Background: The standard screening test for cervical cancer is the Pap smear and cervical cancer is a significant health issue worldwide. Early sexual activity, multiple sexual partnerships, parity, young age at first pregnancy and early marriage are traditional risk factors for developing cervical cancer. The aim of the present study was to assess the effect of early marriage in on the results of Pap smear in Iraqi women. Methods: A cross-sectional study was carried out on 200 women who attended the Women Health Clinic of Al-Elwiya Maternity Teaching Hospital, Baghdad for the period from November 2013 to April 2014. Data were collected through direct interview and a prepared questionnaire including patients’ characteristics and Pap smear results. Results: Mean age of studied women was 39.9 ± 11.4 years and mean age of marriage was 19 ± 5 years. Abnormal Pap results were reported in 63.5% of them. A significant association was observed between abnormal Pap smear and each of age 20 - 30 years, ≤18 years age at marriage, marriage duration >10 years, irregular menstrual cycle, tubal ligation and abnormal medical history (
P < 0.05). Conclusions: Early marriage was strongly associated with abnormal Pap smear results in Iraqi women.
Pap Smear Early Marriage Medical History Gynecologic Complications1. Introduction
World-wide, cervical cancer is considered the fourth most common malignancy and also the fourth most common cause of cancer death in women [1] . However, prevention and decrease mortality rate due to cervical cancer can be achieved by early diagnosis during early stages. In Iraq, there are 10.12 million women (15 years and older) at risk of developing cervical cancer [2] . Current reports indicated that 291 women are diagnosed with cervical cancer every year, and about 142 die from the disease [3] . Moreover, cervical cancer ranks as the 12th most frequent cancer among women in Iraq, and the 10th most frequent cancer among women between 15 and 44 years of age [4] . Early marriage and polygamy play an important role in developing cervical cancer [5] . Common risks for cervical cancer and child marriage are low socioeconomic status, poor access to health care, and husbands who had multiple sex partners [6] . In Iraq, 28% of girls with age of 15 - 18 years are married [7] . Although the cervical cancer has a multifactorial risk, infection with human papilloma virus (HPV) and lack of effective screening have been identified as major components in the development of pre-invasive and invasive types of this disease [8] . First infection with HPV often occurs soon after first sexual intercourse [9] , making early age at first intercourse a reasonable proxy for early age at first exposure to HPV [10] . Despite the high prevalence of cervical cancer, women’s knowledge about HPV, cervical cancer and cervical screening is limited [11] . Moreover, women’s knowledge and awareness of cervical cancer are considered determinant regarding the uptake and success of cervical cancer screening [12] . The benefits of screening for cervical cancer based on Papanicolaou smear test (Pap test) are well established; routine Pap testing has led to the decline in the incidence and mortality rate of cervical cancer [13] . In early marriage, the increased risk of HPV was attributed to biological predisposition of the immature cervix during adolescence, which may be more susceptible to persistent HPV infections and therefore have a greater risk of cancer development [14] . The present study was designed to evaluate the effect of early marriage on the results of Pap smear performed for Iraqi women aged 30 - 40 years.
2. Methods2.1. Study Design
The present cross sectional study was carried out in the women health clinic of Al-Elwiya Maternity Teaching hospital form 1st of November, 2013 to 1st of April, 2014. It includes 200 post pubertal married women who attended the Women Health Clinic of Al-Elwiya Maternity Teaching hospital. Each woman who fulfils the inclusion criteria of being Post pubertal and married or previously married was included, and those with known cases of malignancy, duration of marriage less than one year, cauterization and cone biopsy, cervical scaring due to previous damage in labor, human papilloma virus infection and received any vaginal treatment or douches 72 hours before inclusion were excluded. The study protocol was approved by the local committee of research ethics and the committee of the Arabic Board of Medical Specialties; signed informed consents were obtained from all participants.
2.2. Data Collection and Evaluation
After full clinical investigation, data were collected from each women according to a questionnaire specially prepared for this purpose. It includes demographic data, lifestyle and social information, obstetrical, gynecological and medical history, and sexual history. All anthropometric measurements were performed according to standard methods [15] . Pap smear test was performed between 10th - 20th days of the menstrual cycle by rotating Ayer’s spatula 360 degrees around transformation zone of cervix, while cervical smears were taken by a special endocervical brush. The results were evaluated and interpreted according to the Bethesda system 2001 (ASC-US) [16] . Any case with HPV were was excluded for the aim of focusing on other predisposing factors of cervical carcinoma especially early marriage.
2.3. Statistical Analyses
All results were analyzed using Statistical Package for Social Sciences (SPSS) version 17. Descriptive values were presented as mean ± SD, frequencies and percentages. Multiple contingency tables and appropriate statistical tests were performed utilizing Chi-square for categorical variables and t-test for continuous variables. The level of significance (P value) was set at <0.05. Partial correlation was used to evaluate the effects of other factors and measure the power of studied variables. Binary logistic regression analysis was used for prediction of group membership and also provides knowledge of the relationships and strengths among the variables.
3. Results
Table 1 showed the sociodemographic characteristics of the participants. Mean age of marriage was 19 ± 5 years, half of them ≤18 years and the other half >18 years. The mean duration of marriage was 20 ± 12 years, 29.5% women were with marriage duration ≤10 years and 70.5% with marriage duration >10 years. Mean age at first delivery was 21 ± 6 years, 39.8% were ≤18 years old at first delivery and 60.2% were >18 years old at first delivery. 75.5% of the women were living in urban areas and 24.5% of them in rural areas. 72% of the women had a good socioeconomic history, while 28% of them had a bad socioeconomic history. 82.5% of women were non-smokers and 17.5% were current smokers. Meanwhile, 9.5% of women had normal BMI, 52.5% overweight and 38% were obese (Table 2). Table 2 also showed that the mean gravidity of participants was 6 ± 2, mean parity was 5 ± 2 and mean abortion was 2 ± 1. Additionally, 85.2% of women had normal vaginal delivery and 14.8% had cesarean section. Moreover, the mean age of menarche of women was 13 ± 1 years, on the other hand, 62% of the women had regular menstrual cycle and 38% of them had irregular menstrual cycles. In Table 3, half of studied women used no contraceptive methods, 19% used COCP, 4% used IUCD, 6.5% used progesterone, 8.5% used barrier, 6.5% used coitus interrupts and 3.5% used tubal ligation. About two thirds of the studied women had active sexual history and 31.5% of them had inactive sexual history. Table 3 also showed that only 17.5% of the studied women had history of medical disease, 79.5% had no previous gynecological operations and 20.5% had previous gynecological operations. 66.5% of the women had no previous surgical operations and 33.5% of them had previous surgical operations. Mean interval between marriage and first Pap test was 17 ± 10 years. In Table 4, normal Pap results were represented by 36.5% of women, while those of abnormal results represent 63.5%. Abnormal smears were reported in 36.5% of women, while 33.5% showed atypical squamous cells, 14.5% with low grade squamous intraepithelial lesion, 8% had high grade squamous intraepithelial lesion, and 5% had atypical glandular cells; meanwhile, no women had adenocarcinoma according to Bethesda classification. Table 5 showed that 85.3% of the women with age 20 - 30 years had abnormal Pap results and there was significant association between women with age group 20 - 30 years and abnormal Pap results (P = 0.001). Additionally, a statistically significant association was reported between early age at marriage and abnormal Pap results (P = 0.001), and 87% of women with early age at marriage (≤18 years) had abnormal Pap results. Significant association was reported between long duration of marriage duration (>10 years) and abnormal Pap results, where 68.8% of women with long marriage duration had abnormal Pap results. Moreover, Table 5 shows no significant association was observed between residences, occupation and socioeconomic history of women and their Pap results (P > 0.05). The present study shows no significant association between smoking, BMI and mode of delivery of studied women with their Pap results (P > 0.05), and significant association was reported only between irregular menstrual cycle and abnormal Pap results (P = 0.04) (Table 6). Table 7 shows significant association between women used COCP contraceptive method and abnormal Pap results (89.5%; P = 0.001), and women with abnormal medical history were significantly associated with abnormal Pap results (88.6%; P = 0.001). A significant association was also observed between women with no history of surgical operations and abnormal Pap results (P = 0.001); meanwhile, no significant association was observed between each of sexual and gynecological history with Pap results (P > 0.05) (Table 7). Analysis of variables indicates significant association between early age at marriage and abnormal Pap results (P = 0.001), where the mean age of women at marriage with abnormal results was 16.9 ± 4.6 years. Moreover, women with lower incidence of abortions significantly showed abnormal Pap results (P = 0.001), and those with early age at first delivery were also significantly associated with abnormal Pap results (P = 0.001), where the mean age at first delivery was 18.5 ± 5.2 years. Similarly, a significant association was reported between early age at menstruation (menarche) and abnormal Pap results (P = 0.001), while no significant association was observed between gravidity, parity, frequency of coitus and interval between marriage and Pap test with Pap results (Table 8). After controlling all significant variables with abnormal Pap results by partial correlation test, a significant association was observed between early age at marriage and abnormal Pap results (P = 0.004).
4. Discussion
Many reports have revealed that early age marriage of girls who are not mature physically may predispose to physical problems, mood disorders, depression, and anxiety [17] . Moreover, the first year of marriage increases
Sociodemographic characteristics of studied women
Variable
No.
%
Age (39.9 ± 11.4 years)
20 - 30 years
34
17
31 - 40 years
78
39
41 - 50 years
60
30
>50 years
28
14
Total
200
100
Age of marriage (19 ± 5 years)
≤18 years
100
50
>18 years
100
50
Total
200
100
Marriage duration (20 ± 12 years)
≤10 years
59
29.5
>10 years
141
70.5
Total
200
100
Age at first delivery (21 ± 6 years)
≤18 years
78
39.8
>18 years
118
60.2
Total
196
100
Residence
Urban
151
75.5
Rural
49
24.5
Total
200
100
Occupation
Housewife
175
87.5
Employed
25
12.5
Total
200
100
Socioeconomic history
Good
144
72
Bad
56
28
Total
200
100
Lifestyle and health characteristics of studied women
Variable
No.
%
Smoking
Non
165
82.5
Current smoker
35
17.5
Total
200
100
BMI (27.5 ± 3.3 Kg/m2)
Normal
19
9.5
Overweight
105
52.5
Obese
76
38
Total
200
100
Gravidity (6 ± 2)
Parity (5 ± 2)
Abortion (2 ± 1)
Mode of delivery
Normal vaginal
167
85.2
Cesarean section
29
14.8
Total
196
100
Menarche (13 ± 1 years)
Regularity of menstrual cycle
Regular
124
62
Irregular
76
38
Total
200
100
Health and clinical characteristics of studied women
Variable
No.
%
Contraceptive methods
No
104
52
COCP
38
19
IUCD
8
4
Progesterone
13
6.5
Barrier
17
8.5
Coitus interrupts
13
6.5
Tubal ligation
7
3.5
Total
200
100
Sexual history
Active
137
68.5
Inactive
63
31.5
Total
200
100
Medical history
Normal
165
82.5
Abnormal
35
17.5
Total
200
100
Gynecological operations
No
159
79.5
Yes
41
20.5
Total
200
100
Surgical operations
No
133
66.5
Yes
67
33.5
Total
200
100
Interval between marriage and Pap test (17 ± 10 years).
Pap results of studied women according to Bethesda classification (n = 200)
Variable
No.
%
Pap results
Normal
73
36.5
Abnormal
127
63.5
Total
200
100
Cytological classifications of Pap results
Normal
73
36.5
Atypical squamous cells
67
33.5
Low grade squamous intraepithelial lesion
29
14.5
High grade squamous intraepithelial lesion
16
8
Atypical glandular cells
10
5
Adenocarcinoma
0
0
Total
200
100
Distribution of sociodemographic characteristics according to Pap results
Variable
Normal Pap
Abnormal Pap
Total
χ2
P
No.
%
No.
%
No.
%
Age (years)
18.9
0.001
20 - 30
5
14.7
29
85.3
34
100
31 - 40
40
51.3
38
48.7
78
100
41 - 50
15
25
45
75
60
100
>50
13
46.4
15
53.6
28
100
Age at marriage (years)
47.6
0.001
≤18
13
13
87
87
100
100
>18
60
60
40
40
100
100
Marriage duration (years)
5.7
0.01
≤10
29
49.2
30
50.8
59
100
>10
44
31.2
97
68.8
141
100
Residence
0.9
0.7
Urban
56
37.1
95
62.9
151
100
Rural
17
34.7
32
65.3
49
100
Occupation
0.5
0.4
Housewife
64
36
111
64.0
175
100
Employed
11
44
14
56.0
25
100
Socioeconomic history
3.1
0.07
Good
58
40.3
86
59.7
144
100
Bad
15
26.8
41
73.2
56
100
Distribution of lifestyle and health characteristics of the women according to Pap results
Variable
Normal Pap
Abnormal Pap
Total
χ2
P
No.
%
No.
%
No.
%
Smoking
0.7
0.3
Non
58
35.2
107
64.8
165
100
Current
15
42.9
20
57.1
35
100
BMI
1.6
0.4
Normal
6
31.6
13
68.4
19
100
Overweight
35
33.3
70
66.7
105
100
Obese
32
42.1
44
57.9
76
100
Mode of delivery
2.5
0.1
Normal
55
32.9
112
67.1
167
100
Cesarean
14
48.3
15
51.7
29
100
Regularity of menstrual cycle
4.1
0.04
Regular
52
41.9
72
58.1
124
100
Irregular
21
27.6
55
72.4
76
100
Distribution of clinical characteristics of the women according to Pap results
Variable
Normal Pap
Abnormal Pap
Total
χ2
P
No.
%
No.
%
No.
%
Contraceptive methods
29.2
0.001
No
46
44.2
58
55.8
104
100
COCP
4
10.5
34
89.5
38
100
IUCD
2
25.0
6
75.0
8
100
Progesterone
10
76.9
3
23.1
13
100
Barrier
8
47.1
9
52.9
17
100
Coitus interrupts
3
23.1
10
76.9
13
100
Tubal ligation
0
0
7
100
7
100
Sexual history
0.4
0.5
Active
48
35.0
89
65.0
137
100
Inactive
25
39.7
38
60.3
63
100
Medical history
11.5
0.001
Normal
69
41.8
96
58.2
165
100
Abnormal
4
11.4
31
88.6
35
100
Gynecological operations
1.1
0.2
No
61
38.4
98
61.6
159
100
Yes
12
29.3
29
70.7
41
100
Surgical operations
23.4
0.001
No
33
24.8
100
75.2
133
100
Yes
40
59.7
27
40.3
67
100
Distribution of women characteristics according to Pap results
Variable
Normal Pap
Abnormal Pap
F
P
Age at marriage (years)
23.1 ± 4.3
16.9 ± 4.6
9.1
0.001
Gravidity
5.8 ± 2.2
5.5 ± 2.4
0.9
0.3
Parity
4.5 ± 1.8
4.7 ± 2.3
0.6
0.5
Abortion
1.9 ± 0.8
1.2 ± 0.7
4.1
0.001
Age at first delivery (years)
24.3 ± 4.4
18.5 ± 5.2
7.7
0.001
Menarche (years)
13.3 ± 0.8
12.5 ± 1.6
3.5
0.001
Frequency of coitus/week
3.2 ± 1.6
2.8 ± 1.4
1.4
0.1
Interval between marriage and Pap test (years)
17.3 ± 9.6
17.5 ± 10.7
0.1
0.8
Values are presented as mean ± SD; n = 200 women.
the risk of Cervical Cancer in those girls [18] . The present study indicates that 63.5% of Pap results were abnormal, which is higher than that reported in Iraq by Barzanji, et al. (2013) that recorded only 12.2% of abnormal Pap results [19] . In the present study, abnormal Pap test results were significantly associated with age group 41 - 50 years, which was consistent with that reported by Kritpetcharat, et al. in Thailand (2012)and approximately similar to the UK records, where 60% of women with abnormal Pap results occurred in women with age less than 50 years [20] . Utilization of Pap test with associated diagnostic measures and treatment decreases the incidence of all histologic types and stages of invasive cervical cancer, and the benefit increases with age [21] .The present study revealed that abnormal Pap test results were significantly associated with women married with age ≤ 18 years. This finding is consistent with that reported by Uribe-Perez et al. study in Colombia (2006) [22] ,which indicates that women with pre-malignant or malignant cervical lesions were younger, and start their sexual intercourse earlier with more sexual partners than healthy women. Moreover, Baram et al. (2007)reported increased abnormal Pap test results with early sexual activities in USA [23] , and the association between cervical cancer and early marriage was clearly defined in many developing countries [24] . In 2013, Barazanji et al. reported significant association between duration of marriage and the incidence of cervical cancer in Iraqi women [19] , and the similar was reported in the present study. Additionally, the current study revealed no significant association between Pap test results with residence, occupation and socioeconomic history, which was inconsistent with that reported in India [25] ; this inconsistency might be attributed to difference of in sample size and the difference in socioeconomic status between countries. In this study smoking was not associated significantly with abnormal Pap results because of low prevalence of smoking habit among Iraqi women, while this factor seems highly correlated with abnormal Pap results in other communities where women smock heavily [26] . In addition to the importance of many other factors that determine the Pap results, including menstrual cycle irregularity, method of contraception and the surgical history [25] [27] [28] , early marriage represents the most powerful variable that determine the incidence of abnormal Pap results according to the outcome of the present study. This finding was consistent with the reports of UNICEF on the effect of early marriage, as it may be translated into repeated pregnancies at a tender age when the body is not fully prepared for child bearing [29] . The lack of enforcement renders legislations against child marriage ineffective, and many efforts are highly recommended through media campaigns and educational outreach programs to achieve the target. Meanwhile the governments need to take responsibility for stopping this practice. Local, regional and national governments can also implement health outreach programs, preventive and treatment services for girls and boys regarding all issues of reproductive and sexual health [30] . Similar to other cross sectional studies, difficult assessment temporal relationship, inappropriate laboratory techniques, and non-homogenous sampling are the major limitations of the present study.
5. Conclusion
Among many associated variables, binary logistic regression analyses revealed that early marriage was the mostly effective determinant of abnormal Pap results in Iraqi women.
Acknowledgements
The authors thank the Arab Board of Gynecology and Obstetrics for supporting the project and the medical staff of Elweyia Maternity Teaching Hospital for technical assistance.
Competing Interests
The authors declared that they have no competing interests.
Cite this paper
May KasimKhalaf,Faris AnwerRasheed,Saad AbdulrahmanHussain, (2015) Association between Early Marriage and Other Sociomedical Characteristics with the Cervical Pap Smear Results in Iraqi Women. Advances in Sexual Medicine,05,73-82. doi: 10.4236/asm.2015.54009
NOTESReferencesFerlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelom, M., et al. (2015) Cancer Incidence and Mortality Worldwide: Sources, Methods and Major Patterns in GLOBOCAN 2012. International Journal of Cancer, 136, E359-E386. http://dx.doi.org/10.1002/ijc.29210Nawal M.N. ,et al. (2009)Child Marriage: A Silent Health and Human Rights Issue Reviews in Obstetrics and Gynecology 2, 51-56.ICO Information Centre on HPV and Cancer (2014) Iraq Human Papilloma Virus and Related Cancers, Fact Sheet 2013. www.hpvcentre.netAl-Alwan N.A. ,et al. (2001)Colposcopy, Cervical Cytology and Human Papilloma Virus Detection as Screening Tools for Cervical Cancer East Mediterranean Health 7, 100-105.Sreedevi, A., Javed, R. and Dinesh, A. (2015) Epidemiology of Cervical Cancer with Special Focus on India. International Journal of Women’s Health, 7, 405-414.Thakur, A., Gupta, B., Gupta, A. and Chauhan, R. (2015) Risk Factors for Cancer Cervix among Rural Women of a Hilly State: A Case-Control Study. Indian Journal of Public Health, 59, 45-48.
http://dx.doi.org/10.4103/0019-557X.152862UNICEF Innocenti Research Centre. Early Marriage: Child Spouses, 2001. www.Unicef-icdc.orgGoodman, A. (2015) HPV Testing as a Screen for Cervical Cancer. British Medical Journal, 350, h2372.
http://dx.doi.org/10.1136/bmj.h2372Rodriguez, A.C., Schiffman, M., Herrero, R., Hildesheim, A., Bratti, C., Sherman, M.E., et al. (2010) Longitudinal Study of Human Papilloma Virus Persistence and Cervical Intraepithelial Neoplasia Grade 2/3: Critical Role of Duration of Infection. Journal of National Cancer Institute, 102, 315-324. http://dx.doi.org/10.1093/jnci/djq001Edelstein, Z.R., Madeleine, M.M., Hughes, J.P., Johnson, L.G., Schwartz, S.M., Galloway, D.A., et al. (2009) Age of Diagnosis of Squamous Cell Cervical Carcinoma and Early Sexual Experience. Cancer Epidemiology Biomarkers and Prevention, 18, 1070-1076. http://dx.doi.org/10.1158/1055-9965.EPI-08-0707Getahun, F., Mazengia, F., Abuhay, M. and Birhanu, Z. (2013) Comprehensive Knowledge about Cervical Cancer Is Low among Women in Northwest Ethiopia. BMC Cancer, 13, 2. http://dx.doi.org/10.1186/1471-2407-13-2Chumnan-Kietpeerakool, Y.P., Kriangsak, J., Usanee, S. and Jatupol, S. (2009) Knowledge, Awareness, and Attitudes of Female Sex Workers toward HPV Infection, Cervical Cancer, and Cervical Smears in Thailand. International Journal of Gynecology and Obstetrics, 107, 216-219. http://dx.doi.org/10.1016/j.ijgo.2009.07.023Sriplung, H., Singkham, P., Iamsirithaworn, S., Jiraphongsa, C. and Bilheem, S. (2014) Success of a Cervical Cancer Screening Program: Trends in Incidence in Songkhla, Southern Thailand, 1989-2010, and Prediction of Future Incidences to 2030. Asian Pacific Journal of Cancer Prevention, 15, 10003-10008.
http://dx.doi.org/10.7314/APJCP.2014.15.22.10003Kjaer, S.K., van den Brule, A.J.C., Svare, E.I., Engholm, G., Sherman, M.E., Poll, P.A., et al. (1998) Different Risk Factor Patterns for High-Grade and Low-Grade Intraepithelial Lesions on the Cervix among HPV-Positive and HPV-Negative Young Women. International Journal of Cancer, 76, 613-619.
http://dx.doi.org/10.1002/(SICI)1097-0215(19980529)76:5<613::AID-IJC1>3.0.CO;2-TIARC (2007) IARC Monograph for Evaluation of Carcinogen Risks in Human. International Agency for Research on Cancer, Lyon.Solomon, D., Davey, D., Kurman, R., Moriarty, A., O’Connor, D., Prey, M., et al. (2002) The 2001 Bethesda System: Terminology for Reporting Results of Cervical Cytology. Journal of American Medical Association, 287, 2114-2119.
http://dx.doi.org/10.1001/jama.287.16.2114Nour, N.M. (2006) Health Consequences of Child Marriage in Africa. Emergency Infectious Diseases, 12, 1644-1649.
http://dx.doi.org/10.3201/eid1211.060510Kuhn, L., Denny, L., Pollack, A., Lorincz, A., Richart, R. and Wright, T. (2000) Human Papillomavirus DNA Testing for Cervical Cancer Screening in Low Resource Settings. Journal of National Cancer Institute, 92, 818-825.
http://dx.doi.org/10.1093/jnci/92.10.818Barzanjy, B.K., Talat, L.M. and Ismail, S.A. (2013) Cervical Dysplasia: Assessment and Risk Factors among Women Attending the Maternity Teaching Hospital in Erbil, Kurdistan-Iraq. Zanco Journal of Medical Sciences, 17, 286-293.
http://dx.doi.org/10.15218/zjms.2013.0004Kritpetcharat, O., Wutichouy, W., Sirijaichingkul, S. and Kritpetcharat, P. (2012) Comparison of Pap Smear Screening Results between Akha Hill Tribe and Urban Women in Chiang Rai Province, Thailand. Asian Pacific Journal of Cancer Prevention, 13, 5501-5504. http://dx.doi.org/10.7314/APJCP.2012.13.11.5501Sasieni, P., Castanon, A. and Cuzick, J. (2009) Effectiveness of Cervical Screening with Age: Population Based Case-Control Study of Prospectively Recorded Data. British Medical Journal, 339, b2968.
http://dx.doi.org/10.1136/bmj.b2968Uribe-Perez, C.J., Diaz-Martinez, L.A., Ortiz-Serrano, R. and Meza-Duran, E.E. (2006) Pap Smear Prevalence and That of Pre-Malignant and Malignant Cervical Lesions amongst Women Living in the Carmen Initiative Demonstration Area, Bucarmanga, Colombia. Revista Colombiana de Obstetricia y Ginecologia, 57, 10-18.Baram, D.A. and Basson, R. (2007) Sexuality, Sexual Dysfunction, and Sexual Assault. In: Berek, J.S., Ed., Berek & Novak’s Gynecology, 14th Edition, Lippincott Williams & Wilkins, Philadelphia, 313-349.Sultana, R. and Sultana, N. (2012) Clinical Profile and Treatment Protocol of Invasive Carcinoma of Cervix. Bangladesh Medical Journal (Khulna), 45, 11-14.Singh, S. and Badaya, S. (2012) Factors Influencing Uptake of Cervical Cancer Screening among Women in India: A Hospital Based Pilot Study. Journal of Community Medicine and Health Education, 2, 1-6.
http://dx.doi.org/10.4172/2161-0711.1000157Tay, S.K. and Tay, K.J. (2004) Passive Cigarette Smoking Is a Risk Factor in Cervical Neoplasia. Gynecology Oncology, 93, 116-120. http://dx.doi.org/10.1016/j.ygyno.2003.12.032Cleland, J., Conde-Agudelo, A., Peterson, H., Ross, J. and Tsui, A. (2012) Contraception and Health. The Lancet, 380, 149-156. http://dx.doi.org/10.1016/S0140-6736(12)60609-6Fouda, L.M. and Elkazeh, E.A. (2014) The Impact of an Educational Intervention on Women’s Knowledge and Perception Regarding Cervical Cancer and Human Papilloma Virus Vaccines in Tanta City: Applying Health Belief Model. Life Science Journal, 11, 289-297.Raj, A., Saggurti, N., Winter, M., Labonte, A., Decker, M.R., Balaiah, D. and Silverman, J.G. (2010) The Effect of Maternal Child Marriage on Morbidity and Mortality of Children under 5 in India: Cross Sectional Study of a National Representative Sample. British Medical Journal, 340, b4258. http://dx.doi.org/10.1136/bmj.b4258Osakinle, E.O., Babatunde, J.O. and Alade, F.A. (2013) Youths and Their Choice of Contraceptives towards an Effective Reproductive Health: The Case of Ekiti State, Nigeria. European Scientific Journal, 9, 193-202.