PERCEPTION AND ACCEPTABILITY OF INTEGRATION OF CERVICAL CANCER SCREENING INTO ANTENATAL AND POSTNATAL SERVICES IN A TERTIARY HOSPITAL IN NIGERIA.

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A.A. Abdus-Salam¹, R.A. Abdus-Salam², R.O. Balogun³

1. Department of Radiation Oncology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan/ University College Hospital, Ibadan, Oyo State, Nigeria.
2. Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria.
3. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria.

Abstract

Background: Cervical cancer is preventable, but women in developing countries present in advanced stages of the disease, thus resulting in limited treatment options and high mortality rates. Routine maternal healthcare during pregnancy or puerperium presents a unique opportunity for its prevention, counselling and screening.

Aim: To assess the acceptability and perception of integration of cervical cancer screening into routine antenatal (ANC) and postnatal care (PNC) services among pregnant and postpartum women.

Methodology: This was a questionnaire-based cross-sectional study conducted among 220 consenting women among the ANC and PNC attendees at the University College Hospital, Ibadan. Information on socio-demographic characteristics, perception of routine screening in maternal health, acceptability; and the willingness to undergo screening test were obtained. Data was analyzed using SPSS version 26 and level of significance was p<0.05.

Result: Majority were in the age range of 30-34 years. Only 11.4% and 4.5% of the participants had ever done a pap smear and HPV test respectively. About half (50.9%) of the women reported that they would not be willing to undergo screening during pregnancy with the commonest reason being fear of harm to the pregnancy. Over half (64.1%) of the participants were willing to have screening during the post-natal visit, while 58.6% of the participants wanted the screening to be part of the routine services offered at the ANC or PNC. Majority (69.5%) were willing to continue screening outside of pregnancy.

Conclusion: The practice of routine cervical cancer screening is low among women in developing countries. The ANC or PNC provides an opportunity for screening, early detection and prevention of cervical cancer.

Keywords: Cervical cancer screening integration, Cervical screening antenatal, Cervical screening postnatal, Cervical screening and pregnancy, opportunistic cervical screen

Introduction

Carcinoma of the cervix uteri is a malignant disease of the cervix and the second commonest cancer of the female worldwide after breast cancer.¹ Globally, about 528,000 new cases of cervical cancer are diagnosed, 266,000 deaths occur annually and about 85% of these new cases occur in developing countries.^1,2,3 In Nigeria, cervical cancer is the commonest cancer of the female genital tract and the leading cause of cancer death.^4,5 It accounts for 62.7% of all malignancies seen at the University College Hospital, Ibadan.⁶ It is estimated that about 3% of women with cervical cancer were either pregnant or in the postpartum period at the time of diagnosis. Half of these cases are diagnosed prenatally, and others were diagnosed within 12 months of delivery.⁷ Cervical cancer is not an uncommon malignancy in pregnancy, with an estimated incidence of 3.3–26 cases per 100,000 livebirths.⁸ Current evidence indicates that the chance that pregnant women will be diagnosed with cervical cancer while it is in its initial stages is three times greater than the chance among controls. This is due to vaginal inspections, screening for infections and cervical cytological tests conducted among women in countries where these examinations are part of routine prenatal care.9 It is often first suspected when a screening test for the disease is abnormal.

The performance characteristics of the Papanicolaou test do not appear to differ significantly between pregnant and non-pregnant women. Overall, the rate of significant cytological abnormalities among pregnant women has been reported to be 5–8% and is similar to that of the non-pregnant population.¹⁰ Cervical cancer screening in pregnancy appears to be safe and well tolerated as no major side effects were reported in previous studies. ¹¹ This preventable cancer has a long premalignant stage during which screening can be done; and any precancerous lesions identified can be adequately treated to prevent progression to the invasive cancer stage.^12,13

Conventional cytology commonly referred to as Papanicolaou smear (Pap smear) is a simple and cost-effective technique for early diagnosis of cervical cancer and has been found to be a safe screening method which can be done in pregnancy11 by opportunistic screens. It will not only screen for cervical abnormality but also identify infections that if left untreated, may be harmful to both mother and fetus. It creates an opportunity to counsel and introduce routine cervical screening to pregnant women especially first-time mothers and women who have never heard of or had cervical screening tests. The effectiveness of opportunistic screen has been found to be equivalent to organized screening programs.¹⁴ Cervical cancer screening test in pregnancy or postpartum provides an opportunity to screen women who may not have heard about the screen or who will ordinarily not come to the hospital except for pregnancy and related purposes; and pregnancy is not a contraindication to performing a Pap smear and Human Papilloma Virus (HPV) screening tests.¹⁵

Other benefits of Pap smear include screening and detection of diseases such as Chlamydia infection, bacterial vaginosis and trichomoniasis. Pap smear is not without its own limitations as it has a low sensitivity ⁽¹⁶⁾ and a longer turnaround time compared to Visual Inspection with Acetic acid (VIA). Setting up an organized national screening program is important. Meanwhile, an increase in opportunistic screening such as in antenatal, postnatal, sexually transmitted infection (STI) clinics, family planning clinic, gynaecological clinics, pre-employment medical examination, in-service medical examination and tertiary institutions will be impactful in decreasing cervical cancer burden.

Pregnancy and request for antenatal care may be the only reason a woman presents to the health professional, thus booking visit or a later visit may be the only occasion she can be afforded a cervical screen. In such instance, in the absence of opportunistic screens; HPV infections and treatable precancerous lesions may go unrecognized. It is also crucial to understand the perception of pregnant and postpartum women on the cervical cancer screening and its integration into maternal health services. This study assessed the awareness, acceptability and perception of women attending the antenatal and postnatal clinic towards integration of cervical cancer screening methods into routine maternal health care services.