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Indian Journal of Community Medicine

Prevalence of RTI's Among Women of Reproductive Age Group in Shimla City

Author(s): A. Parashar, B.P. Gupta, A.K. Bhardwaj, R. Sarin

Vol. 31, No. 1 (2006-01 - 2006-03)

Abstract

Objective: To find out the prevalence of RTI’s among women of reproductive age group. Study design: Cross-Sectional Study. Setting and Participants: Women of reproductive age group in 25 Municipal Wards of Shimla City. Study period: March 1999 to October 1999. Sample size: 600 women between 15-49 years age. Study variables: Education, marital status, age at marriage, socioeconomic status, menstrual hygiene practices, contraceptive practices, parity. Results: The study was undertaken based on syndromic approach for RTI’s. Based on the complaints of the patients, laboratory investigations were also undetaken. Overall prevalence of RTI’s was found to be 36.3% and this prevalence was significantly related to mean age at the marriage, marital status, parity, menstrual hygiene practices, current contraceptive method use and socioeconomic status.

Key words: Reproductive tract infections, reproductive age group and syndromic approach.

Introduction

Sexually transmitted diseases (STDs) are a major public health problem worldwide, more so in developing countries where they collectively rank among the five most important causes of healthy productive life lost1. Reproductive tract infections (RTI’s) affect the health and social well being of women, particularly those in the reproductive and economically most productive age groups, and their offsprings2. The World Bank estimates that for adults between 15 to 44 years of age in the developing world, STDs not including HIV infection are the second common cause of healthy life lost in women, after maternal morbidity and mortality3. Studies in women in developing countries have found RTI’s rates ranging from 52% to 92%, and fewer than half the women recognized the conditions as abnormal4.

Globally, prevalence and incidence estimates of selected curable STDs have a very high range5. The studies conducted in India indicate high prevalence of RTI’s6. A broad based study conducted in different parts of the country revealed a prevalence varying from 19 to 71 percent7. Marked variation has been found across all these studies in terms of pattern and level of morbidity which means that no single set of estimates for RTI’s, could apply in such a large and diverse country as India. Hence, the prevalence rates of RTI’s for a particular geographical area need to be assessed so as to help the health administrators in providing better services for their treatment and control.

Since, no community based data has been encountered regarding the prevalence of RTI’s from urban areas and associated risk factors in this hilly state, so the present study was an attempt regarding the prevalence of RTI’s and some risk factors associated with it among women living in Shimla City.

Material and Methods

The study was conducted in the Municipal Corporation limits of Shimla City, which is the capital of Himachal Pradesh and a hilly area located in the northern part of India. The study was done from March to October 1999. The study was conducted among women of reproductive age group, i.e., 15- 49 years of age. The study was cross-sectional in design. The sample size of 600 was calculated assuming prevalence of 40%.

This sample size of 600 was equally divided among 6 wards that were randomly selected to give equal representation to all the strata of community. Hence, 100 women were included in this study from each of the six randomly selected wards. In each of the sample wards, after ascertaining the number of household and geographic spread, first survey house was selected at random. Then the next nearest house was selected till 100 contiguous respondents, i.e., women in 15-49 years age group were covered.

The study was conducted by house-to-house visit with the help of schedule that was pretested in one of the wards of Shimla Municipal Corporation area and appropriate changes were done. The responses were mostly precoded with fixed response categories.

Those women who gave history of complaints relating to reproductive tract were subjected to examination including bimanual and per speculum examination. In addition 10% of total sample, i.e., 60 women who were asymptomatic were also subjected to examination. Unmarried girls were subjected to rectal rather than vaginal examination. The symptomatic women in this study were classified into four categories of syndromes as per standard guidelines of National AIDS Control Organization. The syndromes selected were vaginal discharge, genital ulcer disease, lower abdominal pain and inguinal bubo.

All the women who had symptoms on history taking, were subjected to laboratory examination in the form of blood sample for VDRL test and wet preparation of vaginal smear for Trichomonas vaginalis and Candida albicans. In addition to this, these tests were also conducted in 60 asymptomatic cases by random selection. Other investigations like endocervical swab for culture sensitivity, X-Ray pelvis, urine culture and sensitivity, ultrasonography were also done wherever indicated by the gynecologist. Analysis was done by standard statistical method.

Results

Out of 600 women who were contacted during the study period, 248 (41.3%) reported various types of symptoms related to reproductive tract (Table I). The distribution of population according to gynecological and sexual morbidity through clinical examination as shown in Table II.

Table I: Distribution of Population According to common Gynaecological and Sexual Complaints

Complaint Number* %
Vaginal discharge 160 26.7
Genital ulcer disease 11 1.8
Lower abdominal pain 115 19.2
Low backache 84 14.0
Dyspareunia 10 1.7
Coital bleed 3 0.5
Burning on micturition 39 6.5
Local itch 80 13.3
Local swelling 4 0.7
Local rashes 6 1.0
*Most of the respondents reported more than one complaint.

Table II : Distribution of Population According to Gynaecological and Sexual Morbidity Through Clinical Examination.

Morbidity Number %
Vaginal discharge 97 16.2
Genital ulcer disease 9 1.5
Pelvic inflammatory disease 108 18.0
Inguinal bubo 4 0.7
Urinary tract infection 11 1.8
Primary infertility 13 2.2
Secondary infertility 5 0.8
Ectopic pregnancy 2 0.3
Scabies 6 1.0
Genital wart 3 0.5
Ovarian cyst 4 0.7
Carcinoma cervix 4 0.7
Uterovaginal prolapse 3 0.5
Fibroid 2 0.3
Others
Post-menopause 1 0.2
Primary amenorrhoea 1 0.2
Dysmenorrhoea 2 0.3
Antenatal case 10 1.7
Fungal infection on vulva 1 0.2

Prevalence of RTI’s: Out of 600 respondents, 218 (36.3%) were suffering from one or other type of syndromes though 248 had reported various types of complaints during course of history taking. Out of these 248, 208 (83.9%) were confirmed by clinical examination, rest of 10 women were those who did not report history of any complaints related to reproductive tract.

The laboratory investigations, i.e., vaginal smear examination and blood test for VDRL were done in 248 symptomatic and 60 asymptomatic women on history. Out of 60 asymptomatic, 7 (11.7%) cases were positive for vaginal smear examination. Out of symptomatics, 110 (44.4%) cases were positive for vaginal smear examination and 2 (0.8%) were with positive blood test for VDRL. The vaginal smear examination has sensitivity of 94%, specificity 27.7% and positive predictive value of 44%.

Most of the cases of RTI’s, i.e., 60 cases (58.2%) were illiterate. The prevalence of RTI’s, decreased with attainment of higher educational status (χ2 = 55.76 p < 0.001). 214 (41.7%) of RTI cases were married. Only 2 (2.5%) of unmarried respondents reported RTI’s. 9 (69.2%) of those who were in class IV of Prasad’s classification were suffering from RTI’s. 38 (54.3%) of those in class III, 120 (43.3%) of those in class II, 51 (21.2%) of those in class I were suffering from one or other type of syndrome. The prevalence of RTI’s was significantly related to per capita monthly income (χ2 = 45.36, p <0.001).

Out of 600 respondents, 1 woman had primary amenorrhoea and 1 had attained menopause. The prevalence of RTI’s was significantly high (χ2 = 100.21, p <0.001) in those who were using any type of cloth whether clean or unclean. Most of the cases that got married at age <15 years were suffering from RTI’s. There was significant decrease in the prevalence of RTI’s as the age at marriage advanced (χ2 = 40 p<0.001). Out of 520 ever-married women, 10 were newly married and one did not opt to conceive because her husband already had children from first marriage. From the remaining 509 women, maximum number of RTI cases 33 (64.7%) were found in women with parity 4 followed by 50% of those with parity 6, 46.2% in those with parity 5, this relationship was statistically significant χ2 = (13.28 p<0.05). 146 women (42.4%) reported RTI’s out of 344 women who were currently using modern contraceptive methods. 50.6% of terminal method users and 45.6% of IUDusers were suffering from RTI’s. The prevalence of RTI’s was significantly low among those who were using barrier methods χ2 = (8.8 p<0.005).

Discussion

The prevalence of RTI was 36.3% among the women in reproductive age group in Shimla town. The prevalence of various RTI syndromes i.e. vaginal discharge was 16.2%, genital ulcer disease was 1.5%, pelvic inflammatory disease was 18.0%, and inguinal bubo was 0.7%. The prevalence of RTI’s in our study is lower as compared to a similar study conducted in Delhi among MCH attendee, where the prevalence of VD was 63.4% and PID 33.4%8. The difference may be due to the study design as that study was clinic-based study. The prevalence of VD in our study is almost half as compared to that of 33% observed during another clinic-based study in a hospital in Kerala9.

In our study, 248 (41.3%) women reported one symptom or the other relating to RTI’s / STIs which is lower than that of 52% obtained during a baseline study conducted in district Sirmaur during early 1998 by UNFPA10. The reported complaints of vaginal discharge were very high (54%) in another study from district Sirmaur, which was based on health camps11. This may be due to different selection criteria taken in that study and different settings adopted for the study as our study was in urban set up.

The prevalence of RTI’s decreased with the attainment of higher educational status. The prevalence was highest among illiterate women. The relationship of education and health is a wellestablished fact. Attainment of education clears various misconceptions about many illnesses including RTI’s and encourages preventive practices. These facts have also been authenticated in various studies conducted in India9,12.

Majority of the women contacted, used any type of cloth, whether clean or unclean and prevalence was comparatively very high in them χ2 = (100.21 p<0.001). These findings are in line with another study conducted in Himachal among rural population10. The resulting infections are due to overgrowth of normal vaginal flora, resulting from unhygienic practices, which causes local as well as ascending infection including pelvic inflammatory diseases.

The prevalence of RTI’s was more in those who got married before the age of 15 years. Even though, the study area being the capital city, one third of the respondents got married before the legal age for marriage, the fact which needs to be emphasized while planning interventions for the control RTI’s. Early age at marriage means early sexual activities, which may cause trauma, hence offering a platform for future infections. These findings have been observed by various other workers13,14 where early sexual debut had a greater number of RTI/STIs and more cervical atypias. In our study, the prevalence of RTI’s was significantly low in those women who were using barrier methods. Barrier contraceptives are known to provide protection against RTI/STIs. The prevalence of RTI’s was more among IUD users and those using terminal methods of contraception. This is because introduction of foreign body in uterine cavity make women more prone for ascending infection from lower genital tract. Bang et al6 in their study have also revealed the similar association.

Out of 600 respondents, 218 (36.3%) were found suffering from any of the four syndromes selected for the study. Out of 248 women complaining in history, 208 were confirmed by clinical examination. 60 asymptomatic women were also subjected to the vaginal smear examination, 10 (11.7%) of them were positive on vaginal smear examinatiion. This means, many women are asymptomatic hence may not be seeking treatment, though they may be suffering from disease. There is an urgent need to create relevant awareness among the target population regarding the sign and symptoms pertaining to RTI’s. The peripheral health workers should be oriented and sensitized for identifying various sign and symtoms of RTI’s and be able to treat or refer the patients to the primary health centers for early and prompt treatment. The treatment based on syndromic approach should be adopted to ensure confidentiality.

References

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Deptt. of Community Medicine and Obstetrics & Gynecology
Indira Gandhi Medical College, Shimla (Himachal Pradesh)- 171001
E-mail: [email protected]

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