The concept of sexual and reproductive health was first fully articulated at International Conference on Population and Development held at Cairo in 1994 and the Government of India has launched reproductive and child health programme in 1997 with special emphasis on management of reproductive tract infection (RTI)1, since then most efforts to estimate the prevalence of RTI were primarily based on hospital data or poor quality vital statistics, which were not representative of the population. There was a wide range of 17 to 70% prevalence of RTIs in different areas of India due to different sociocultural practices and taboos prevailing in different communities. With 5% annual incidence rate, there are approximately 40 million new infections occur every year2. Present community-based study was conducted to assess the prevalence of RTI among women in a rural area of Rajasthan and the sociocultural factors related with it.

Material and Method

A community-based cross-sectional study was carried out in the village Naila, a field practising area of PSM deptartment of SMS Medical College, Jaipur during August 2002 to November 2002. Assuming the 40% prevalence of RTI among women in Rajasthan3, 600 houses were surveyed, out of total 4693 houses by systematic random sampling technique.
Sample size = Z2 P Q / L2 ( Z =2, P = 40%, Q = 60%, L = 10 % of prevalence, so the sample size = 600)
In order to allow some non-response, all the ever married women aged 15 to 45 years residing in these 600 houses were interviewed by MPWs and Interns posted at rural health training centre (RHTC), Naila. A pretested, semi-structured interview schedule was used. Women were asked about their age, education, parity, type if contraceptive methods used, history of gynaecological surgical interventions and whether they have any problem related to reproductive tract, followed by direct questions on presence of unusual vaginal discharge, itching vulva, pain during menstruation, premenstrual congestion, irregular menstruation, lower abdominal pain, low backache and pain during sexual intercourse. A total of 859 women were interviewed, out of them 471 were symptomatic and rest did not have any symptom. All the 859 women interviewed were offered clinical and microbiological examinations at RHTC, Naila. A total 432 women ( 249 symptomatic and 183 non-symptomatic ) came forward to get themselves examined gynaecologicaly. Vaginal smear and swab were taken after per speculum (PS) per vaginal (PV) examination.
Microbiological tests — pH of vaginal discharge, KOH staining test, wet mounting, Gram-staining, culture were done to confirm the presence of RTI. Amsel criteria4 was used to diagnose bacterial vaginitis, wet mount and Gram-staining were used for diagnosing trichomonas vaginitis. Cervical erosion was diagnosed on PS examination and pelvic inflammatory disease (PID) was labelled when there was pain on moving cervix and bilateral fixed tender fornices.
Vaginal pH testing — Vaginal pH was determined by dipping a pH paper into the discharge present on the vaginal speculum after removing from vagina to differentiate the different types of infection. pH of > 4.5 was used as a diagnosis for bacterial vaginitis and pH > 5.5 for trichomonas vaginitis.
Amine test — It was done by adding a drop of 10% KOH on vaginal discharge taken on a clean microscopic slide, intense fishy odour indicated bacterial vaginitis.
Wet mounting – Drop of vaginal fluid mixed with one drop of normal saline, covered with cover slip and observed under light microscope for trichomonas and clue cell.
Gram-staining — This was used for the test of Gram-negative coccobacilli (clue cell) suggestive of bacterial vaginitis and presence of Gram-positive yeast bodies suggesting candidiasis.
Amsel criteria — For bacterial vaginitis a positive diagnosis is made if 3 of the following 4 criteria are present: (1) P/S – Homogenous discharge. (2) Clue cell – On microscopy ( >20%). (3) Vaginal pH – > 4.5. (4) A fishy odour is produced when 10% of KOH is added to vaginal secretions.
Stastical analysis was done using chi-square test, proportions utilising SPSS software.

Observations

Mean age of the 859 women interviewed at household survey was 31.2 years. Majority (84%) of the women were Hindu, 62% (535/859) were illiterate. Their mean age of marriage and cohabitation were 15years and 17 years respectively. One or other type of contraceptive was used by 35% (304/859). Tubectomy was the most common (67%) contraceptive method prevalent among them. Average number of children born to these women were 3.2. A sizeable section (64%) of women got their deliveries conducted at home and around 50% of deliveries conducted by untrained personnel. On survey 54% (466/859) were found to be symptomatic and 46% (393/859) were asymptomatic. All the 859 women were called for medical examinations but only 50% (432/859) gave consent for it and 53% (249/466) symptomatic and 47% (183/393) asymptomatic women got themselves examined medically. Background characteristics of women who came forward for gynaecological check-up were compared with women who could not be examined. No significant difference could be observed in the mean age, mean age of marriage and cohabitation, average number of children born, mean annual family income, caste, place of delivery, use of contraceptive methods, menstrual hygiene and their treatment seeking behaviour. Thus women who came for examination can be considered representative of the ever married women of 15 to 45 years age group of this area.
Vaginal discharge was the most common (47%) complaint, followed by lower abdominal pain and low backache (34%). Symptoms related to menstruation were reported by 35%. Only one woman reported swelling at groin (Table 1).

Clinical evidence of RTI was found in 93% (231/249) of symptomatic and 17% (32/183) in asymptomatic women and the overall observed morbidity was 61% (263/432). The most common (43%) observed morbidity was cervicitis followed by PID(37%) and bacterial vaginitis (26%) (Table 2).
The study observed lowest number of RTI in age group 15-19 years and highest number in 30-34 years age group (p<0.001), lowest (6%) incidence in nullipara and highest (76%) in multi and grand multigravida (p<0.01). History of gynaecological surgery had RTI in 76% women, while 54% of women had RTI without history of gynaecological surgery (p<0.05); 73% of invasive contraceptive users were suffering from RTI against 57% of non-user and non-invasive contraceptive users (p<0.01) (Table 3). Around 67% of women with poor and fair personal hygiene were RTI positive as compared to 39% of women with good personal hygiene (p<0.001). Seventy per cent of women who used unhygienic pad for menstrual blood had RTI while 52% of women who used hygienic pad had RTI (p<0.01). There is no statistically significant difference in RTI status of women from different literacy status, caste and place of delivery but type of attendance at child birth had significant difference in RTI status (p<0.05), this might be due to five clean practices practised by trained birth attendants.

 

Discussion

Comparable prevalence (92%) of RTI was observed by Bang et al5, 47% by Deokinandan and Saxena6, 75% in a study over 800 women from different states in India7 and 65-84% in four community-based studies conducted in urban slums of Baroda, Mumbai and West Bangal8. Little lower prevalence (28-30%) of RTI was observed in a major base line survey in the states of Bihar, Rajasthan and Himachal Pradesh by Centre for Operation Research and Training (CORT). Wilkinson9 observed 25% prevalence of RTI among women of South Africa, Bansali et al3 observed 40% of women suffering from RTI in an urban slum of Udaipur. Per person morbidity was almost 1.48 in present study which is well comparable with the finding (2/person) observed by 4-community based studies conducted in Baroda, Mumbai and West Bangal8 but it is lower than finding (3.6/person) of Bang et al5. The wide variation in the prevalence of gynaecological morbidity in different studies can be explained by the fact that India is a vast country with different culture, taboos and health practices which influence the prevalence of RTI.

 

Regarding clinical profile of RTI, almost similar findings were observed by Passey et al10, where vaginal infection was 50-52%, cervical erosion 23-27%, while a very high prevalence was observed by Nayer et al11 in urban slum of New Delhi who observed cervicitis in 86%, vaginitis in 21.5% and PID in 45% of women. Slightly low prevalence of vaginal infection (32%), cervicitis (21%) and PID (19%) was observed by Latha et al8.
Present study revealed that the prevalence of RTI was highest (76%) in women aged 30-34 years and lowest (33%) in 15-19 years age group. This may be explained by the facts that with increasing age women experienced more married life, pregnancies, gynaecological surgery, deliveries, use of invasive contraceptives; these make women more vulnerable for RTIs. This explanation is further supported by the observation made in the present study that RTI is more common in multi and grande multigravida than nulligravida.
During surgical intervention infection can occur as it is evident from this study where women with history of such interventions had more RTI. It is well complemented with the findings of Brabin et al12 who observed that 30.5% of PID cases had undergone tubal ligation, which is the most common gynaecological surgery. Operative procedure of tubal sterilisation and introduction of foreign body (Cu-T) in uterine cavity make women more prone for ascending infection from lower genital tract.

 

References

1.National Institute of Health and Family Welfare — Reproductive and Child Health Module for Medical Officers. New Delhi : National Institute of Health and Family Welfare, 2000.
2 Bang R, Bang A — A Community Based Study of Gynecological Disease in Indian Villages– Some Experiences and Reflections: New York Population Council. New York: UNFPA, 1996: 223-37.
3 Bansali KM, Singh K, Bhatnager S — Prevalence of lower reproductive tract infections among married female in reproductive age group (15-45). J NIHFW 2001; 24: 157-63.
4 UNFPA — Training in Laboratory Investigation for Common Reproductive Tract Infections: A Manual for Laboratory Workers for Diagnosis of STD. New Delhi : NACO, 1998.
5 Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O — High prevalence of gynaecological diseases in rural Indian women. Lancet 1989; i: 85-8.
6 Deokinandan, Saxena BN — Maternal morbidity and mortality pattern in UP. Indian J Commun Med 1997; 22: 10-5.
7 WHO/SEARO — Focus on Women: Regional Health Report. New Delhi: WHO/ SEARO, 1998.
8 Latha K, Kanani SJ, Maitra N, Bhattacharya RV — Prevalence of clinically detectable gynecological morbidity in India : result of four community based studies. J Fam Welfare 1997; 43: 8-16.
9 Wilkinson D, Abdool Karim SS, Harrison A, Currie M, Colvin M, Connolly C, et al — Unrecognised sexually transmitted infection in rural South African women : a hidden epidemic. Bull World Health Organ 1999; 77: 22-7.
10 Passey M, Mgone CS, Lupiwa S, Tiwara S, Lupiwa T, Alpres MP — Screening for STD in rural women in Papua New Guinea : are WHO therapeutic algorthim appropriate for case detection? Bull World Health Organ 1998 ; 76: 401-11.
11 Nayer T, Misra D, Chawla SC, Bajaj P, Goyal U, Pillai BP — Gynecological disease in women of reproductive age group – unmet need in MCH care. Indian J Commun Med 1997 ; 22: 104-9.
12 Brabin N, Gigate A, Karande A, Khanna R, Dollimore N — Reproductive tract infection, gynaecological morbidity and HIV seroprevalence among women in Mumbai, India. Bull World Health Organ 1998; 76: 227-85.

 

Department of Preventive and Social Medicine, SMS Medical College, Jaipur 302004
*MD (PSM), Senior Demonstrator, Department of PSM, RNT Medical College, Udaipur 313001
**MD (Pathol and Microbiol), Associate Professor, Department of Microbiology
***MD (PSM), Professor and Head of the Department
Accepted September 4, 2003