Fifty midwives participated in the study. The average age was 32.46 ± 3.2 years with extremes of 23 and 50 years. In 92% of cases, their professional experience did not exceed 10 years of practice.

Table 1 below shows the distribution of midwives according to their knowledge of cervical cancer.

Ninety-six percent of midwives felt that cervical cancer is preventable. Twenty-four percent believed that cervical cancer is not fatal if detected early. They all agreed to routinely offer cervical cancer screening to any woman attending a gynecology or obstetrics department. They all expressed the need for a national cervical cancer control program that would allow for free screening and management of pre-cancerous lesions. All midwives expressed the need to be trained in the screening and management of pre-cancerous lesions.

Of the 50 midwives, none had yet performed a screening test as part of their gynecological follow-up. Only one midwife reported performing VIA/VILI on a patient once.

All midwives are aware of cervical cancer. Oncogenic HPV infections were identified in 74% of cases as causing cervical cancer. Our results are similar to those obtained in Saudi Arabia (68.5%) by Sail KH et al. [7] and in Mexico (79%) by Aldrich T et al. [8]. On the other hand, the responsibility of oncogenic HPV in the genesis of cervical cancer is less known in the studies of Nani S et al. [5] in Morocco (21%) and of Mutyaba T. et al. [9] in Uganda (29%). As regards risk factors, 77% of our respondents were able to identify at least two. The clinical manifestations were essentially dominated by malodorous vaginal discharge, postmenopausal and provoked hemorrhage. Only 22% of midwives had a good knowledge of these clinical signs. Our results are lower than those of Goyal A et al. in Ghana who found 73.5% [10]. The anatomical accessibility of the cervix offers the opportunity of screening through simple and inexpensive means, especially for our developing countries where the disease is diagnosed at an advanced stage with few treatment options. In our study, only 28% and 32% of midwives were aware of UFH and VIA/VILI as the commonly used screening methods in our settings. In the study by Goyal A et al. [10], UFH (52.5%) was the most commonly known, followed by colposcopy (19%) and VIA/VILI (4.5%). Regarding the target population and the periodicity of screening, only 8% knew the age group concerned and 30% the 3-year periodicity. Several authors have reported varying degrees of knowledge on the subject. Nani S et al. [5] in Morocco reported only 2.9% for a start of screening at 25 years of age and a periodicity every 3 years in 47.5% of cases. In Mexico, Aldrich T et al. [8] reported 77% for the beginning of screening after the first sexual intercourse with an annual periodicity in 73% of cases. According to WHO recommendations, screening by UFH should be performed between the ages of 25 and 65 years with an interval of 3 years after a second negative test at 1 year interval. Currently there is no international consensus on the age of onset nor on the frequency of screening but all agree that the choice should take into account the means of each country and most recommend a frequency of 3 years.

Ninety-six percent of midwives believe that cervical cancer is preventable. The same contacts were made in Tunisia by Hsairi M et al. [11] who reported that 96.2% of the respondents thought that screening was an effective means of reducing the incidence of cervical cancer. Hence the importance of raising awareness about risk factors, vaccination and especially screening and management of pre-cancerous lesions. Thus, 84% of the midwives felt that it was possible to screen all women seen in gynecological and prenatal consultations. Our results are similar to those of Amal A et al. [12] in Qatar. These screenings will only be effective if a national screening program includes the training of midwives. In our study, all midwives expressed the need to be trained in the screening and management of pre-cancerous lesions.

Since midwives are the first line of contact with the female population, they should be the primary actors in raising awareness about cervical cancer screening. However, in our study, none of the midwives had yet performed a cervical cancer screening test as part of their health check-up. This attitude of health personnel not to be screened has also been reported by several authors. This is the case in Morocco, where in a study of general practitioners by Nani S et al. [5], 67.9% of female doctors said they had never performed an ECF. In India and Saudi Arabia, the same findings were reported respectively by Chamaraja et al. [13] and Sail KH et al. [7] with 11.6% and 19% in their studies of nurses. According to Mutyaba T et al. [9] in Uganda, the main reasons for the low rate of screening among medical staff are not feeling at risk, lack of warning signs of the disease, and fear related to screening. As a highly preventable disease, screening and early management should be a public health priority in the fight against cancer. This avoids invasive cancer whose management is cumbersome and often inadequate, especially in our developing countries where the technical platform is often insufficient. Thus, since screening is the simplest way to reduce the incidence of cervical cancer and improve survival, in our study, no midwife has yet performed UFJ and only one reported performing VIA/VILI once on a patient. Low screening rates were also reported in Morocco by El Feikir S et al. [14] (7.87%) and in Tunisia by Hsairi M et al. [11] (18.3%). In Uganda, according to Mutyaba T et al. [9], midwives and nurses stated that the practice of ECF is a procedure reserved for doctors. As the lack of human resources is a barrier to a successful cervical cancer screening program, the involvement of all health personnel in cervical cancer control would be beneficial.