The Test That Women Does Do

Symbolic of the poor state of cervical cancer, this ribbon is made of a burst rubber band on a backdrop of a cheap paper towel!

Symbolic of the poor state of cervical cancer, this ribbon is made of a burst rubber band on a backdrop of a cheap paper towel!

Cancer of the cervix begins with great benevolence.

It gives us a chance to spot it long before it becomes a fully-fledged cancer.

Yet until the Pap smear becomes a routine part of our lives we are giving our chance at derailing cervical cancer early a slap in the face.

Too many of us just aren’t sure what a Pap smear is.

One perky, young UWI graduate, teaching at an all girls secondary school asked me if the Pap smear had something to do with her ovaries!

Another well-spoken woman, already at least 40, couldn’t remember the words ‘Pap smear.’ She referred to “The Test That Women Does Do,” specifically “the one” that Family Planning people do at health events.

Very simply, the Pap smear simply scrapes some cells off the cervix surface. (alliteration not intended!) In layman’s terms the cervix is known as ‘the neck of the womb’. This part of the womb is easily accessed as it hangs into the vagina – so the nurse or doctor can both reach and see it once the vaginal passage is held open with a speculum under good lighting.

(A speculum is a simple flattish but rounded instrument smaller in diameter than an erect penis. For the Pap smear it’s lubricated with gel and at this point I emphasize that the speculum’s only crime is that it is often a bit cold! The dread it conjures in ladies’ minds is most unjustified!)

The cells scraped off for testing are then fixed on a slide and sent for microscopic evaluation by a cytologist or pathologist.

Though cancer cells, infections and even the presence of the human papilloma virus may be indicated when the test report is prepared, these are not the reasons you go for a Pap smear.

You go because cervical cancer develops slowly enough to be caught and arrested while the cells are still transitioning through varying degrees of dysplasia. Dysplastic cells are abnormal cells which don’t yet have the full characteristics or behavior of cancer cells.

Women who postpone their Pap smears indefinitely or who choose to believe that going every five years is okay, run the risk of missing the window of opportunity to arrest transitioning cells, long before they become frankly cancerous.

The nurse or GP will typically refer abnormal Pap smear results to a gynaecologist.

In these earlier stages, the gynaecologist advises on the right protocol for your case often based on a further more sensitive test: colposcopy.

Some mild changes that a Pap smear might reveal, especially with younger women and teenagers, are often self-reversing and need only be monitored, but always ensure that your gynaecologist gives you clear follow up advice and answers all your questions.

So now you’re saying, “Oh thank God! If I go for regular Pap smears the chance of treating and removing any unwelcome changes very early is much higher!”

So how regularly should you go? Recent US guidelines suggest that all sexually active women over 21 should have Pap smears. How often? Some practitioners will say for women under 30 every two years is enough. Others prefer that you get tested every year till you have a record of three normal consecutive smears, after which testing frequency will depend on your individualized risk.

The professional advice given considers risk factors such as chlamydia infection, the presence of HPV virus, cigarette smoking and having several partners.

Especially if you are under 30 though, the possibility of cancer seems so remote and distant that it’s easy to procrastinate and make excuses.

Remember, cancer does not happen overnight. While most women with cervical cancer are not under 30, the early changes that lead to closer evaluation and life saving removal of dyspastic tissue can be found in women still in their 20’s and early 30’s.

The risk of cancerous changes in the cervix are higher for women who smoke cigarettes, started sexual activity very young or had many partners.

But all women who are sexually active (or used to be) should reduce their risk by having routine Pap smears.

So no matter how monogamous or inexperienced you’ve been, take the precautions. Don’t equate lower risk with zero risk!

One way to overcome any fear and awkwardness is to go with a girlfriend or relative who had a positive Pap smear experience.

Once you’re relaxed and your practitioner has the basic skill required, a Pap smear is at worst, mildly uncomfortable.

On the other hand, if your practitioner is rough, rude or just makes you uncomfortable then you need to get some advice from your girlfriends about who else you can go to.

You have the right to keep a trusted friend, relative or female nurse present for your Pap smear.

If your local health centre does not offer the service every week to large numbers of clients your Member of Parliament needs to know that the government service is inadequate and putting lives at risk.

Costs of private care can be prohibitive. A visit and Pap smear can easily cost $450.00 at the gynaecologist. You may need to budget and plan for it just as you might do for school fees, a vacation or a new car.

For those on the UWI campus though, the service may be available at UWI’s Health Service Unit.

And if not, is there a good reason? Is it that campus girls are known to prefer having their pap smears done off-campus? And for the young researchers among you as well as the campus activists, has this question ever been studied?

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This article was first published in The Campus Chronicle’s last edition. It has been edited slightly before re-publication on this blog. The Campus Chronicle was a short lived newspaper and this article was published in its last edition in November 2011.

The Campus Chronicle was published with the readership of Trinidad and Tobago’s tertiary education students in mind.

The Poor Sister of Breast Cancer

This article was written in 2011 but has never been published in full before. Nearly four years later, the general message, that there’s a lot of work to be done to reduce the incidence of cervical cancer, particularly in the so-called developing countries, remains relevant.

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Dr. Gordon Narayansingh used his characteristic dry humour to illustrate why cervical cancer should rightly be described as the “Poor Sister of Breast Cancer.”

Dr. Narayansingh was speaking at the first Oncology Update Conference at the Hyatt last Sunday when he pointed out that this year breast cancer had a Breast Cancer Month. In previous years they had Breast Cancer Week and Breast Cancer Day. Next year, he added, might be Breast Cancer Year.

But who is running for Cervical Cancer?

The doctor, Trinidad’s only gynae-oncologist at present, made his point with statistics collected from our Cancer Registry over 1997-2006. During this time breast cancer accounted for 2960 cases of which 44 women died but cervical cancer claimed 55 lives despite only 1226 cases.

With a higher number of deaths from fewer cases, clearly cervical cancer is the more deadly of the two for us here in Trinidad and Tobago.

He supported this observation with more extensive data from Central and South America where cervical cancer accounts for vastly fewer cases but similar numbers of deaths compared to breast cancer.

While we panic about young women getting breast cancer, 15% of breast cancer cases are under 50 whereas 50% of cervical cancer cases are under age 50.

The tragedy of this is that it can be prevented. In the United States cervical cancer is the thirteenth most frequent cancer among women whereas it ranks as the No.2 most frequent in Trinidad and other less developed nations.

Why? Dr. Narayansingh explains that two-thirds of all local cases are diagnosed in an advanced stage so complete cure is less likely. This is so because only 25% of our women go for regular Pap smears.

He told a heart breaking true story of a 40 year old mother of two who went for her Pap smear only to be turned away repeatedly from the health centre because she was having “vaginal bleeding”.

The take home lesson for all of us is that all abnormal bleeding must be assessed by a doctor. This story reflects a clear deficiency in the knowledge and understanding of the workers who turned the client away. They may not have been able to do the Pap smear but she should have been assessed and treated.

Even when clients are properly channeled, due to lack of technical skills, Pap smear reports are delayed and so are follow-up investigations. We have a need for more skilled cytotechnicians to read Pap smears and gynaecologists who can perform colposcopy, an investigative procedure that may be needed after an abnormal Pap smear.

So laboratory and medical students, and those in planning and management pay attention!

Dr. Naraynsingh lamented that in the public sector, Pap smear reports can take up to three months with existing ineffeciencies. He emphasized that he was not to be accused of running a smear campaign against the system though! By stating the facts he hoped to stimulate a “Pap Smear campaign,” instead.

He estimated that in addition to regular Pap smears, we could follow the example of the developed countries and include routine vaccinations against HPV (the human papilloma virus) believed to be the underlying cause of cervical cancer.

Since most people who are sexually active will contract strains of the HPV virus during their lifetime, some of which are cancer promoting , he advocated vaccinating young girls in the 9-15 category to stimulate immunity against HPV before they become sexually active.

He said bluntly that we are a society of “hypocrites”. We say “my daughter is not going to have sex” yet our culture is one of “wining and prancing” on Carnival day.

Introducing the HPV vaccine should not be about sex but about saving lives. He felt that with bulk purchases, a rough estimate of the cost of annually vaccinating our Form One school girls would be just TT$9.6 Million, significantly lower than the cost of providing laptops at TT$35 Million.

He estimated we could save three lives per year that way.

Not one for mincing words or keeping his opinions to himself, Dr. Narayansingh couldn’t help but add that of the eight graduates of the University of the West-Indies Medical Faculty who went on to become gynae-oncologists, he was the only one serving in Trinidad.

He described the “pain” of the situation and called for a programme to encourage locals to come back to Trinidad and Tobago to serve their country, not merely in sub-specialties like gynae-oncology but across the board.

Notwithstanding word from the “developed world” that T&T can now boast of being a developed country, Dr. Naraynsingh suggested that our progress in defeating cervical cancer should be a marker for true development.

Dr Gordon Narayansingh

Dr. Gordon Narayansingh

I agree with him and by that measure, we are not there yet.

Since the emerging youth are going to be the ones with a key role in changing this I hoped there were lots of student doctors, nurses and pharmacists in training present and internalizing the message.

The 1st Oncology Update Conference was facilitated by the Trinidad and Tobago Medical Association under the auspices of the University of the West-Indies.

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The HPV vaccine was made available in the public health sector of Trinidad and Tobago the following year (2012), though its introduction was not without controversy and there remains such opposition to it. The HPV vaccine had been available to private clients who were able and willing to pay for it prior to 2012.

The Pap smear, which is an established tool in reducing the incidence of cervical cancer when used effectively in screening programmes worldwide, remains underutilised in Trinidad and Tobago. For many women, the steep cost of having the test done privately is prohibitive and the local health centres are yet to make the service widely available via a dedicated service.

Pregnancy and Birth Across The Pond: From Trinidad to London

The long walk to the Women’s Health Department in the Sutton hospital was almost déjà vu. The physical building resembled that of Port-of-Spain’s General Hospital. I suspected both institutions had been designed in the same era.

In many ways, public health care in Trinidad and Tobago resembles the UK’s National Health Service (NHS). Both systems are state funded, claim to be under financial pressure and are heavily criticized by the public they serve. The NHS today is frequently in the spotlight with problems that are old thorns for Trinidad’s General Hospitals: unacceptably long waiting times at the Accident and Emergency; overcrowded wards; patients unable to access non-emergency care at their local centres; shortages of doctors; questions over expenditure by administration; client deaths linked to inadequate care.

It’s well known that the human resource element in Trinidad and Tobago’s public health system has not in recent decades been able to support its clients by spoiling them for choice.

I chose private care for my first and second pregnancies in Trinidad because this allowed me the luxury of choice; which doctor or midwife to see; when to schedule appointments; which hospital to choose; what to include in my birth plan; if to have a doula; even some choice over my post-birth breakfast menu!

I wanted to avoid the unpredictability of being attended to by various strangers. Relationship building takes time but builds trust. Trust facilitates confidence and confidence makes birthing easier, on the mind, if not on the body.

For my third pregnancy I found myself living in the UK. I chose to be a client of the overburdened NHS for my third pregnancy, would I be satisfied with my options?

Well, the policy of the NHS is to encourage home births where possible since studies of UK and similar populations show that home births cost less but add no significant increased risk for “low risk pregnancies.”

Waiting to see the midwife for the first visit 12 weeks into my pregnancy, I found myself in torrents of tears after looking at the cards and photographs posted on the walls from families that had chosen home births. An emotional bomb had hit me unexpectedly. Underneath the nausea and fatigue there was a little human being under development who would, by God’s Grace, be joining us just six months into the future. Reality hit home.

The midwife loaded my answers to her numerous questions into her computer programme. The programme did its analyses, reducing the error of human misjudgements. I was deemed “low risk” and a candidate for home birthing. This, despite me being almost two years short of the big Four Zero!

I was thrilled.

The midwife who was responsible for managing home births in the area was an amazing woman. Like my obstetrician in Trinidad, she gave me all the time in the world when my questions needed to be asked and my anxieties needed to be addressed.

She emphasized my right to choose a home birth. She showed me the assessment criteria for home birth to be met towards the end of the pregnancy but expressed her conviction that the client’s right to choose should prevail. She referred to women who did not meet the criteria but whose preference for home births was respected despite contradicting medical advice; one woman was diabetic; another was giving birth for the seventh time. “We cannot refuse to come, once we have the staff,” she insisted.

Pregnancy care under the NHS offers more routine screening blood tests (including assessment of body iron stores and degree of Down Syndrome risk) and shorter waiting times than typical community health centres in Trinidad and Tobago. On the other hand, under the NHS low risk women have half the number of routine clinic visits on their schedule and perhaps because I never appeared over or under weight I was only ever weighed once.

To my surprise and horror I was expected to bring urine in a narrow glass tube supplied by the clinic, wash the tube and use it again for the duration of the pregnancy! Yes, the NHS has been under great pressure to manage its expenditure but I have to admit their system is more environmentally friendly than the use of styrotex cups!

Midway through my nine months I learned of a card for pregnant women which entitled me to free medicine and dental care for the pregnancy and first year after baby’s birth. Well off I went to the dentist, grateful for my savings of a few hundred pounds and mindful of the money previously spent because I did not know about this ‘pregnancy privilege!’  There were no doctors at the community clinics I attended so though the midwife could recommend iron, she couldn’t write a prescription and I had to wait my turn at the GP’s office again – or pay at the pharmacy.

I took the tour of the hospital’s labour ward and birthing centre. It was delightful to have the option of a water birth in a private room at a birthing centre but in the end the attractions of a homebirth won me over. In theory I could have rented my own birthing pool and had a water birth at home but the labour proceeded so efficiently when it did get going that I doubt I would have even made it into any pool.

A must read if you are interested in birthing naturally and in understanding waterbirth!

Gentle Birth Choices by Barbara Harper, a must read if you are interested in birthing naturally and in understanding waterbirth! I really wanted a waterbirth after reading this and after being introduced to the subject at the Mamatoto birthing centre in Belmont, Trinidad. But in the toss up between the inconvenience of renting or buying – and filling (then emptying and maybe selling) a pool at home, versus using the waterbirthing facilities at the hospital’s birthing centre in Sutton, home birth pool free actually won! Any my early labour was so long while my active labour was so short, there would have been no time to get in and out of the pool anyway!

After the birth, our doula (labour support person), made the midwives tea and brought them fruit and chocolate we’d set aside for them as refreshments. We took photos together. NHS policy emphasises the role of the midwife in helping mother and baby to get started with breastfeeding and the midwives were happy to wait for baby to have her first feed before weighing her.

She was remarkably calm. She nursed and slept and was unperturbed by the activity and conversation around her. And if it  wasn't for our doula we would have had no photos of her first hour as her grandma and dad are not camera enthusiasts!

She was remarkably calm. She nursed and slept and was unperturbed by the activity and conversation around her. And if it wasn’t for our doula we would have had no photos of her first hour as her grandma and dad are not camera enthusiasts!

Midwives and the district health visitor made at least four visits to our home in the two weeks that followed. It was wonderful not to be roasting our newborn at the bus stop in what was a sweltering hot summer. It was comforting to know that the system actively searches out mothers at risk of postnatal depression. The home visits also seek to help and support breastfeeding and even though this was my third time with a nursling, they had some useful reminders and assurances for experienced mums too.

Despite the conscious efforts by midwives both in the UK and T&T to encourage, inspire and support breastfeeding, not many women breastfeed exclusively for the first six months. In the UK new mothers are less likely to have the family support needed to facilitate sustaining breastfeeding and despite knowing that best is breast, despite baby latching on and breasts full of milk,  the sheer quanta of time required to breastfeed means that many busy mums – even stay-at-home mums – are defeated before they begin.

Reading about breastfeeding is a useful part of preparing for your new baby. You won't have time to do much of it once the little one arrives.

Reading about breastfeeding is a useful part of preparing for your new baby. You won’t have time to do much of it once the little one arrives.

The Birth Book by Sears and Sears

Read as much as you like but be sure to attend birth preparation classes too! Nothing replaces the insights of experienced women. Nothing replaces the sharing and caring, the camaraderie amongst pregnant women. The Birth Book by US paediatrician Dr. William Sears and his wife, registered nurse and midwife, Martha Sears.

Nursing Mother, Working Mother by Gale Pryor

You may have thoughts of pumping and working but don’t rely on optimism or even on Gale Pryor’s brilliant book, Nursing Mother, Working Mother. By all means, learn what you can from books such as this one but your strategy and how best to execute it must come from women who’ve done it successfully, from understanding the obstacles you might face and maybe even from working with the breastfeeding counsellors and consultants whose experience and guidance can sometimes be a make or break factor.

While breastfeeding and ‘low tech birthing’ for low risk mothers with adequate antenatal care are cost effective for the national purse, in Western society freedom of choice is upheld as a sacred principle. Yet with dire predictions that nations’ health bills will be strained by ageing populations heavy laden with Alzheimers’, cancers and other chronic diseases, will a push towards natural birthing and breastfeeding be forced into policy? And isn’t policy impotent all by itself? In the UK, home births and exclusive breastfeeding remain the exception and not the norm, despite the policy support they enjoy.

For women to embrace breastfeeding and low tech birthing as gold standards to be aspired to where possible, the following would be imperative:-

  1. Conveying the information and reassurance needed for women to embrace such options with conviction.
  2. Providing adequate and flexible maternity and paternity leave
  3. Providing easily accessible and relevant antenatal classes for all
  4. Providing workplace support for mothers who wish to pump milk at work
  5. Providing competent and widely accessible breastfeeding support for mothers after birth.
  6. New training and retraining for a wider cadre of supporting health care workers.

This article was first published by Fresh Start, the on-line magazine of Best Start, the breastfeeding and advocacy organisation run by the very dedicated and amazing Adepeju Oyesanya. Thankyou for the privilege of publishing with Fresh Start, Adepeju.

The article was first published on page 20 of Fresh Start’s May 2014 edition, link below: 

http://issuu.com/freshstartbybeststart/docs/fresh_startbybeststart_may_2014__4

The original publication did not include the photographs that are part of this post.