in Saudi Arabia (68.5%) by Sail KH et al. [7] and in Mexico (79%) by Aldrich T et al. [8]. On the other hand, the responsibility of oncogenic HPV in the genesis of cervical cancer is less known in the studies of Nani S et al. [5] in Morocco (21%) and of Mutyaba T. et al. [9] in Uganda (29%). As regards risk factors, 77% of our respondents were able to identify at least two. The clinical manifestations were essentially dominated by malodorous vaginal discharge, postmenopausal and provoked hemorrhage. Only 22% of midwives had a good knowledge of these clinical signs. Our results are lower than those of Goyal A et al. in Ghana who found 73.5% [10]. The anatomical accessibility of the cervix offers the opportunity of screening through simple and inexpensive means, especially for our developing countries where the disease is diagnosed at an advanced stage with few treatment options. In our study, only 28% and 32% of midwives were aware of UFH and VIA/VILI as the commonly used screening methods in our settings. In the study by Goyal A et al. [10], UFH (52.5%) was the most commonly known, followed by colposcopy (19%) and VIA/VILI (4.5%). Regarding the target population and the periodicity of screening, only 8% knew the age group concerned and 30% the 3-year periodicity. Several authors have reported varying degrees of knowledge on the subject. Nani S et al. [5] in Morocco reported only 2.9% for a start of screening at 25 years of age and a periodicity every 3 years in 47.5% of cases. In Mexico, Aldrich T et al. [8] reported 77% for the beginning of screening after the first sexual intercourse with an annual periodicity in 73% of cases. According to WHO recommendations, screening by UFH should be performed between the ages of 25 and 65 years with an interval of 3 years after a second negative test at 1 year interval. Currently there is no international consensus on the age of onset nor on the frequency of screening but all agree that the choice should take into account the means of each country and most recommend a frequency of 3 years.
4.2. Attitudes toward Screening
Ninety-six percent of midwives believe that cervical cancer is preventable. The same contacts were made in Tunisia by Hsairi M et al. [11] who reported that 96.2% of the respondents thought that screening was an effective means of reducing the incidence of cervical cancer. Hence the importance of raising awareness about risk factors, vaccination and especially screening and management of pre-cancerous lesions. Thus, 84% of the midwives felt that it was possible to screen all women seen in gynecological and prenatal consultations. Our results are similar to those of Amal A et al. [12] in Qatar. These screenings will only be effective if a national screening program includes the training of midwives. In our study, all midwives expressed the need to be trained in the screening and management of pre-cancerous lesions.
4.3. Practice
Since midwives are the first line of contact with the female population, they should be the primary actors in raising awareness about cervical cancer screening. However, in our study, none of the midwives had yet performed a cervical cancer screening test as part of their health check-up. This attitude of health personnel not to be screened has also been reported by several authors. This is the case in Morocco, where in a study of general practitioners by Nani S et al. [5], 67.9% of female doctors said they had never performed an ECF. In India and Saudi Arabia, the same findings were reported respectively by Chamaraja et al. [13] and Sail KH et al. [7] with 11.6% and 19% in their studies of nurses. According to Mutyaba T et al. [9] in Uganda, the main reasons for the low rate of screening among medical staff are not feeling at risk, lack of warning signs of the disease, and fear related to screening. As a highly preventable disease, screening and early management should be a public health priority in the fight against cancer. This avoids invasive cancer whose management is cumbersome and often inadequate, especially in our developing countries where the technical platform is often insufficient. Thus, since screening is the simplest way to reduce the incidence of cervical cancer and improve survival, in our study, no midwife has yet performed UFJ and only one reported performing VIA/VILI once on a patient. Low screening rates were also reported in Morocco by El Feikir S et al. [14] (7.87%) and in Tunisia by Hsairi M et al. [11] (18.3%). In Uganda, according to Mutyaba T et al. [9], midwives and nurses stated that the practice of ECF is a procedure reserved for doctors. As the lack of human resources is a barrier to a successful cervical cancer screening program, the involvement of all health personnel in cervical cancer control would be beneficial.
5. Conclusion
At the end of our study, we found that midwives had satisfactory knowledge about cervical cancer and its screening. Due to the lack of a national screening program, the practice of cervical cancer screening remains almost non-existent. They expressed the need to strengthen their skills and all agreed that they should popularize the practice during gynecological and prenatal consultations.