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Indian Journal of Community Medicine

Community Based Study of Self Reported Morbidity of Reproductive Tract Among women of Reproductive Age in Rural Area of Rajasthan

Author(s): Monika Rathore, S.S. Swami, B.L. Gupta, Vandana Sen, B.L. Vyas, A. Bhargav, Rekha Vyas

Vol. 28, No. 3 (2003-07 - 2003-09)

Deptt. of Preventive and Social Medicine, S.P. Medical College, Bikaner, Rajasthan

Abstract:

Research question: What is the prevalence of morbidity of reproductive tract among women in a rural area of Rajasthan?

Objectives: l. To assess the load of reproductive morbidity among the rural women. 2. To study the association of potential risk factors with reproductive tract infection.

Study design: Cross-sectional.

Setting: A village of Bikaner (rural western Rajasthan).

Participants: 1044 rural women aged 15-45.

Study period: June 2000 to October 2000.

Statistical analysis: Percentages and Chi square test.

Results: The prevalence of self reported morbidity related to reproductive tracts was 31.8% and reproductive tract infections (RTIs) was 22.3%. Only 12.5% of symptomatic women consulted health personnel for their illness before this survey. Prevalence of RTIs was significantly associated with age, married life, gravida status, invasive contraceptives, gynaecological surgical interventions and type of family.

Conclusion: There was a moderately high prevalence of self reported morbidity of reproductive tract, whereas, treatment seeking behavior was low. Many factors were found to be associated with RTIs.

Key Words: Reproductive tract infection, Reproductive morbidity, Self reported

Introduction:

Reproductive tract morbidity is high among women of developing countries resulting in devastating consequences on health and social well being of women. Majority of women in India continue to suffer from reproductive tract infections resulting into pelvic inflammatory diseases, salpingitis, pelvic adhesion, infertility, cervical cancer and chronic pelvic pain. Although early detection and treatment of RTIs can prevent and minimize the severity of long term sequel, many infections go unnoticed. Utilization of specialized services for the management of RTIs is often low, because these infections are frequently asymptomatic or produce vague, non-specific symptoms, as 50% chlamydial and gonorrheal infections among women remain asymptomatic1. Low female literacy rate and consequent low level of awareness lead to poor understanding of sexual and reproductive health. Further, the socio-cultural norms, values and taboos also withhold the women from seeking health care for RTIs.

Material and Methods:

A community-based cross-sectional study was conducted in Udairamsar, a rural area of district Bikaner,

Rajasthan (India) during June, 2000 to October 2000. Total population (i.e., 1200) of eligible females in reproductive age group were included in study, expecting a high drop out in view of the fact that for typical rural women gynaecological inquiry and examination is a sensitive matter.

A pretested, semi-structured interview schedule was used during house-hold survey. Women were asked about their age, education, marital status, parity, type of family, type of use of contraception method, history of any gynaecological surgical interventions, and whether they had any problem related to reproductive tract. This was followed by direct questions on presence of symptoms like excessive vaginal discharge, pain in lower abdomen or lower backache, pain/burning while passing urine, genital ulcer and swelling in groin. Women, who suffered from any of these symptoms were asked to report voluntarily, for pelvic examination by the doctor posted at the PHC. Syndromic protocol was used to diagnose reproductive tract infections after per speculum examination.

Vaginitis was diagnosed in presence of visible vaginal discharge without involvement of cervix and without low backache/lower abdominal pain. Cervicitis was defined as presence of cervical discharge, irrespective of the presence was history of lower abdominal pain or lower backache or or absence of vaginal discharge and without lower pain on moving cervix, with or without cervicitis or abdominal pain/low backache. vaginitis. More than one diagnosis were assigned to same

Results:

Table I: Profile of reproductive morbidity.

Type of reproductive morbidity No. of women
(n=1044)
No.(%)
RTIs 233 (22.3)
Menstrual problem 63 (6.1)
Sterility 59 (5.7)
Prolapse uterus 21 (2.01)
UTI 10 (0.96)
Uterine & ovarian lump & growth* 6 (0.57)
Total 392

More than one diagnosis was given to few women, (per person gynaecological morbidity was 1.18 as 332 women suffered from 392 reproductive morbidities.
*Diagnosis of uterine & ovarian growth was made on the basis of existing investigation report with the patient

Total 1044 women were interviewed. Mean age of 22.3%(233) of study population was suffering from RTIs, women suffering from reproductive tract infections was 6.1% women had menstrual problem, 5.7% women were 33.59 years. 332 females were suffering from reproductive sterile, 2% had prolapse uterus, 0.96% had UTI and only morbidity, more than one morbidity was found per person. 0.57% women had uterine and ovarian growth.

Table II: RTI profile of the study population.

Type of RTI (n=1044)
RTI present No.(%)
Pelvic inflammatory disease 164 (15.7)
Vulvovaginitis and vaginitis 118 (11.3)
Cervicitis and cervical erosion 44 (4.2)
Gonorrhoea and syphilis 2 (0.2)

More than one diagnosis were assigned to few women.

Pelvic inflammatory disease was the commonest followed by vaginitis, whereas, cervicitis and cervical RTI, erosion were 4.2% and only 0.2% women had Genital ulcer (Table II).

Table III: Association of RTIs with risk factors.

RTI status (n=1044)
Factors Present (n=233) Absent (n=811) Level of significance
no. %
Age (Yrs.)
15-19 4 (1.7) 229  
20-24 19 (9.5) 180  
25-29 38 (24.5) 117 X2 = 146.7
30-34 61 (33.2) 123 p<0.001
35-39 44 (35.8) 79  
40-45 67 (44.7) 83  
Literacy
Illiterate 148 (29.5) 353  
Primary & Middle 64 (22.8) 217 X2 =46.7
Sec. & Higher Sec. 15 (7.3) 190 p<0.001
Graduate & above 6 (10.5) 51  
Marital status
Unmarried 2 (0.9) 215 X2 =58.3
Married 228 (27.9) 587 p<0.001
Widow/Divorcee 3 (25) 9  
Gravida
Nullipara* 7 (2.4) 290  
Priori gravida 15 (13) 100 X2 = 138.1
Multi gravida 127 (28.5) 318 p<0.001
Grand multi 84 (44.9) 103  
Gynaecological surgery
Done 114 (43.5) 148 X2 = 91.5
Not done 119 (15.2) 663 p<0.001
Contraceptives*
Invasive*** 117 (37.6) 194 X2 = 23.03
Non Invasive & non users # 114 (22.1) 402 p<0.001
Family
Nuclear 153 (26.6) 423 X2= 12.87
Joint 80 (17.1) 388 p<0.05

*All married/unmarried women who have never conceived were included in nullipara.
**Only married women (827) were taken into consideration
***IUCD and Tubal ligation were considered invasive.
# OCP, Condom and Vasectomy were considered non-invasive.

There was increasing trend in RTIs with increase in age, ranging from 1.7% to 44.7% (p<0.001). 48% of the study population was illiterate, out of which 29.5% was suffering from RTIs, while only 7.3% of women with secondary and higher secondary education were suffering from RTIs (p<0.001). Only 1 % of unmarried women had RTIs against 27.9% of married women (p<0.001). Lowest (2.4%) prevalence of RTIs was found in nullipara and highest (44.9%) in grand multipara (p<0.001). 43.5% of women with history of gynaecological surgery had RTIs while only 15.2% of women who had not undergone any gynaecological surgery had RTIs (p<0.001). Women from nuclear families had more RTIs. 37.6% of invasive contraceptive users were suffering from RTIs against 22.1 % of non-invasive contraceptive users (p<0.001).

Discussion:

Comparable prevalence of reproductive tract infections (i.e., 28 to 30%) was observed in a major baseline survey in the state of Bihar, Rajasthan and Himachal Pradesh by Center for Operations Research and Training (C.O.R.T.). Excessive vaginal discharge followed by menstrual problems were commonly reported problems2. Wielkinson observed 24.9% prevalence of RTIs among women of rural South Africa3. Much higher prevalence was observed by Bang et al4Deokinandan5 et al, in a study of over 800 women from different states in India in 1995 and in 4 community based studies conducted in urban slums of Baroda, Mumbai and West Bengal observed (92%), (47%), (75%), (65-84%) prevalence respectively.

Per person morbidity was 1.18 in present study, which is comparable with the finding observed - (2/person) by 4 community based studies conducted in Baroda, Mumbai and West Bengal7, but it is little bit lower than the findings (3.6/person) by Bang et al4 . The wide variation in the prevalence of gynaecological morbidity in different studies can be explained that India is a vast country with different cultures, taboos, health practices which influence the prevalence of reproductive morbidity. Regarding clinical profile of RTIs, almost similar findings were observed by Agrawal et al in Haryana with vaginal infections (32%), cervicitis (21%), PIDs (19%) 8.

A study conducted by Baroda Citizen Council (1995) in rural and urban areas found vaginal infection in 22 to 57%, lower backache in 5 to 39% and lower abdominal pain in 9 to 22%9. Passey et al observed higher prevalence of vaginal infection (50 to 52%), cervical infection (23 to 27%)10, while a very high prevalence was observed by Nayer (1993), in New Delhi who found cervicitis in 86%, vaginitis in 21.5% and PID in 45% of women11, whereas, Deokinandan5 and Brabin et al12 observed vaginitis in 47% and 24% respectively. The load of symptomatic reproductive morbidity in rural community of Rajasthan is moderately high and despite available free of cost services, the utilization of facility was only 12.5%.

Present study revealed that prevalence of RTIs was highest (44.7%) in age group 40 to 45 years and lowest (1.7%) in 15 to 19 years age group; this may be explained by the fact that with increasing age, women experience more sexual life, pregnancies, gynaecological surgery, deliveries, invasive contraceptives etc. which make women vulnerable for RTIs. This explanation is further supported by the observation made in present study that RTIs were much more common in grand multigravida (44.9%) in comparison to nullipara (2.4%). During surgical intervention, infection can occur as is evident from this study, where 43.5% of women with history of such intervention had RTIs, while only 15.2% of women with no history of intervention had RTIs. It compares well with the finding of Brabin et al12 , who observed that 30.5% of PID cases had undergone tubal ligation, which is one of the most common gynaecological surgical intervention. A nationwide prospective study (1970 to 1976)13, also observed that the principal adverse effects after tubal sterilization were menstrual irregularities, dysmenorrhia and PIDs.

Operative procedure of tubal ligation and introduction of foreign body (IUCD) in uterine cavity make women more prone for ascending infection from lower genital tract. Similarly, U.S. Women Health study also observed that IUCD users were 1.6 times more prone for PIDs and WHO studies in 12 countries observed that IUCD users were 2.3 times more prone for PIDs. Bang et al4 and Brabin et al12 in their studies revealed that there was association of invasive methods of contraception with RTIs.

Gynaecological examination should have been done in every married woman to find out the total load of RTIs (symptomatic + asymptomatic) but Indian norms, values, taboos and illiteracy do not allow them to come forward to participate in such type of examinations that is why only 46.9% of symptomatic women could be examined gynaecologically. Though micro-biological investigations are the best confirmatory evidence of reproductive tract infections but it was not feasible in such field based study.

References:

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