This study reveals that more than half of the midwives surveyed in Abidjan had appropriate knowledge on CC disease and more than 40% had appropriate knowledge on CC prevention, specifically by screening and vaccination. Factors associated with appropriate knowledge were professional experience, courses on CC taken at school of midwifery, participation in conferences and training workshops on CC. Moreover, the majority of midwives were aware of screening and more than one third of them had regularly recommended it to their patients. Finally, more than half of midwives knew the existence of HPV vaccine.
The proportion of midwives with appropriate knowledge regarding epidemiology, risk factors and symptoms of CC is higher in this study than in other reports. A previous survey conducted among nurses in Tanzania, reported a proportion of adequate knowledge on cervical cancer of < 40% . This difference could be explained by our study population exclusively made up of midwives who received specific courses on gynecologic cancers at the school of midwifery and who usually manage diseases of the reproductive system.
Studies conducted among wider sample of nurses and other health workers on knowledge of prevention of CC were reported in Pakistan (screening 54%; vaccine 9%), in India and Tanzania (18% and 22% for vaccine, respectively) [21–23]. The relatively high level of knowledge on prevention of CC in our study could be explained by the fact that midwives work closely to gynecologists who perform screening and give advice to patients. Therefore, they are more likely to be well informed on CC prevention than other health professionals. This argument is reinforced by the fact that the most frequently reported information source was colleagues (70%) including gynecologists and midwives with more experience.
On the other hand, the fact that one-third of midwives did not have appropriate knowledge on CC prevention reveals unequal access to information. Indeed, in our study sample, only 18.0% of midwives attended conferences and less than 6.0% took part in seminars or training sessions on CC. Although these proportions are higher than in Tanzania (8.0% and 2.9%, respectively), they are low considering the fact that participation to such activities was associated to good knowledge in our study . This association was not investigated in other reports. Yet, it is important to notice that age, employment status and type of health facility that had been reported in other studies as being associated with good knowledge, remained not significant in our study when adjusted on information sources. Conferences and training sessions usually take place in university hospitals; midwives of these health facilities are then more likely to participate in such activities and may exhibit better knowledge than others.
In our study, 18.4% of midwives had already been screened for CC, and 37.7% often proposed screening to their patients. The low proportion of midwives screened was already reported in previous studies conducted in Nigeria and Uganda, where the authors found respectively 20.5% among 200 nurses and 19.0% among 310 nurses [24, 25]. Mutyaba et al. in Uganda reported that this low proportion could be the result of negligence and/or the feeling of invulnerability induced by the fact of being a health professional . This highlights the importance of encouraging midwives to get tested, since this study also revealed that midwives screened were more likely to propose screening to their patients.
We found out that only 8.4% of midwives had already conducted a visual inspection. This low proportion is consistent with the fact that visual inspection is not yet routinely used in the country and reflects the absence of national guidelines on the practice of CC screening. Of note this guideline is currently being written for Côte d’Ivoire. More than 50% of midwives were aware of the existence of an HPV vaccine and among them 71% would recommend it. McGarey et al. reported similar findings in Cameroon .
Our observations highlight the importance of relying on midwives to sensitize women to CC prevention. More than half of the female populations in the country are in their childbearing age. They attend reproductive health facilities where they are offered routine care and prevention services by midwives. Introducing CC prevention into reproductive health services managed by midwives could reinforce the awareness of the disease on the target population and could strengthen the national cancer control program. Since more than half of midwives in Abidjan already have appropriate knowledge on CC prevention, they could provide correct information and convince women to get screened and to have their children vaccinated.
The relatively high proportion of midwives lacking appropriate knowledge is mainly due to the difficulty of access to information. Thus, expanding access to information by organizing seminars and training sessions specifically designed for paramedical staff in all types of health facilities could significantly increase the proportion of midwives with adequate knowledge on CC prevention.
The low practice of CC primary (vaccine) and secondary prevention (screening for cervical precancerous lesions), and the inappropriate attitudes found in this sample, demonstrate once again the lack of comprehensive policy for CC prevention and insufficient communication about the HPV vaccine that has been available in the pharmacies of Abidjan since 2009. Inappropriate attitudes and practices of midwives argue in favor of the adoption of a comprehensive policy for CC prevention and also emphasize the need to adopt national guidelines for screening and vaccination.
This study was the first specifically conducted among a large sample of midwives to assess their knowledge, attitudes and practices toward CC in West Africa. Midwives from all categories of the health care system were represented. Moreover, the procedure of data collection allowed us to retrieve all the survey forms and to limit missing data. Thus, the results of this study accurately reflect the current knowledge of midwives in Abidjan.
One of the limitations of this study is the use of a questionnaire and a scoring approach not validated to assess knowledge of midwives as well as the 70% threshold chosen with reference to national academic grading systems. The study was limited to urban areas where most health facilities have a reproductive health unit. Therefore, results and recommendations may not be applicable to rural areas where nearly 40% of the populations of Côte d’Ivoire live  and which are poorly equipped in material and human resources. Despite its limitations, this study covered almost all midwives in the urban area of Abidjan and public health recommendations arising from these results could benefit more than 5 million inhabitants in Côte d’Ivoire.