Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data.

INTRODUCTION: Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity. METHODS: Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators. RESULTS: This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda. DISCUSSION: Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

ABCD criteria to improve visual inspection with acetic acid (VIA) triage in HPV-positive women: a prospective study of diagnostic accuracy.

OBJECTIVES: A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting. DESIGN: Prospective study of diagnostic accuracy. SETTING: Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon. PARTICIPANTS: Asymptomatic non-pregnant women aged 30-49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35-45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial. INTERVENTIONS: HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards). PRIMARY OUTCOME MEASURE: Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values. RESULTS: ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day. CONCLUSIONS: ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context. TRIAL REGISTRATION NUMBER: NCT03757299.

Study protocol for a two-site clinical trial to validate a smartphone-based artificial intelligence classifier identifying cervical precancer and cancer in HPV-positive women in Cameroon.

INTRODUCTION: Cervical cancer remains a major public health challenge in low- and middle-income countries (LMICs) due to financial and logistical issues. WHO recommendation for cervical cancer screening in LMICs includes HPV testing as primary screening followed by visual inspection with acetic acid (VIA) and treatment. However, VIA is a subjective procedure dependent on the healthcare provider's experience. Its accuracy can be improved by computer-aided detection techniques. Our aim is to assess the performance of a smartphone-based Automated VIA Classifier (AVC) relying on Artificial Intelligence to discriminate precancerous and cancerous lesions from normal cervical tissue. METHODS: The AVC study will be nested in an ongoing cervical cancer screening program called "3T-study" (for Test, Triage and Treat), including HPV self-sampling followed by VIA triage and treatment if needed. After application of acetic acid on the cervix, precancerous and cancerous cells whiten more rapidly than non-cancerous ones and their whiteness persists stronger overtime. The AVC relies on this key feature to determine whether the cervix is suspect for precancer or cancer. In order to train and validate the AVC, 6000 women aged 30 to 49 years meeting the inclusion criteria will be recruited on a voluntary basis, with an estimated 100 CIN2+, calculated using a confidence level of 95% and an estimated sensitivity of 90% +/-7% precision on either side. Diagnostic test performance of AVC test and two current standard tests (VIA and cytology) used routinely for triage will be evaluated and compared. Histopathological examination will serve as reference standard. Participants' and providers' acceptability of the technology will also be assessed. The study protocol was registered under ClinicalTrials.gov (number NCT04859530). EXPECTED RESULTS: The study will determine whether AVC test can be an effective method for cervical cancer screening in LMICs.

Connaissances, attitudes et pratiques des professionnels de santé sur le cancer du col de l'utérus au Cameroun.

INTRODUCTION: Cervical cancer is the cause of 311,000 deaths each year worldwide and 1,540 deaths in Cameroon. It is a public health problem, but only one in ten women is screened for cervical cancer screening in Cameroon. Little data is available on the KAPs of health professionals in the Mifi Health District, in the west Region of Cameroon. The objective of this study was to assess the knowledge, attitudes and practices of these professionals vis-à-vis cervical cancerResults: Overall, 200 health professionals were interviewed. Regarding the knowledge of the cause of cervical cancer, only 35% of participants were able to declare HPV. With regards to prevention measures, 32% of health professionals knew HPV vaccine. Regarding the perception of the disease; 79.3% of Physicians evoked cervical cancer as severe disease. Concerning the practice of screening, only 15% of health professionals routinely advise screening. CONCLUSION: Health workers in the health district of Mifi have poor knowledge on cervical cancer and weak practice of screening. Training of health professionals and the development of cervical cancer screening units are needed.

[Knowledge, attitudes and practices of health professionals regard to cervical cancer in Cameroon]. / Connaissances, attitudes et pratiques des professionnels de santé sur le cancer du col de l'utérus au Cameroun.

INTRODUCTION: Cervical cancer is the cause of 311,000 deaths each year worldwide and 1,540 deaths in Cameroon. It is a public health problem, but only one in ten women is screened for cervical cancer screening in Cameroon. Little data is available on the KAPs of health professionals in the Mifi Health District, in the west Region of Cameroon. The objective of this study was to assess the knowledge, attitudes and practices of these professionals vis-à-vis cervical cancerResults: Overall, 200 health professionals were interviewed. Regarding the knowledge of the cause of cervical cancer, only 35% of participants were able to declare HPV. With regards to prevention measures, 32% of health professionals knew HPV vaccine. Regarding the perception of the disease; 79.3% of Physicians evoked cervical cancer as severe disease. Concerning the practice of screening, only 15% of health professionals routinely advise screening. CONCLUSION: Health workers in the health district of Mifi have poor knowledge on cervical cancer and weak practice of screening. Training of health professionals and the development of cervical cancer screening units are needed.