Access to oncology care in Mali: a qualitative study on breast cancer.

BACKGROUND: Breast cancer is the most common cancer in terms of incidence and mortality among women worldwide, including in Africa, and a rapid increase in the number of new cases of breast cancer has recently been observed in sub-Saharan Africa. Oncology is a relatively new discipline in many West African countries, particularly Mali; thus, little is known about the current state of cancer care infrastructure and oncology practices in these countries. METHODS: To describe the challenges related to access to oncology care in Mali, we used a qualitative approach, following the Consolidated Criteria for Reporting Qualitative Research (COREQ). Thirty-eight semistructured interviews were conducted with health professionals treating cancer in Mali (n = 10), women with breast cancer (n = 25), and representatives of associations (n = 3), and 40 participant observations were conducted in an oncology unit in Bamako. We used the theoretical framework on access to health care developed by Levesque et al. a posteriori to organise and analyse the data collected. RESULTS: Access to oncology care is partly limited by the current state of Mali's health infrastructure (technical platform failures, repeated strikes in university hospitals, incomplete free health care and the unavailability of medicines) and exacerbated by the security crisis that has been occurring the country since 2012. The lack of specialist doctors, combined with limited screening campaigns and a centralised and fragmented technical platform in Bamako, is particularly detrimental to breast cancer treatment. Women's lack of awareness, lack of information throughout the treatment process, stereotypes and opposition to amputations all play a significant role in their ability to seek and access quality care, leading some women to therapeutically wander and others to want to leave Mali. It also leaves them in debt and jeopardises the future of their children. However, the high level of trust in doctors, the involvement of international actors, the level of social support and the growing influence of civil society on the issue of cancer also represent great current opportunities to fight cancer in Mali. CONCLUSION: Despite the efforts of successive Malian governments and the commitment of international actors, the provision of health care is still limited in the country, entrenching global inequalities in women's bodies.

Radiothérapie et lutte contre les cancers : défis de maintenance de l'unique accélérateur linéaire à l'Hôpital du Mali.

Cancer incidence and mortality rates are increasing in West Africa. Cancer is a recent discipline in Mali and the means available to treat patients are insufficient. Mali has only one radiotherapy machine for the country and its malfunctions are regularly reported in the media. In order to understand the recurrent dissatisfactions linked to access to radiotherapy in Mali, we retraced the history of this machine and described its functioning. Based on semi-directive interviews with patients’ associations and health professionals involved in cancer care in Bamako, we describe how radiotherapy in Mali reveals global health issues through the intervention of numerous international cooperations. In addition, based on data collection from medical registers and institutional reports, we report that the average time to get a radiotherapy appointment is 3 to 6 months in Mali, but also that the radiotherapy machine has experienced 198 breakdowns between April 3, 2014 and September 24, 2021, which represents more than 54 weeks of cumulative downtime. Radiotherapy is a crucial element in the treatment of cancer and the lack of access to this treatment worsens the vital diagnosis of patients. While the Malian government is committed to universal health coverage reforms, strengthening cancer treatment facilities should also be considered a public health priority for Mali.

[Risk factors and management of uterine rupture in a 1st reference structure in Mali: case of the Bougouni health district]. / Facteurs de risque et prise en charge de la rupture uterine dans une structure de 1ere reference du Mali : cas du district sanitaire de Bougouni.

The objective was to assess the risk factors for and to suggest therapeutic aspects. MATERIALS AND METHODS: We carried out a case-control study at the Bougouni Reference health center in 2019. RESULTS: From January to December 31, 2019; out of 1161 deliveries, 43 uterine rupture were recorded, 3.7% corresponding to one uterine rupture for 27 deliveries. Patients 35 years and older were more affected by uterine rupture (44.2%) with ORaIC95% = 6.3 [1.5 - 26.3]. Obstetric evacuations had an ORaIC95% = 25.6 [7.8-83.7]. All of the patients were housewives (97.7%) versus (82.3%) controls with ORaIC95% = 8.9 (1.1-69). Pauciparous and multiparous had an ORaIC95% = 6.2 [1.8 - 20.3] and 4.1 [1.3 - 12.9], respectively. The uterine scar (20.9%) of cases versus 8.1% of controls had a 95% ORaIC95% = 2.9 [1.1 - 8.7]. Indeed the absence of ANC was a risk factor, ORaIC95% = 3.0 [1.3 - 6.9]. The time to uterine rupture was < 6 hours in 95%. In fact 34 complete uterine rupture (79.1%) and 9 incomplete uterine rupture (20.9) were noted. Only 2.3% of cases gave birth vaginally. Treatment of uterine rupture was based on surgery (100%) supplemented by shock (51.2%) of cases and infection (100%) of cases. CONCLUSION: Uterine rupture is common in our countries under medical care. Its effective prevention involves strategies aimed at acting on risk factors.

L'objectif était d'évaluer les facteurs de risque de la RU et de proposer les aspects thérapeutiques. MATÉRIELS ET MÉTHODES: Nous avons réalisé une étude cas-témoins au centre de santé de Référence de Bougouni en 2019. RÉSULTATS: De janvier au 31 décembre 2019 ; sur 1161 accouchements 43 RU ont été enregistrées soit 3,7% correspondant à une RU pour 27 accouchements. Les patientes de 35 ans et plus ont été plus touchée par la RU (44,2%) avec ORaIC95%= 6,3 [1,5 - 26,3]. Les évacuations obstétricales avaient un ORaIC95%=25,6 [7,8- 83,7]. La totalité des patientes étaient des femmes au foyer (97,7%) des cas versus (82,3%) des témoins avec ORaIC95%=8,9 (1,1-69). Les Paucipares et multipares avaient respectivement un ORaIC95%= 6,2 [1,8 - 20,3] et 4,1[1,3 - 12,9]. La cicatrice utérine (20,9%) des cas contre 8,1 % les témoins avait un ORaIC95%= 2,9 [1,1 - 8,7]. En effet l'absence de CPN étaient un facteur de risque, ORaIC95%= 3,0 [1,3 ­ 6,9]. Le délai de la RU était < 6 heures chez 95%. En effet 34 RU complètes (79,1%) et 9 RU incomplètes (20,9%) ont été notées. Seulement 2,3 % des cas avaient accouché par voie basse. Le traitement de la RU reposait sur la chirurgie (100%) complétée par celui du choc (51,2%) des cas et de l'infection (100%) des cas. CONCLUSION: La RU est fréquente dans nos pays sous médicalisés. Sa prévention efficace passe par des stratégies visant à agir sur les facteurs de risque.

[Evaluation of patient transfer system in the health district of Bla]. / Evaluation du systeme de reference ­ evacuation dans le district sanitaire de Bla.

The rapid access of the population to basic and comprehensive health care determines the prognosis of the disease and decreases mortality and morbidity. METHODOLOGY: we carried out a prospective study over 12 months at the Bla Reference Health Center. All patients evacuated for obstetric complications were included. Women admitted on an emergency basis by self-referral were not included. The data was analyzed from the software Epi Info version: 3.5.4, the text entry from the software version Word 2013. RESULTS: We recorded 430 evacuations or 42.36% of admissions to the maternity hospital in Bla. The patients were young under 20 years 17.9% (n = 77), nulliparous 22.1% (n = 95). They had not performed an antenatal consultation in 30.7% of cases (n = 132). Matrons evacuated in 50.2% of cases (n = 216). The transfer diagnosis was hemorrhage in 14.2% of cases. The main intervention performed was cesarean section (92.3% of cases). The evacuation time was greater than one hour in 95.1% (n = 21). The actors for the financing of the fund were the district council, the town halls and the Community Health Associations (ASACO). The mobilization rate of ASACOs was 82%, that of town halls 17%. The circle council did not pay its quota. CONCLUSION: A better financial involvement of the communities in the management of the evacuation reference system in the health district of Bla is a necessity.

L'accès rapide de la population aux soins de santé de base et complet détermine le pronostic de la maladie et diminue la mortalité et la morbidité. MÉTHODOLOGIE: nous avons mené une étude prospective sur 12 mois au Centre de Santé de Référence de Bla. Ont été incluses toutes les patientes évacuées pour complications obstétricales. Les femmes admises en urgence par autoréférence n'ont pas été incluses. Les données ont été analysées à partir du logiciel Epi Info version : 3.5.4, la saisie des textes à partir du logiciel version Word 2013. RÉSULTATS: Nous avons enregistré 430 évacuations soit 42,36% des admissions à la maternité de Bla. Les patientes étaient jeunesmoins de 20 ans 17,9% (n=77), des nullipares 22.1% (n=95). Ellesn'avaient pas réalisé de consultation prénatale dans 30,7%des cas (n=132). Les matrones ont évacué dans 50,2% de cas (n=216). Le diagnostic de transfertétait l'hémorragie dans 14,2% de cas. La principale intervention pratiquée était la césarienne (92,3%des cas). Le délai d'évacuation était supérieur à une heure dans 95,1% (n=21). Les acteurs pour le financement de la caisse étaient le conseil de cercle, les mairies et les Associations de Santé Communautaires (ASACO). Le taux de mobilisation des ASACO a été de 82%, celui des mairies de17%. Le conseil de cercle n'a pas payé sa quote-part. CONCLUSION: Une meilleure implication financière des collectivités dans la gestion du système de référence évacuation dans le district sanitaire de Bla est une nécessité.

[Consent To The Episiotomy About 331 Cases At The Health Reference Center Of The "Commune I" Of The District Of Bamako]. / Consentement A L'Episiotomie A Propos De 331 Cas Au Centre De Sante De Reference De La Commune I Du District De Bamako.

Episiotomy is a surgical act performed during childbirth to widen the vaginal opening; like any other medical procedure, its benefits and risks must be made known to patients in accordance with the legal and regulatory provisions of each country.The principle of immunity of the human body makes that the consent in the care is the keystone of the doctor-patient relationship, this consent is the first legitimization of the medicalact. The consent has to «be free and lit¼ as far as the decision of the patient must be taken without any constraint or pressure having obtained all the necessary information. This practice is not respected most of the time in our countries in spite of the fact that it's not observance engages the responsibility of the practitioner. OBJECTIVE: Study the consent of women who have undergone an episiotomy at the reference health center of "commune I" in the District of Bamako. METHOD AND MATERIAL: This is a prospective cross-sectional study conducted at the Obstetric Gynecology Department of the "Commune I" Health Center of the Bamako District from March 1, 2010 to February 29, 2012, involving 331 patients. We conducted the history and physical examination of women seen in post natal consultation who had undergone an episiotomy, a survey sheet was completed for each of them meeting our criteria. Data capture and analysis was done on SPSS 18; the texts and tables were processed on Microsoft Word Office 2007 software; Graphic representations were processed on Microsoft Excel Office 2007. ETHICAL ASPECTS: Women were informed of the study's objectives and interests; Confidential and anonymous insurance. RESULTS: In our study the practice of the episiotomy concerned 32, 19 % of the cases of assisted childbirths. The average age of the patients was of 25 years with extremes going of 14-46 years, the rigidity of the perineum was the main indication of the episiotomy in 41.1% of cases. Only 32.02% of the participants were previously informed prior to the practice of episiotomy. The information given was well understood in the same proportions is 32, 02% of cases and the assent lit with the episiotomy was obtnained in 29.31%. of cases. The information given was well understood in the same proportions of 32.02% of cases and informed consent to episiotomy was obtained in 29.31% of cases. CONCLUSION: In our study, the majority of our women have undergone episiotomy without any consent; the respect of the fundamental rights of the sick by health personnel, through the search for free and informed consent throughout the process of care, any breach of this duty constitutes a violation of the legal and ethical provisions.

L'épisiotomie est un acte chirurgical pratiqué aucours de l'accouchement pour élargir l'orifice vaginal ; comme tout autre acte médical, ses avantages et risques doivent être mis à la connaissance des patients conformément aux dispositions légales et réglementaires de chaque pays. Le principe d'inviolabilité du corps humain fait que le consentement aux soins est la clé de voûte de la relation médecin-patient, ce consentement est la légitimation première de l'acte médical. Le consentement doit être « libre et éclairé" dans la mesure où la décision du patient doit être prise sans aucune contrainte ou pression après avoir obtenu toutes les informations nécessaires. Cette pratique n'est pas le plus souvent respectée dans nos pays en dépit du fait que la non observance engage la responsabilité du praticien. OBJECTIF GÉNÉRAL: Etudier le consentement des parturientes ayant subi une épisiotomie au centre de santé de référence de la commune I du District de Bamako. OBJECTIFS SPÉCIFIQUES: Déterminer la fréquence des patientes ayant subi l'épisiotomie chez lesquelles l'information est donnée ; Déterminer la fréquence des patientes ayant subi l'épisiotomie ayant parfaitement compris l'information donnée ; Déterminer la fréquence des patientes ayant subi l'épisiotomie chez lesquelles le consentement éclairé à l'épisiotomie est obtenu. RÉSULTATS: Dans notre étude la pratique de l'épisiotomie a concernée 32,19% des cas d'accouchements assistés. L'âge moyen des patientes était de 25 ans avec des extrêmes allant de 14-46 ans. La rigidité du périnée était la principale indication de l'épisiotomie avec 41,1% des cas. Seulement 32,02% des parturientes étaient au préalable informées avant la pratique de l'épisiotomie. Les informations données étaient bien comprises dans les mêmes proportions soit 32,02%des cas et le consentement éclairé à l'épisiotomie a été obtenu dans 29,31%des cas. CONCLUSION: Dans notre étude, la majorité de nos parturientes a subi l'épisiotomie sans aucun consentement ; le respect des droits fondamentaux des malades par le personnel sanitaire, passe par la recherche d'un consentement libre et éclairé tout au long du processus de la prise en charge, tout manquement à ce devoir constitue une violation des dispositions légales et déontologiques.