Survey on knowledge, attitude, acceptance and related factors among pregnant women in Thailand regarding antenatal thalassaemia screening.

Thalassaemia is a common haematologic health condition in Southeast Asian countries (SEA) including Thailand. Reducing the birth of new thalassaemia cases is an effective method to control disease. The background level of knowledge and attitude of pregnant women on the disease influences their decision to perform antenatal screening. Unfortunately, the information about pregnant women's knowledge and attitude on antenatal thalassaemia screening in a developing country such as Thailand is lacking. We therefore conducted this cross-sectional study to examine patients' knowledge and to evaluate the factors which influence the patient's knowledge and attitude on antenatal thalassaemia screening. 1006 pregnant women who attended antenatal care at the Maha Chakri Sirindhorn Medical Center, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand were enrolled. We found that women's knowledge on antenatal thalassaemia screening is low. A maternal age of ≥35 years was associated with a higher level of knowledge. A higher level of education and multigravidity, a family history of thalassaemia and a positive level of attitude were found more likely to have higher scores for knowledge. A higher level of education and level of knowledge score were also more likely to have a positive attitude score, but multigravidity negatively affected the attitude score. Effective counselling should be monitored among women with a lower levels of education, those with no family history of thalassaemia, and in primigravidas. Lastly, a concurrent Down syndrome screening or foetal sex determination may be useful incentives to encourage the decision to undergo screening. Impact statement What is already known about this subject? Screening for the paternal and maternal thalassaemia carrier status is important for reducing the incidence of severely thalassaemia-affected children. Poorer education and receiving genetic counselling for the first time were the predictive factors for the low post-counselling knowledge in genetic counselling before second trimester genetic amniocentesis. What do the results of this study add? Pregnant women's knowledge of antenatal thalassaemia screening was low. We found that pregnant women aged ≥35 years had a higher level of knowledge. Women with a higher level of education, multigravidity, the presence of a family history of thalassaemia and a positive attitude were more likely to have higher scores for knowledge. A higher level of education and level of knowledge score were also more likely to have a positive attitude score but multigravidity negatively affected the attitude score. The encouraging factors, such as an adjunctive Down syndrome screening or foetal structural screening or foetal sex determination may be useful as the incentive tools. What are the implications of these finding for clinical practice and/or further research? The awareness of a possible incorrect understanding is important for the antenatal counselling in the developing countries. Intensive monitoring of effective counselling using a post-counselling test should be scheduled. The methods of effective counselling for antenatal thalassaemia in developing countries should be evaluated.

The Association of Breastfeeding Practices with Neonatal Jaundice.

Background: Neonatal jaundice is a common problem in newborns. Inadequate breastfeeding jaundice is an important consideration for the neonatal jaundice. Early breastfeeding initiation and good breastfeeding practices may help to prevent neonatal jaundice. Objective: To find the association of breastfeeding practices, the time to initiate breastfeeding, the breastfeeding frequency, breast milk volume, and appropriate latching with neonatal jaundice at the early postpartum. Material and Method: The subjects were postpartum women and newborns who had normal deliveries without complications at the HRH Princess Maha Chakri Sirindhorn Medical Center in the Nakhon Nayok province between July 2013 and June 2014. During postpartum period, the time of the first neonatal suckling, the breastfeeding frequency per day, the breastfeeding duration for each instance, the breast milk volume, and appropriate latching were assessed. The newborns had routine microbilirubin evaluation done at 48 hours postpartum. The data of newborn with neonatal jaundice was collected, analyzed, and compared with no jaundice newborn. The demographic data and breastfeeding factors were analyzed by Chi-square, t-test, and the Fisher's exact test. Results: The data of 176 newborns (neonatal jaundice 88 cases and no jaundice newborn 88 cases) and mothers were analyzed. It had shown that the mean time for the initiation of breastfeeding was 1.57±0.6 hours in the no jaundice newborn group and 5.56±3.1 hours in the neonatal jaundice group. The percentages of 'breastfeeding frequency less than eight times per day' in the neonatal jaundice and no jaundice newborn groups were 92.0% and 1.1% at day 1 postpartum, and 42.0% and 0.0% at day 2 postpartum, respectively. The percentages of 'breastfeeding duration less than 10 minutes' per feeding in the neonatal jaundice group were 35.2% and 13.6% at day 1 and day 2 postpartum. No one in the no jaundice newborn group had breastfeeding durations of less than 10 minutes for each feeding. The percentages of mothers in the neonatal jaundice and no jaundice newborn groups having no milk were 84.1% and 1.1% at day 1, and 4.5% and 0.0% at day 2 postpartum, respectively. The percentages of 'latch scores greater than 8' in the neonatal jaundice and no jaundice newborn groups were at 15.9% and 50.0% at day 1, and 31.8% and 95.5% at day 2 postpartum. There were statistically significant differences in the breastfeeding parameters. Conclusion: The factors of the time of the initiation of breastfeeding, breastfeeding frequency, duration, breast milk volume, and appropriate latching are associated with neonatal jaundice at the second day postpartum.

Effect of Obesity and Early Breastfeeding Initiation on Exclusive Breastfeeding Rates.

Objective: To compare the 6-week postpartum, exclusive breastfeeding rates between obese mothers and mothers with a normal body mass index (BMI), with early breastfeeding initiation. Material and Method: The subjects were 415 singleton, postpartum, obese mothers who delivered without complications at the HRH Princess Maha Chakri Sirindhorn Medical Center in the Nakhon Nayok province between the years of 2013 through 2015 and the same number of matched normal body mass index mothers. The early breastfeeding initiation of both the obese mothers and the normal BMI mothers was recorded. The exclusive breastfeeding rates were collected at the second day postpartum. Following discharge, telephone follow-ups were used for the collection of breastfeeding data at the 7th, 14th day and six weeks postpartum. The exclusive breastfeeding rates of the obese mothers were analyzed and compared with the exclusive breastfeeding rates of normal BMI mothers at the 2nd, 7th, 14th day and 6 weeks postpartum. The data was analyzed by Chi-square, relative risk and 95% confidence interval. Results: At the 2nd, 7th, 14th day and 6th week postpartum; the exclusive breastfeeding rates of the obese mothers' group were 94.5, 71.1, 64.8 and 51.3%, respectively. The exclusive breastfeeding rates of the normal BMI mothers' group for the same periods were 95.7, 79.3, 75.4 and 63.1%, respectively. There are statistically significant differences between the exclusive breastfeeding rates of the obese mothers' group and the normal BMI groups at the 7th day, 14th day and 6th week postpartum. In the situation of early breastfeeding initiation, the exclusive breastfeeding rates of the obese mothers at the 2nd, 7th, 14th day and 6th week postpartum were 96.3, 77.0, 71.2 and 58.4%, respectively. The exclusive breastfeeding rates of the normal BMI mothers who had early breastfeeding initiation were 96.2, 81.3, 77.4 and 67.2% at the 2nd, 7th, 14th day and 6th week postpartum, respectively. No significant differences were seen between the two groups in the exclusive breastfeeding rates at the 2nd, 7th and 14th day postpartum. Conclusion: The obesity had negative effect on exclusive breastfeeding rates during six weeks postpartum after mothers' discharge. But the exclusive breastfeeding rates of both the obese and normal BMI mothers were not significantly different during two weeks postpartum in early breastfeeding initiation situation. The obese mothers could be advised about early breastfeeding initiation.

Effect of Early Skin-to-Skin Contact to Breast Milk Volume and Breastfeeding Jaundice at 48 Hours after Delivery.

Objective: To evaluate effect of maternal-infant skin-to-skin contact in the first hour postbirth to breast milk volume and breastfeeding jaundice at 48 hours after delivery. Material and Method: This was a prospective cohort study. The subjects were 133 postpartum women, who delivered without complications between October 2013 and July 2014 at MSMC and was allocated into early skin-to-skin contact (SSC) and control groups. In the SSC group, the newborns were placed prone on mothers' bare chest after finishing routine newborn care for at least 30 minutes. The breast milk volume were collected at 16-24 hours, 40-48 hours postpartum and before discharge. The infants' microbilirubins were measured at 48 hours postbirth. Demographic data including age, parity, GA at delivery, birth weight and gender of the newborns were collected. Data were analyzed using descriptive statistics, Chi-square test and t-test. Results: The mean breast milk volume in the SSC group were 5.68+5.46, 16.98+11.09, and 31.44+20.06 milliliters at 16-24 hours, 40-48 hours postpartum and before discharge, respectively, while the mean breast milk volume in the control group were 6.19+5.77, 13.99+13.07 and 25.81+20.26 milliliters, respectively in the same period of time, and no statistically difference of the breast milk volume was found between the two groups. The percentage of mothers who had the onset of lactation within 24 hours postpartum in the SSC group (95.51%, 85/89) was significantly higher than the control group (77.27%, 34/44, p<0.01). The percentages of breastfeeding jaundice cases were 16.85 in the SSC group and 27.27 in the control group, and had no significant difference. Conclusion: Early skin-to-skin contact had no direct effect to breast milk volume and incidence of breastfeeding jaundice at 48 hours after delivery but related to the onset of lactation within 24 hours postpartum.

The Number of Infant Feeding Positions and the 6-Month Exclusive Breastfeeding Rates.

BACKGROUND: Appropriate infant feeding positions will help with latching. Good latching will help decrease cracked nipple and complication leading to early breastfeeding cessation. OBJECTIVE: To investigate the association of the number of infant feeding positions on exclusive breastfeeding during the first six months postpartum period. MATERIAL AND METHOD: The subjects were primiparous women who delivered without complications and intended to breastfeed their newborns at least six months at the HRH Princess Maha Chakri Sririndhorn Medical Center in Nakhon Nayok Province, Thailand, between May 2012 and April 2013. On the first day postpartum, the mothers had received instructions on four infant feeding positions. These included the cradle, cross cradle, football carry, and side-lying positions, and all were practiced. The mothers were assessed on their use of the numbers of infant feeding positions at the second day postpartum prior to their discharge. Telephone follow-ups at the second, fourth, and sixth month postpartum periods were collected and used for exclusive breastfeeding data collection following discharge. Demographic data and exclusive breastfeeding rates were analyzed by Chi-square test, one-way ANOVA test, and relative risk with a 95% confidence interval (CI). RESULTS: Five hundred forty five primiparous women were enrolled in the present study. The data showed that the 6-month exclusive breastfeeding rates of the studied group who could breastfeed by one, two, three, and four positions, had statistically signifcant differences (p-value < 0.05). The relative risks for exclusive breastfeeding rates between the mothers who used two infant breastfeeding positions or more and the mothers who used only one position were 1.68 (95% CI 1.45-1.95) at the 2-month, 1.69 (95% CI 1.38-2.09) at the 4-month, and 1.51 (95% CI 1.18-1.94) at the 6-month postpartum periods. CONCLUSION: The number of infant breastfeeding positions had an association with the exclusive breastfeeding rates during the six months postpartum period.

Comparisons of Latching on between Newborns Fed with Feeding Tubes and Cup Feedings.

BACKGROUND: Feeding tubes and cup feedings were used as alternative feedings. There is scant data regarding the facilitation of latching on by newborns with the use of these alternative supporting techniques. OBJECTIVE: The comparison of the latching on of newborns when fed with the additional support of feeding tubes or cup feedings. MATERIAL AND METHOD: The subjects were 120 normal, postpartum women, who delivered without complications at the HRH Princess Maha Chakri Sririndhorn Medical Center in the Nakhon Nayok Province between October 2012 and September 2013. No breast milk was expressed by the mothers at day 2, postpartum. They were divided into two groups by simple randomization. In the first group, the newborns were fed with a feeding tube in support of breastfeeding. In the second group, the newborns were fed by cup feedings. Latch scores were assessed at the end of postpartum day 3. Demographic data and latch scores were collected and analyzed by Chi-square, t-test and Mann-Whitney U test. RESULTS: No differences in the demographic data of mothers and newborns between the two groups were found. Latch scores for the feeding tube group were significantly higher than the latch scores in the cup feeding group (p < 0.05). CONCLUSION: Latching of newborn after feeding tube method is better than latching of newborn after cup feeding.

Comparisons of the latching on between newborns with tongue-tie and normal newborns.

BACKGROUND: Breastfeeding is recommended as the exclusive feeding for the first six months of the newborns life. Difficulty in latching and breastfeeding resulting from tongue-tie are believed to be a problem. OBJECTIVE: To compare the latching on between newborns with tongue-tie (ankyloglossia) and normal newborns. MATERIAL AND METHOD: The subjects were 833 normal, postpartum women who delivered without complications at HRH Princess Maha Chakri Sririndhorn Medical Center in Nakhon Nayok Province between January and June 2013. Their newborns oral cavities' were checked for tongue-tie screening and diagnoses using Kotlow's criteria. Latch scores were used for latch-on assessment at the second day postpartum. Demographic data and latch scores were collected and analyzed by the t-test, Chi-square test, Odds ratio with 95% confidence interval and One-way of ANOVA test. RESULTS: The data shows that the incidence of tongue-tie was 13.4% (6.2% with mild tongue-tie, 5.5% with moderate tongue-tie, and 1.7% with severe tongue-tie). The mean of latch scores in the tongue-tied groups were significantly lower than that in the normal group, especially in the moderate and severe tongue-tie subgroups. The odds ratios for latch scores were < or = 8 compared between the moderate and severe tongue-tied subgroups and the score in the normal and mild tongue-tied subgroups was 1.4. CONCLUSION: The latch scores in tongue-tied newborns were significantly lower than those in normal newborns.

Nipple length and its relation to success in breastfeeding.

OBJECTIVE: To find the critical cut-off point of nipple length that facilitates success in breastfeeding. MATERIAL AND METHOD: The subjects were 449 postpartum women, who delivered at HRH Princess Maha Chakri Sirindhorn medical center in Nakhon Nayok province between October, 2010 and March, 2011. Data regarding nipple length and its relation to success in breastfeeding were collected and analyzed by a receiver operating characteristic curve (ROC curve). This is a graphical method of assessing the characteristics of a diagnostic test. RESULTS: The data shows that 7-millimeters in nipple length had been shown to be the cut-off point that facilitates successful breastfeeding. Sensitivity was at 72.5%. Specificity was at 46.2%. The positive predictive value was at 97.8% and the negative predictive value was at 4.9%. CONCLUSION: The cut-off point for nipple length that facilitates successful breastfeeding has been measured at 7 millimeters. Nurses and health personnel may use 7 millimeters of nipple length as a criteria for a successful breastfeeding screening test and give close breastfeeding support if postpartum women have less than 7 millimeters in nipple length.

The prevalence of snoring in Thai pregnant women.

OBJECTIVE: To determine the prevalence of snoring in Thai, pregnant women. MATERIAL AND METHOD: This study was carried out from April 2008 through August 2008 at the antenatal clinic, HRH Princess Maha Chakri Sirindhorn Medical Center Nakorn Nayok province. Two hundred and thirty-eight pregnant women were enrolled. All subjects answered the Berlin questionnaire; this include information on age, weight, height, gravid health status, gestational age, witnessed incidences of snoring, and symptoms associated with sleep apnea. The description of snoring as frequency, volume, complaints from other people and bouts of sleep apnea were recorded and analyzed. RESULTS: The prevalence of snoring in pregnancy was 35.29%. The snoring volume, recorded as slightly louder than breathing, in this group was 91.67%. One-fourth of the cases presented with snoring approximately 3-4 times a week with complaints of snoring bothering other people. The incidence of sleep apnea was found in 5.95% of this group. CONCLUSION: The prevalence of snoring was found in approximately one-third of the pregnant women screened.

Outcomes of Video-Assisted Teaching for Latching in Postpartum Women: A Randomized Controlled Trial.

BACKGROUND: Latching is an important process of breastfeeding and should be taught and practiced by the postpartum mother. OBJECTIVE: The objective is to compare latching outcomes between video-assisted and routine teaching methods among postpartum women. MATERIALS AND METHODS: A randomized controlled trial was conducted. Postpartum women who had deliveries without complications were randomized into two groups: 14 cases in the video-assisted teaching group and 14 cases in a routine teaching group. In the first group, the mothers were taught breastfeeding benefits, latching methods, and breastfeeding positions and practiced breastfeeding in a controlled setting for a 30-minute period and watched a 6-minute video with consistent content. In the second group, the mothers were taught a normal 30-minute period and then practiced breastfeeding. In both groups, Latching on, Audible swallowing, the Type of nipples, Comfort, and Help (LATCH) scores were assessed at 24-32 and 48-56 hours after the breastfeeding teaching modals. Demographic data and LATCH scores were collected and analyzed. RESULTS: There were no statistically significant differences in the mothers' ages, occupations, marital status, religion, education, income, infants' gestational age, body mass index, nipple length, route of delivery, and time to first latching between the video-assisted and routine breastfeeding teaching groups. First and second LATCH score assessments had shown no significant differences between both breastfeeding teaching groups. CONCLUSION: The video-assisted breastfeeding teaching did not improve latching outcomes when it was compared with routine teaching.

Effect of Herbal Compresses for Maternal Breast Engorgement at Postpartum: A Randomized Controlled Trial.

BACKGROUND: Maternal breast engorgement is one of the most common problems in the postpartum period. There are several alternative treatments, but there have not been any randomized controlled trial studies about the effects of herbal compresses for breast engorgement. OBJECTIVE: The objective is to investigate the effects of herbal compresses for maternal breast engorgement. MATERIALS AND METHODS: A randomized controlled trial was conducted. The postpartum mothers who had breast engorgement were randomly assigned to herbal or hot compress treatments. The breast engorgement pain scores were assessed by visual analog scales pre- and post-treatment. The pain reduction scales of the herbal compress treatments were analyzed and compared with the hot compress treatments. The adverse effects of each treatment were recorded and collected after 24 hours from treatments. RESULTS: The data from 500 postpartum mothers with breast engorgement were available for analyses, 250 from the herbal compress group and 250 from the hot compress group. The baseline characteristics of both groups were similar except baseline breast engorgement pain score (herbal compress group higher than hot compress group). There were statistically significant mean differences of breast engorgement pain before and after treatment between the herbal and hot compress groups. No serious complications were found after treatment from herbal compresses. CONCLUSION: Among the postpartum mothers who had breast engorgement, the herbal compresses could decrease breast engorgement pain. The pain reduction after herbal compresses was found to be greater than with the hot compresses.

Nipple Pain Incidence, the Predisposing Factors, the Recovery Period After Care Management, and the Exclusive Breastfeeding Outcome.

BACKGROUND: Nipple pain is the most common complaint of breastfeeding mothers during the immediate postpartum period. Persistent nipple pain is associated with low breastfeeding rate at 6 months postpartum. OBJECTIVE: To further explore the incidence of nipple pain, associated predisposing factors, time for recovery after management, and the impact on exclusive breastfeeding rates. MATERIALS AND METHODS: Included in this study were 1,649 singleton, pregnant women who delivered and had their 1-week follow-up at the breastfeeding clinic during the period of January 2013 to December 2015. The mothers who experienced nipple pain were analyzed for the incidence, the predisposing factors, and the recovery period after care management. The breastfeeding outcome comparison of both, mothers with and without pain, was measured by the exclusive breastfeeding rate at the sixth week postpartum. RESULTS: The incidence of nipple pain was at 9.6% by day 7. A predisposing factor of nipple pain was primiparity (relative risk = 1.8, 95% confidence interval 1.3-2.5). The reasons for nipple pain were inappropriate positioning and latching (72.3%), tongue-tie (23.2%), and oversupply (4.4%). The recovery period after care management was 1-2 weeks. There were no statistically significant differences between the 6-week exclusive breastfeeding rates of the mothers with nipple pain with treatment and the mothers without nipple pain. CONCLUSION: Persistent nipple pain was a common problem. The active management, including early detection and treatment, would help the mothers recover within a 2-week period and there was no significant difference of exclusive breastfeeding rates between the mothers who had early care management and the mothers without nipple pain.

Comparison of Breastfeeding Outcomes Between Using the Laid-Back and Side-Lying Breastfeeding Positions in Mothers Delivering by Cesarean Section: A Randomized Controlled Trial.

BACKGROUND: The breastfeeding position routinely used following a cesarean section is the side-lying position. However, there have been few studies about the effect of breastfeeding positions, including laid-back position on breastfeeding outcomes. OBJECTIVE: To compare the breastfeeding outcomes between using laid-back and side-lying breastfeeding positions in mothers delivering by cesarean section. MATERIALS AND METHODS: A randomized controlled trial was conducted. The postpartum mothers delivering by cesarean section who delivered term newborns were randomly assigned to learn the use of a laid-back or side-lying breastfeeding position. The breastfeeding outcomes were assessed by LATCH scores at the second day postpartum and exclusive breastfeeding rates during the 6-week postpartum period. The mother's satisfaction of each breastfeeding position was collected before discharge from the hospital. RESULTS: The data from 152 postpartum mothers delivering by cesarean section were available for analysis, 76 from the laid-back position group and 76 from side-lying position group. The baseline characteristics of both groups were similar. There were no statistically significant differences of the breastfeeding outcomes, LATCH scores at the second day postpartum and the exclusive breastfeeding rates during the 6-week postpartum period. But the mothers had expressed more satisfaction from the side-lying than the laid-back position. CONCLUSIONS: Among the mothers who delivered by cesarean section, the use of the laid-back breastfeeding position had not shown different breastfeeding outcomes from the side-lying breastfeeding position. It might be an alternative breastfeeding position, which can be taught for mothers delivering by cesarean section along with the side-lying position.

The Effect of Ginger on Breast Milk Volume in the Early Postpartum Period: A Randomized, Double-Blind Controlled Trial.

BACKGROUND: In Thailand, ginger is a popular natural galactagogue among breastfeeding women. However, there has never been evidence to support the effectiveness of ginger in increasing the breast milk volume. OBJECTIVES: To compare breast milk volume on the third and seventh day postpartum between lactating mothers who receive 500 mg dried ginger capsules twice daily with those receiving placebo. MATERIALS AND METHODS: A randomized, double-blind controlled trial was conducted. Women who deliver a term baby were randomly assigned to receive dried ginger or placebo for 7 days postpartum. Breast milk volume was measured on third day postpartum using test weight method for a period of 24 hours and on seventh day postpartum using 1 hour milk production. We also compared the third day serum prolactin level between the two groups. RESULTS: Data from 63 women were available for analysis, 30 from the ginger group and 33 from the placebo group. The two groups were similar regarding baseline characteristics. Women in the ginger group have higher milk volume than the placebo group (191.0 ± 71.2 mL/day versus 135.0 ± 61.5 mL/day, p < 0.01). However, the seventh day milk volume in the ginger group does not differ from the placebo group (80.0 ± 58.5 mL versus 112.1 ± 91.6 mL, p = 0.24). The mean serum prolactin levels were similar in both groups (321.5 ± 131.8 ng/L in the ginger group, and 331.4 ± 100.7 ng/L in the placebo group, p = 0.74). No side effect was reported in this study. CONCLUSION: Ginger is a promising natural galactagogue to improve breast milk volume in the immediate postpartum period without any notable side effect.

Knowledge, attitudes and practices regarding cervical cancer screening among village health volunteers.

BACKGROUND: In the years 2014, coverage rates of cervical cancer screening in Nakornnayok province accounted to 76.5%. This was lower than the government's specified goal of 80%. Community health volunteers are members of a Thai healthcare alliance established to help promoting healthcare service communication and collaboration at the primary level. Such village health volunteers (VHVs) are established in most villages. OBJECTIVE: To assess the knowledge and attitudes of cervical cancer screening among VHVs. MATERIALS AND METHODS: The subjects were 128 VHVs from four Nakornnayok sub-districts; namely KlongYai, Chomphol, Buangsan and Suksara, Thailand. The study was conducted from December 2014 to January 2015. The questionnaire was designed to assess the knowledge and attitude of cervical cancer screening provided by the VHVs. In addition, cervical cancer screening coverage rates of each area were collected. The demographic data, scores of knowledge, attitudes, practices and the cervical cancer screening coverage rates were analyzed by one-way ANOVA. RESULTS: The questionnaire reliability was assessed as 0.81. The total knowledge and attitude scores were 10 and 15 points. The mean knowledge scores of KlongYai, Chomphol, Buangsan and Suksara were 6.8, 7.0, 6.5 and 9.0 points, respectively. The VHVs had a high level of overall knowledge about cervical cancer screening. The mean attitude scores were 12.4, 13.2, 13.4 and 13.1 points. VHVs had a positive attitude to the promotion of cervical cancer screening at the overall level. The percentages of VHVs promoting cervical cancer information in respective districts were 72.2, 94.3, 94.9 and 50.0. However, the cervical cancer screening coverage rates were 62.4%, 34.7%, 80.3% and 47.3% respectively. CONCLUSIONS: The knowledge, attitudes and percentages of promoting information of cervical cancer screening among VHVs in the four sub-districts were high but did not correlate with the cervical screening coverage rates for each area. VHVs needed to understand socio-cultural beliefs of the women in the target population and design suitable strategies to encourage higher cervical screening coverage.