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Indian Journal of Community Medicine

Self-Reported Gynecological Problems from Twenty-Three Districts in India (An ICMR Task Force Study)

Author(s): Indra P. Kambo, B.S. Dhillon, Padam Singh, B.N. Saxena, N.C. Saxena

Vol. 28, No. 2 (2003-04 - 2003-06)

Division of Reproductive Health & Nutrition, Indian Council of Medical Research, New Delhi - 110 029

Abstract:

Research question: What are the self-perceived gynecological problems in married women of reproductive age (15-45 years) group in the rural areas?

Objective: To assess womens' perceptions, knowledge and practices regarding reproductive health.

Study design: Cross-sectional survey.

Setting: Rural areas of 23 Districts in 14 States.

Participants: Married women of reproductive age (15-45 years) from the rural areas.

Statistical analysis: Simple proportions and rates.

Results: On the whole 24.4% women mentioned having one or more gynaecological problems. The commonest problem was backache (10.4%) followed by low abdominal pain (8.3%). Majority (20.6%) of the women knew, from where to seek services but only 14.2% went to any health facility. Of these only 9.8% were satisfied with the services. Majority of women had gone to practitioners of modern system of medicine with similar number of women going to the Medical Officer of the primary health centre or the local medical practitioner (3.7 & 3.9%). The reasons for not seeking care were mostly personal including, lack of time, inability to go alone etc. as mentioned by 68% of women with problems. Reasons indicating inadequate facilities and indifferent attitude of health care providers were mentioned by 13.4and 6.4%of women respectively.

Conclusion: The study indicates need for creating community awareness about health care facilities and instil self concern in women for their own health needs.

Key Words: Gynaecological problems, Rural, India

Introduction:

Addressing reproductive health issues of women is now on the global social agenda for the forthcoming century. Primary health care for women had been limited to family planning and to some antenatal care. Maternal mortality has long been the only indicator of womens' health even though reproductive morbidity occurs far more frequently and seriously affects womens' lives1,2. There is very little information on prevalence of reproductive health problems in the community and their perceived needs, knowledge and attitudes. Assessing morbidity is a complex process. This is more so for gender related sensitive health problems of women where the attitudes of the interviewers as well as the respondents contribute considerably to the problem of estimating morbidity. In India and the sub-continent, varying prevalence of reproductive morbidity has been reported from different studies3-6. There are two major sources for information on any type of morbidity 1) the service providers 2) and those who require service. The data from health providers based on examinations and investigations has higher accuracy of diagnosis but does not provide burden of the problem in the community. The data from such sources is more useful to hospital administrators for specialized tertiary care, whereas, community based estimates are less accurate but have more relevance.

Indian Council of Medical Research (ICMR) has been engaged in studies focussing at developing strategies for improving maternal and child health (MCH) and family planning (FP) services at grass root level for over a decade. With a shift in focus from MCH and FP towards comprehensive reproductive health care, ICMR initiated a project on Integrated Reproductive Health Care Delivery through its network of Human Reproduction Research Centres (HRRCs) located at Medical Colleges in various regions of the country. This paper is based on observations related to gynaecological problems during a large reproductive health survey of married women of age 15-45 years.

Material and Methods:

A multi-indicator cluster survey of eligible women (married women of 15-45 years of age), covering various reproductive health issues including gynaecological problems, was conducted in 23 districts from 14 major States/Union Territories of the country between January 1996 to February 1997. A three stage stratified random cluster sampling was adopted for selection of villages from the rural areas for the survey. Selection of districts was done by the HRRCs in consultation with the district health authorities. Stratification for sampling of villages was done at two stages on the basis of distance from the health facilities. In the first stage blocks were stratified into two groups based on distance from the District Hospital and one block was selected randomly from each group. In the second stage villages were stratified into three groups on the basis of distance from Primary Health Care Centre (PHC) and presence of subcentre (SC) in the village thus forming six strata. At the third stage random clusters (villages) were selected from each stratum to provide a coverage of about 4,000 eligible women from the district. The sample size was decided on the basis of prevailing birth rate to provide about 50 currently pregnant women in each stratum.

Questionnaires for the survey were prepared centrally in English and were translated into regional languages at the respective HRRCs. The questions pertaining to womens perceptions, opinions, knowledge, attitudes etc. were open- ended and the probable responses were listed to facilitate recording and minimizing interview time. No leading or suggestive questions were asked to avoid courteous responses and over estimation. Women were interviewed at their homes by female interviewers. Only volunteered responses were recorded. Necessary instruction manuals were prepared and regional workshop of HRRC Medical Officers were held for discussing conduction of the survey. Selection of the interviewers was done locally by the HRRCs. Training of interviewers was carried out by the HRRC Medical Officers. Data analysis was carried out at the ICMR Headquarters. Statistical analysis include simple percentage distribution, rates and comparison of rates by 'students' test.

Results:

A total of 93,356 married women in the age group of 15 to 45 years of age were covered in this survey. All women, in addition to general information on current age, age at marriage, number of living children, contraceptive use etc. were asked if they were having or had in the recent past (last six months) any gynaecological problem. Women were also asked about the type of problems, knowledge and utilization of services as well as reasons for not seeking health care for their problems.

Table I: Study districts and women covered for the survey.

    Percentage of Women
State District Total Women Covered With Gynae complaints Knowlege about Services Seeking Care Satisfied with Services
Uttar Pradesh Barabanki 5276 6.1 6.1 2.8 1.5
  Allahabad 3935 25.2 24.7 12.3 9.4
  Kanpur 4036 57.5 56.3 28.0 19.8
  Meerut 4283 7.5 6.7 6.0 5.1
Buhar Patna 4210 26.8 25.6 19.9 13.1
Rajasthan Bukaner 3028 4.5 4.4 3.9 3.4
  Jaipur 4376 15.5 15.5 13.8 11.3
Orissa Jajpur 3566 20.1 20.0 9.7 5.8
J&K Jammu 3391 14.8 11.4 7.0 5.2
Haryana Yammuna NAgar 3716 33.9 32.6 21.9 10.1
West Bengal 24 Parangas 3853 17.8 9.4 5.7 2.6
  Hooghly 4739 23.9 20.9 14.2 11.8
Assam Nalbari 2830 50.1 48.1 40.5 40.5
Gujarat Baroda 3142 20.0 16.6 6.9 3.6
Maharashtra Raigad 3459 58.9 53.2 44.1 39.7
  Satara 4838 10.1 9.6 6.9 3.6
  Pune 4585 22.7 20.0 13.0 11.5
Karnataka Belgaum 4910 3.7 3.4 2.7 2.1
Tamil Nadu Chennai MGR 4139 3.5 3.2 2.9 2.1
  Nth. Changelput 5741 25.7 21.5 15.6 8.1
  Cuddalore 4805 23.1 22.2 12.4 9.6
Kerala Trivandrum 4435 29.1 16.3 11.6 8.2
Goa Nth Goa 1963 13.3 12.2 11.9 8.5
Total   93,356 24.4 20.6 14.2 9.8

On the whole 24.4% of women reported with one or more gynaecological complaints and only 20.6% of women knew the availability of services for such problems, but more than one quarter (6.4%) of these did not seek any care. Out of the 14.2% women who visited some health facility for their gynaecological problems only 9.8% felt satisfied with the availed services.

Large variations with regard to extent and nature of problems were observed. The percentage of women complaining of gynaecological problems varied between 3 to as high as 59% between districts. Differences were observed between districts within the same State also.

Table II: Type of gynaecological problems reported by age of woman.

Tyoe of Gynae. Complaints
(Multiple responses)
Percentage of Women Reporting
15 - 19 yrs 20 - 29 yrs 30+ yrs Total
Backache 6.6 10.1 14.4 10.4
Low abdominal pain 7.6 8.3 11.0 8.3
Menstrual Disoeders 4.5 5.1 6.1 5.1
Unexplained bleeding 2.1 2.9 3.6 2.8
Vaginal discharge 2.9 4.8 6.1 4.9
Fever 2.3 3.5 4.2 3.4
Itching 0.7 1.3 1.3 1.3
Frequent Urination 0.7 1.6 1.8 1.7
Burning Sensation 0.7 1.2 1.4 1.2
Total 16.7 20.9 25.4 24.4

On analysing the data by age it was observed that younger women had comparatively less complaints irrespective of the types of complaints. On the whole age specific gynaecological problems showed increase from 16.7% in women below 20 years of age to 20.9% among women 20-29 years of age and further to 25.4% among older women (>29 years). This trend of increasing gynaecological complaints with increasing age was found to be statistically significant (p<0.001).

The commonest problem mentioned by the women in most of the districts was backache followed by low abdominal pain and menstrual problems.

About 15% of the women had mentioned two or more complaints. Fever alone was mentioned by less than 1% of the women. Fever was accompanied by low abdominal pain, backache and/or menstrual problems in 1.5% of the women, indicative of pelvic inflammatory diseases and in about 1% frequent urination, and/or burning sensation, which could be urinary infection. Backache and low abdominal pain without fever was mentioned by about 3% of the women. A complaint of vaginal discharge alone was made by only 1.5% of the women. By about 4% women vaginal discharge was mentioned along with combinations of other complaints including itching, backache, low abdominal pain, etc. suggestive of reproductive tract infections.

Table III: Type of health facilities visited by women.

Health Facility % Women
visiting
% expressing
satisfaction
Rural Medical practitioner
(Indian system of Medicine
0.3 54.8
Rural Medical practitioner
Homeopath
0.4 58.1
Rural Medical practitioner
Allopath
3.9 71.0
Sub centre 1.1 74.3
Primary Health Centre 3.7 76.2
Community Health Centre 0.8 63.7
district Hospital 0.9 73.8
City Hospital 1.5 75.7
Others 1.6 71.9
Total 14.2 69.1

Women had visited private as well as governmental health facilities for their gynaecological problems. Fewer women (0.7%) had visited local practitioners of Indian system of medicine than modern system of medicine (3.9%) or the doctor at PHC (3.7%) , the closest peripheral health facility. It may be noted that more women had visited far off urban hospital (2.4%) than the so called First Referral Unit (FRU) at Community Health Centre (0.8%). Of the total 14.2% women who had visited some health facility, only 9.8% felt satisfied with the services received. On the whole satisfaction level was between 55-76% with the various type of health facilities visited by these women.

Table IV: Reasons for not seeking health care

Reasons for not visiting any health facility
(multiple responses)
% women
Personal 68.0
Do not have time 48.3
loss of wages 12.0
cannot go alone 23.2
Family not bothered 6.3
others 3.6
Inadequate facilities 13.4
PHP/CHC is too far 1.6
No female MO at PHC 1.8
No Privacy 2.4
Medicines not available 10.1
others 1.2
attitude of health providers 6.4
Demand money 2.7
ANM/Doctor not available at SC/PHC 1.3
Doctors do nto bother 1.4
Staff at PHC is rude 1.5
Others 7.3
No Response 10.2

Of 24.4% women who complained of gynaecological problems 10.2% (more than 40% of the women with problem) did not visit any health facility for seeking care. This included 3.8% who did not know where to go and 6.4% who did not seek any care inspite of expressing having knowledge about health care facilities. The major reasons, as mentioned by women for not seeking any health care for gynaecological problems were personal (68%) including 'lack of time (48.3%)', 'loss of wages (12.0%)', 'inability to go alone (23.2%)' and 'family not bothered (6.3%)'. In addition 13.4% of women gave reasons related to inadequate health services/infrastructure like 'medicines not available (10.1%)', 'no female doctor (1.8%', 'lack of privacy (2.4%)' etc. Attitude of the health providers like 'demand money (2.7%)' 'doctors/ANMs not available (1.3%)', 'doctors do not bother' etc. were mentioned by 1.4% of the women.

Discussion:

Community based information on prevalence of reproductive health problems and service seeking behaviour is scarce. This study has provided us with an estimate of self perceived gynaecological problems. The information on gynaecological problems, in this study, was obtained by paramedical persons by administering an open-ended questionnaire to women of reproductive age at their homes. On the whole 24.4% women had mentioned one or more gynaecological complaints. Varying estimates of gynaecological morbidity, with little uniformity in methodology and definition of illness, ranging from 5-90% for some specific complaints, are available from many Indian studies3-7. The percentage of women complaining of gynaecological problem in this study, from 23 districts of India, varied greatly between 3.5-58.9%.

It is difficult to explain these variations which could be related to many factors including ability, intention, willingness of women to respond and express fully and freely. Women are more likely to sponsor information on their personal problems to a physician than to a lay person. Studies have shown that almost three to four times more women reported their problems when interviewed by a gynaecologist5,8,9. Large variations between self reported complaints and clinical examination/lab investigations have been observed. Physicians find signs of health problems in women who have no complaints and lab results are positive in whom physicians have found no problems on clinical examination110. Large variations, between districts in this study, with uniformity in type of questionnaire and interview methodology could largely be due to response bias as only sponsored information was recorded. Where reproductive morbidity is concerned it is still an open question whether to rely most upon womens' self reports, physicians' clinical examination or laboratory investigations. Studies have shown a difference of 4-40% between self reported gynaecological morbidity to an interviewer, a physician or on a clinical examination8,11. Health interviewers are likely to provide under estimates when only volunteered responses to open ended questions are recorded as compared to when checklist is administered12. Health interview survey is important from public health point of view as it is an inexpensive and quick procedure of getting information on self assessed problems which may promote community participation in health care activities. At the primary health care level this could be a most feasible and effective-way of collecting information on reproductive morbidity. Multiple responses put together can provide estimates of conditions like reproductive tract infections, urinary infections or pelvic inflammatory diseases etc. for medical interventions, when interpreted by clinician.

The study indicates need for creating community awareness about health care facilities and instil self concern in women for their own health needs. Many women do not know from where to seek health care for such problems and further a large proportion do not seek any care till the problem becomes acute. The reasons are mostly lack of awareness, self concern and financial among others. In this study 10.2% out of the 24.4% women with gynaecological complaints had not gone to any health facility. Another major issue is effectiveness. Only 9.8% (40% of the total 24.4% women) had received satisfactory services. Inadequate facilities under the Government health infrastructure, as reasons for not making any effort to seek treatment were mentioned by 13.4% of the women who were suffering. These included shortage of medicines, non- availability of female doctors and inaccessibility. In addition 6.4% women had mentioned callous attitude of the health care providers. About equal number of women had sought care from local private practitioners, peripheral health services or tertiary care. More women had visited far off hospital than the so called First Referral Unit (FRU). The reason could be that FRUs are still not fully equipped for providing the desired level of services. About 4 out of 14.2% women who had tried to seek health care were not satisfied with the services. Other studies have also shown ineffectual health care7.

First referral units i.e. the Community Health Centres are required to be equipped infrastructurally as well as with manpower for addressing reproductive health problems of women and to provide appropriate referral services. Built-in service component and confidentiality may improve self reporting of gynaecological morbidity in rapid health surveys. Studies have shown that self reporting corresponds closely to clinical diagnosis when diagnostic criterion is clear13. Thus such surveys could prove to be an inexpensive way for generating continuous information on reproductive health issues for health managers.

References:

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  2. Fortney JA. Reproductive epidemiological research in developing countries. Annals of Epidemiology 1990; (12): 187-94.
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  4. Wasserheit Judith N, Jeffery R Harris, Chakraborty J, Bradford A Kay et al. Reproductive Tract Infections in a family planning population in rural Bangladesh. Studies in Family Planning 1989; 20(2): 69-80.
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  9. Bhatia Jagdish C, John Cleland, Bhagvan Leela, Rao study of gynaecological and related morbidities in NSN. Levels and determinants of gynaecological rural Egypt. Studies in Family Planning 1993; 24(3): morbidity in a district of South India. Studies in 175-86.
  10. Family Planning 1997; 28(2): 95-103. 13. Zurayk H, Khattab H, Younis N et al. Comparing
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  12. Latha K, Kanani SJ et al. Prevalence of clinically detectable gynaecological morbidity in India: Results of four community based studies. The Journal of Family Welfare 1997; 43(4): 8-16. 6:31-9.
  13. Younis N, Khattab H, Zarayk H et al. A community study of gynaecological and related morbidities in rural Egypt. Studies in Family Planning 1993; 24(3): 175-86.
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