This was a cross-sectional descriptive study with analytical aims conducted from March to September 2024 at the University Clinics of Kisangani (Tshopo Province, North-East of the RDC). The University Clinics of Kisangani served as the research site. This establishment is the only one to organize sickle cell disease screening campaigns over the last decade in the city of Kisangani, the last of which took place between March and October 2024.

The present study involved 215 women aged 18 to 35 years who presented after awareness-raising for sickle cell trait screening and who consented to participate in the study. Excluded from this study were all women who recognized themselves as carriers of the sickle cell trait or who had a homozygous sickle cell family member, married women.

This was a temporary and voluntary sampling that registered women who consented to participate in the study.

The women were received by an investigator, a consent form written in French and local languages (Swahili and Lingala) was given to them, so that the respondent could become aware of the study before giving her approval. Once consent was obtained, a pre-established questionnaire was given to the respondent and the following information was sought: Sociodemographic data (age, level of education, socioeconomic level, marital status), obstetric and medical history (obstetric formula, sickle cell disease, high blood pressure, diabetes mellitus, asthma), knowledge of sickle cell disease (etiological classification, transmission, prevention, high-risk marriages, clinical manifestations, progression of the disease), attitude of the woman in relation to the choice of an AS spouse, as well as the reasons justifying each attitude.

After completing the form, the respondent was referred to the research laboratory of the University Clinics of Kisangani for screening sickle cell trait and the result was immediately returned to the respondent after the test. For the AS respondents who were registered in this study, an appointment was made for a health education session on sickle cell disease. After the session, we asked again the question on the attitude in relation to the choice of an AS spouse as well as the reasons justifying each attitude and the answers were reported on the same collection form. For the AS respondents who were not included in this study, the same health education session was organized for them on the same day of screening.

After disinfection of the elbow crease, 1 mL of venous blood was collected by venipuncture and the sample was placed in a procoagulant tube (dry tube or immunized tube). A quantity of 1.5 μL blood was immediately withdrawn for hemoglobin S screening. Screening was done using the HemoTypeSC manufactured by Silver Lake Research Corporation, 1300 West Optical Drive Azusa, THAT 91702, USA Hemotype.com/ISO 134845. It is a rapid competitive lateral flow test incorporating monoclonal antibodies for the detection of hemoglobin A, S and C. The test followed the procedure determined by the supplier [17] .

L’interpretation of the hemoglobin type test results will be made by comparison as shown in Figure 1 .

The collected data were entered and encoded using the Excel spreadsheet (Microsoft Excel, CDC, 2010) and then imported for analysis using R software version 4.4.1 (2024-06-14 ucrt). The results were presented as percentages with their 95% confidence intervals. To search for the determinants of the choice of spouse, we carried out simple logistic regression. The significance threshold was set at P < 0.05.

Participation in the study was voluntary, written consent was obtained from the participants. The data were used only by the people involved in the study.

A number was assigned to each participant to ensure anonymity during and after the study. This study received approval from the ethics committee of the University of Kisangani: UNIKIS/CER/022/2024.

Of 215 women aged 18 to 35 years registered during our study, 51 women were screened as carriers of the sickle cell trait, representing a prevalence of 23.7%. Among them, 9 were excluded. We finally retained a sample of 42 respondents.

In total, 64.3% of respondents were under 25 years old, 78.6% had a higher level of education, 78.6% were not employed and 78.6% had no family history of sickle cell disease ( Table 1 ).

Among the respondents, 78.6% were nulliparous and 61.9% were nulligest and 80.9% had no antecedent of abortion ( Table 2 ).

Most respondents knew that sickle cell disease is a hereditary disease (42.9%), incurable (59.5%), the type of union at risk (76.19%), but were unaware of the means of prevention (40.5%). This was represented in Table 3 .

Table 4 shows that 64.3% of respondents accepted the choice of a spouse carrying hemoglobin AS. before confirmation of sickle cell trait carrier status, giving as a reason in 33.3% that not all children will be SS and that marriage was a gift from God in 29.6%.

The results below show that 73.8% of respondents had refused the choice of the spouse carrying AS hemoglobin after confirmation of the status of carrier of sickle cell trait after screening for sickle cell trait, with poverty as the reason in 38.7% ( Table 5 ).

The table below shows that the choice over a carrier spouse was significantly linked to age and profession before the test, with p-values of 0.027 and 0.015 respectively ( Table 6 ).

The table below shows that the choice of the respondents regarding a carrier spouse was significantly linked to knowledge of the union at risk after the test, with a p-value of 0.006 ( Table 7 ).

In logistic regression, women who did not know about risky marriage were 9.10 times more likely to accept the choice of a carrier spouse (P-value = 0.005) ( Table 8 ).

The results showed that before the test, the choice of a joint carrier was significantly linked to parity and gestation with a p value of 0.039 and 0.034 respectively ( Table 9 ).

The results showed that after testing, the choice of the carrier spouse was not statistically linked to any gyneco-obstetric history ( Table 10 ).

In our study, we found a prevalence of 23.7% of sickle cell trait among women

aged 18 to 35 years in Kisangani. This value is higher than those of Guilherme et al. [18] , Fenomanana et al. [19] and Teguete et al. [20] with the values of 13.45%, 1.17% and 18.7% respectively. We think that the prevalence in our study could be justified by the endemic nature of sickle cell disease in the Democratic Republic of Congo, the second most affected in Africa [21] . In contrast, value obtained in this study is lower than those found by Baffour et al. [22] with the prevalence of 41.7%; this could be justified by a small sample size of 12 donors in Samuel Antwi-Baffour’s study.

We found a prevalence of sickle cell trait close to that found in the general Congolese and Nigerian population [23] - [26] , justified by the endemic nature and autosomal recessive transmission of the disease.

During our study, before confirmation of hemoglobin status and health education, 64.3% of respondents had accepted the union with a partner carrying the sickle cell trait. But after testing confirming the sickle cell trait carrier status and health education, the proportion of respondents who had accepted the union with a partner carrying the sickle cell trait had significantly decreased. This attests to the impact of screening associated with health education on the control of health phenomena [16] [27] .

Before screening and health education, the choice of a spouse carrying the sickle cell trait was associated with age and profession. Indeed, the older the woman was, the more she tended to agree to marry a carrier of the sickle cell trait. This could be justified by the fact that it is known that female fertility decreases with age [28] , this could impact the chances of getting married, especially in the context of Black Africa where motherhood is the expression of a successful marriage and where the woman is held responsible for the couple’s infertility [11] [12] . Women seeing their chances of getting married decrease with age, are sometimes ready to marry without objectivity as soon as an opportunity arises.

In our study, before testing, women who had a profession tended to accept the choice of a sickle cell trait carrier, while those who did not have a profession tended to refuse. This could be justified by the fact that the majority of the population knows that the survival of sickle cell children requires a financial cost that is almost beyond the reach of the majority of the population [29] , justified by the eighth position among the poorest countries in the world occupied by the Democratic Republic of Congo, with an unemployment rate estimated at more than 80% of the general population [30] .

After testing and health education, the choice was associated with knowledge of the risky union. In bivariate analysis, most women who knew the union that exposed them to the risk of having children with sickle cell disease refused the choice of a spouse carrying the sickle cell trait. However, those who were unaware tended to accept the choice of a spouse carrying the trait. After logistic regression, the same trend was observed. We believe that these objective trends in the choice of spouse could be due to health education sessions that we had provided, but also to the various awareness campaigns for different studies conducted on sickle cell disease in Kisangani over the last decade [2] [23] [31] [32] .

It was observed that in our series, the choice of a carrier spouse before screening and health education was significantly related to parity and gestation. Women who had already given birth were more likely to accept the choice of a carrier spouse. We believe that this trend could be due to the different considerations of society towards single mothers. Indeed, in some African societies, it is not admissible to be a mother without having a husband, which means that single mothers and women see their chances of having a husband reduced, which exposes them to confiding in the first spouse who comes along [33] - [35] .

Limit of the study

The limitation of this study is that it was on a single site, with a small sample, hence the results of this study cannot be generalized. Nevertheless, this is a first study of its kind in the Democratic Republic of Congo and one of the rare in the literature.