Barriers to the uptake of cervical cancer services and attitudes towards adopting new interventions in Peru

Cervical cancer mortality is high among Peruvian women of reproductive age. Understanding barriers and facilitators of cervical cancer screening and treatment could facilitate development of contextually-relevant interventions to reduce cervical cancer incidence and mortality. From April – October 2019, we conducted a cross-sectional survey with 22 medical personnel and administrative staff from Liga Contra el Cancer, in Lima, Peru. The survey included structured and open-ended questions about participants’ roles in cervical cancer prevention and treatment, perceptions of women’s barriers and facilitators for getting screened and/or treated for cervical cancer, as well as attitudes towards adopting new cervical cancer interventions. For structured questions, the frequency of responses for each question was calculated. For responses to open-ended questions, content analysis was used to summarize common themes. Our data suggest that the relative importance and nature of barriers that Peruvian women face are different for cervical cancer screening compared to treatment. In particular, participants mentioned financial concerns as the primary barrier to treatment and a lack of knowledge or awareness of human papillomavirus and/or cervical cancer as the primary barrier to screening uptake among women. Participants reported high willingness to adopt new interventions or strategies related to cervical cancer. Building greater awareness about benefits of cervical cancer screening among women, and reducing financial and geographic barriers to treatment may help improve screening rates, decrease late-stage diagnosis and reduce mortality in women who have a pre-cancer diagnosis, respectively. Further studies are needed to generalize study findings to settings other than Lima, Peru.

Surgical management of cervical cancer in a resource‐limited setting: One year of data from the National Cancer Institute, Sri Lanka

Objective
To evaluate the surgical management of cervical cancer without the use of preoperative pelvic imaging in a resource‐limited setting.

Methods
A retrospective study was carried out using clinical records and the ongoing electronic database at the Gynaecological Oncology Unit, National Cancer Institute (Apeksha Hospital), Maharagama, Sri Lanka. Details regarding the radical hysterectomies carried out from January 1, 2019, to December 31, 2019, were retrospectively studied.

Results
Out of nearly 700 patients with cervical cancer admitted during the year 2019, 57 surgically managed radical hysterectomies were included. Of these, seven cases were ineligible and excluded and 50 cases of radical hysterectomies were included for analysis. Mean age was 53.6 ± 9.5 years and median parity was 3 (range 2–4). Of the cases, 94% were found to have no parametrial involvement showing the success of clinical examination in assessing local tumor spread. Overall, 11 (22.0%) were upstaged due to lymph node metastasis that was statistically significant.

Conclusion
Preoperative clinical staging is a practical method in selecting surgically treatable cervical cancer in low‐ and middle‐income countries (LMICs). Combining clinical assessment with comparatively more readily available computed tomography scans could be helpful in triaging patients for treatment of cervical cancer in LMICs.

Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage

Background
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse.

Method
We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort.

Result
A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population.

Conclusion
A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.

We Asked the Experts: Global Surgery—Seeing Beyond the Silo

The COVID-19 pandemic requires comprehensive health systems response, with 14% of infected people developing severe sickness leading to hospitalization and 5% admitted to an intensive care unit [1]. The need for oxygen and intensive care means that perhaps for the first time, surgery and anesthesia find themselves playing a central role in a global health emergency; but is global surgery integrated enough to the wider global health community to have an impact?

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.

The Cervical Cancer (CC) Epidemiology and Human Papillomavirus (HPV) in the Middle East

Viral infections contribute 15–20 percent of all human cancers as a cause. Oncogenic virus infection may spur various stages of carcinogenesis. For several forms for HPV, about 15 associated with cancer. Following successful test techniques, cervical cancer remains a significant public health issue. Prevalence and mortality of per geographic area of cervical cancer were vastly different. The fourth most common cause of death from cancer among women is cervical cancer (CC). Human papillomavirus (HPV) infection in the cervix is the most significant risk factor for forming cervical cancer. Inflammation is a host-driven defensive technique that works rapidly to stimulate the innate immune response against pathogens such as viral infections. Inflammation is advantageous if it is brief and well-controlled; however, it can cause adverse effects if the inflammation is prolonged or is chronic in duration. HPV proteins are involved in the production of chronic inflammation, both directly and indirectly. Also, the age-specific prevalence of HPV differs significantly. Two peaks of HPV positive in younger and older people have seen in various populations. A variety of research has performed worldwide on the epidemiology of HPV infection and oncogenic properties due to specific HPV genotypes. Nevertheless, there are still several countries where population-dependent incidences have not yet identified. Additionally, the methods of screening for cervical cancer differ among countries.

Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients’ demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa

Background
In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa.

Methods
All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods.

Results
Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities.

Conclusion
Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Mechanical and surgical interventions for treating primary postpartum haemorrhage

Background: Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

Objectives: To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

Search methods: We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

Data collection and analysis: Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

Main results: We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review’s important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter (‘condom catheter’), an air-filled latex balloon-loaded catheter (‘latex balloon catheter’), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean ‘intraoperative’ blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

Authors’ conclusions: There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

Trauma in pregnancy at a major trauma centre in South Africa

Background. Trauma in pregnancy poses a unique challenge to clinicians. Literature on this topic is limited in South Africa (SA).

Objectives. To review our institution’s experience with the management of trauma in pregnancy in a developing-world setting.

Methods. This study was based at Grey’s Hospital, Pietermaritzburg, SA. All pregnant patients who were admitted to our institution following trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR).

Results. During the 6-year study period, 2 990 female patients were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS), of whom 89 were pregnant. The mean age of these patients was 25.64 (range 17 – 43) years. The mechanism of injury was road traffic crash (RTC) in 39, stab wounds (SW) in 19, assault other than SW or gunshot wounds (GSW) in 19, GSW in 8, snake bite in 5, impalement in 1, dog bite in 1, hanging in 1, sexual assault in 1 and a single case of a patient being hit by a falling object. A subset of patients sustained >1 mechanism of injury. Thirty patients were managed operatively. The mean time of gestation was 19.16 (5 – 36) weeks. Three patients died, and there were 16 fetal deaths (including 3 lost after the mother’s death). Forty-five fetuses were recorded as surviving at discharge, while 25 fetal outcomes were not specifically recorded. There were 2 threatened miscarriages and/or patients with vaginal bleeding, 1 positive pregnancy test with no recorded outcome and no premature births as a result of trauma.

Conclusions. Trauma in pregnancy is relatively uncommon and mostly due to a RTC or deliberately inflicted trauma. Fetal outcome is largely dependent on the severity of the maternal injury, with injuries requiring laparotomy leading to a high fetal mortality rate.