Human Papillomavirus (HPV) is the most common sexually transmitted infection globally. It spreads primarily through skin-to-skin contact during vaginal, anal, or oral sex. There are over 100 strains of HPV, but they are broadly divided into low-risk and high-risk types. Low-risk types, such as HPV 6 and 11, do not cause cancer but lead to genital warts. High-risk types, particularly HPV 16 and 18, are responsible for the vast majority of cervical cancer cases.
Most people who contract HPV will clear the virus naturally within one to two years thanks to their immune system. However, when a high-risk infection persists for many years, it can cause persistent cellular changes in the cervix. Over time, these untreated changes progress from mild dysplasia to severe precancerous lesions, and eventually to invasive cervical cancer. In Nigeria, cervical cancer remains a leading cause of cancer death among women, making early understanding and detection critical for public health midwives.
Primary prevention stops a disease before it ever starts, and for cervical cancer, this is achieved primarily through HPV vaccination. These vaccines protect against the high-risk viral strains responsible for cellular mutations in the cervix.
Midwives play a vital role in community mobilization, debunking myths that the vaccine promotes promiscuity, and educating parents that early vaccination is safe, highly effective, and life-saving.
Because primary prevention via vaccination has only recently been scaled up in Nigeria, millions of adult women remain unprotected and vulnerable to cervical cancer. Secondary prevention through screening is therefore essential to detect precancerous changes before they become malignant.
Nigeria's national guidelines recommend specific strategies tailored to our resource-limited health system. Unlike high-income countries that rely heavily on liquid-based cytology and HPV DNA testing, Nigerian primary health centers primarily utilize VIA (Visual Inspection with Acetic Acid) due to its low cost and immediate results. Cytology-based screening like the traditional Pap smear is largely available in tertiary and secondary health facilities. A 'screen-and-treat' approach is often adopted, allowing providers to offer immediate treatment such as cryotherapy if a VIA test is positive, minimizing loss to follow-up.
The Pap smear (Papanicolaou test) is a cytological screening method designed to detect abnormal cellular changes in the transformation zone of the cervix.
During the procedure, the midwife or doctor inserts a speculum to visualize the cervix and uses a spatula or cytobrush to collect cellular samples from both the ectocervix and endocervix. The sample is transferred to a glass slide, fixed immediately, and sent to a laboratory for cytopathological analysis.
| Cytology Result Category | Clinical Meaning |
|---|---|
| NILM | Negative for Intraepithelial Lesion or Malignancy (Normal) |
| ASC-US | Atypical Squamous Cells of Undetermined Significance |
| LSIL | Low-grade Squamous Intraepithelial Lesion (Mild dysplasia) |
| HSIL | High-grade Squamous Intraepithelial Lesion (Severe dysplasia) |
Laboratory reports guide further management. While NILM means routine screening interval, HSIL requires immediate colposcopy and biopsy referral.
Visual Inspection with Acetic Acid (VIA) is a practical, low-cost screening tool suited for busy clinics across Nigeria. The procedure involves applying a 3% to 5% solution of acetic acid (common vinegar) directly onto the cervix using a cotton swab.
Within one minute, the acetic acid causes abnormal, protein-dense precancerous cells to temporarily turn a distinct acetowhite color. Healthy mature squamous epithelium does not change color significantly.
Midwives performing VIA must undergo proper competency-based training to correctly differentiate true acetowhite lesions from normal physiological variations like nabothian cysts or immature metaplasia.
Midwives are often the first point of contact for women seeking reproductive health services in Nigeria. Comprehensive care requires sensitive communication, clinical skill, and organized referral pathways.
Before any screening procedure, the midwife must provide thorough pre-test counseling, explaining what the exam entails, reassuring the client about discomfort, and addressing anxiety or cultural misconceptions. During the speculum examination, maintaining privacy and a gentle touch builds trust and encourages compliance.
If screening results are abnormal, the midwife's role shifts to supportive post-test counseling. For minor lesions, explanation prevents panic since many clear on their own or are easily treated. For suspicious or advanced lesions, the midwife coordinates rapid triage and referral to a gynecologist for colposcopy, biopsy, or staging. Midwives also document findings accurately and promote community education regarding HPV prevention.