Prevalence of Reproductive Tract Infections Among Rural Married Women in Tamil Nadu, India: A Community Based Study

Reproductive health of women is of immense importance due to its implications on women’s health, health of their children, family members and socioeconomic development of society. Reproductive health includes several components such as fertility control, safe motherhood, and prevention and control of reproductive tract infections, which include sexually transmitted infections (STIs) [1]. Reproductive tracts infections (RTIs) and their complications are among the most important causes of illness and death for women in poor regions of the world [2]. Women in the reproductive age group are at risk of RTIs/STIs during natural events in their life such as menstruation, pregnancy and childbirth due to the inherent physiological characteristics of the female reproductive tract [3]. The problem is more pronounced in developing and underdeveloped countries where women often have to deal with unwanted pregnancies, unsafe abortions, problems arising from poor contraception practices, different sociocultural norms and lack of economic independence, which further reduce their capacity to protect themselves from RTI/STIs [2, 3]. According to the second National Family Health Survey (NFHS-II), nearly 4 out of 10 currently married women in India report at least one reproductive health problem that could be symptomatic of a more serious RTI [4]. The most recent District Level Household and Facility Survey (DLHS-3) found a prevalence of 18.2% of RTI symptoms among ever-married women. The prevalence was higher in the rural (19.6%) compared to urban areas (15.0%) [5]. Although the prevalence of RTIs shows a declining trend, RTIs continue to be a significant health problem among women in terms of morbidity and mortality. Many prevalence studies for RTIs/STIs based on symptoms have been conducted throughout the country in both rural and urban areas. But there is a paucity of community based studies from rural Tamil Nadu in recent years. This study was conducted to estimate the current prevalence of RTIs based on a syndromic approach among women between 18 to 45 years of age, in a rural area of the Kancheepuram District in Tamil Nadu. Additionally, the study aimed to determine the association of symptoms of RTI with socio-demographic characteristics, marital and obstetric history, contraceptive practices, and personal and menstrual hygiene practices.

A community-based, descriptive, cross-sectional study was carried out in the Karanai Puducheri village of Panchayat (Kancheepuram District, Tamil Nadu, India) from March to November 2011. Approval for this study was obtained from the Institutional Ethics Committee of Madras Medical College. To determine the appropriate sample size for this study, we looked at the prevalence of RTIs among married women aged between 15-45 years in Veerapandi Panchayat Union (Salem District, Tamil Nadu). The prevalence was 44.6% [6], which, with an allowable error of 10%, means the required sample size estimates to 477. Assuming a 10% non-response rate, the final sample size chosen was 525. All married women in the age group 18-45 years constituted the sampling frame. There were 1733 married women in this group based on the voter’s list. Using this as the sampling frame, 525 women were chosen through random sampling using computer generated random numbers. Women who had any major gynecological problems such as cervical carcinoma, uterine fibroids, uterine prolapse, those not willing to participate in the study and those who could not be contacted after 3 visits, were excluded from the study. A semi-structured interview schedule based on a questionnaire used in DLHS-3 [5] was devised in English, translated into Tamil and back into English (to check for accuracy and consistency). The schedule was divided into five sections, namely: social and demographic characteristics, perceived symptoms of RTIs/STIs, obstetric history, contraceptive practices and personal and menstrual hygiene practices. The Tamil schedule was pretested for clarity and reliability. The prevalence of RTIs was assessed based on the self-reporting of a set of symptoms (thus termed the ‘syndromic approach’) as was used for diagnosis of RTIs/STIs in the NFHS-2 and DLHS-3 [4, 5]. A diagnosis of RTI was considered if the participant had experienced one of the following symptoms in the previous 12 months: abnormal vaginal discharge (discharge accompanied by itching or irritation, bad odor, abdominal pain, fever and other problems), ulcers or boils in and around the genital region, pain in lower abdomen which was not related to menstruation, pain or burning sensation during urination, swelling in the groin and painful blister like lesions in and around vagina. Among currently married women, pain during sexual intercourse and spotting after sexual intercourse was also taken to be indicative of RTI. The participants who reported symptoms of RTI were referred to the nearest governmental primary health center and followed up for completion of treatment and resolution of symptoms. The data were recorded in Microsoft Office Excel 2007. Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS for Windows Version 12.0). Prevalence of individual symptoms of RTI/STI was calculated. Cross tabulations were done to assess factors associated with RTIs. Chi-square test was used to analyse the significance of associations. A p-value of less than 0.05 was considered significant.

The number of women who participated in the study was 520. The mean age of participants was 29.5 years (± 6.9 years). The mean age at marriage was 21 years (± 3.5 years). Among the total 520 participants, 173 (33.3%) women reported at least one symptom of RTI/STI in the past 12 months. Abnormal vaginal discharge was the commonest symptom reported (23.7%) followed by painful urination (5.4%). None of the participants reported inguinal swelling. 140 (26.9%) women reported only one symptom of RTI.

26 (5%) reported 2 symptoms and 7 (1.3%) reported 3 symptoms (Figure 1). The distribution of social and demographic characteristics was analyzed between those who did experience symptoms of RTI/STI and those who did not, in the past 12 months. The socioeconomic status of the study participants was classified from monthly per capita income based on the Modified B. G. Prasad scale for rural area (Class I being the highest socioeconomic group and Class V the lowest) (Table 1). Among the 520 participants, 52 women (10%) had never conceived. Among the 468 women who had ever conceived, 24 women (5.1%) had their first conception at <18 years of age, while the remaining 444 (94.9%) women were aged 18 years and above at their first conception (Table 2). The prevalence of RTIs was proportionately higher among those using a Copper T (an intrauterine device) – an observation that was statistically significant. Inadequate personal hygiene practices related to micturition, such as non-usage of sanitary toilets and non-washing of private parts, was found to be associated with a higher prevalence of RTI, and this difference was also statistically significant (p<0.05). Use of cloth or homemade pads during menstrual periods and poor washing and drying practices of reused napkins was also found to be related to higher prevalence of RTI (Table 3).

The prevalence of RTIs/STIs using the syndromic approach was found to be 33.3% (95% CI; 33.3% ± 3.4%) in our study. This is lower than the 95% confidence limits of the prevalence of RTIs/STIs in Veerapandi Panchayat Union [6]. This lower prevalence could be due to the wide-spread use of the syndromic approach in management of RTIs/STIs. However, it is still higher than the prevalence of RTIs reported in rural areas by DLHS-3 [5], which was 19.6%. Vaginal discharge was the most commonly reported symptom (123 women; 23.7%) followed by dysuria (28 women; 5.4%). Vaginal discharge was also the commonest symptom reported in other studies in rural areas of India [7, 8, 9, 10]. The prevalence of RTI/STI symptoms was highest in the age group 18-20 years (57.1%) followed by 36-40 years (48.1%) and this pattern showed a significant association (p=0.006). Kosambiya et al., [9] Sharma et al. [11] and Rathore et al. [12] have reported a maximum prevalence in the 25-34 years age group. The difference in the present study could be attributed to the composition of study groups (only 5.4% in 18-20 years group), biological factors and lack of awareness among women aged 36 to 40 years. There was a statistically significant association between duration of marriage and the prevalence of RTIs, with women married for less than 1 year showing highest prevalence (56%). This might be due to the community attitudes in rural India encouraging early conception after marriage resulting in non-usage of contraceptive methods in early years of marriage. Our study did not show any significant association between the symptoms of RTI/STI and number of conceptions, live births or abortions. This could be due to the improved reproductive health care services and safe abortion services available now. The current contraceptive status had a significant association with prevalence of RTI (p=0.000). The prevalence of RTIs/STIs was lowest among those who used condoms, highest in those who used Copper T, followed by those who used none of these methods. This confirms the well-known fact that contraceptive methods like condoms have a protective role in the prevention of RTI/STI. The increased prevalence in women using Copper T could be due to the poor follow-up care after insertion. Sharma et al. in West Bengal, Rathore et al. in rural Rajasthan, and Kumar et al. and Ravindran et al. in the Dharmapuri district of Tamil Nadu, have reported similar findings [11, 12, 13, 14]. The prevalence of RTI was lower among women who use toilets for urination and those who wash their private parts after urination (p<0.05). Low levels of personal hygiene was found to be associated with RTIs in studies by Riyami et al. among Omani women, Yang et al. in rural China and Singh S et al. in rural Dehradun [15, 16, 17]. Analyzing menstrual hygiene practices, the prevalence of RTIs was higher among wo

men who used cloth or homemade pads, followed by those who used both cloth/ homemade pads and commercial sanitary napkins (p<0.05). The prevalence of RTI was higher among women who reuse napkins, though the association was not significant. Women who use only soap and water for washing the napkins to be reused were found to have a higher prevalence than those who also use a disinfectant with soap (p<0.05). Analyzing the drying practices of napkins washed for reuse, women who dry the napkins under sunlight were found to have a significantly lower prevalence of RTI symptoms compared to those who dried the napkins in the shade (p<0.05). Similar association has also been reported by Riyami et al., Yang LR et al. and Singh S et al [15, 16, 17]. This association suggests the role for proper menstrual hygiene practices in prevention of RTIs.  RTIs/STIs result in numerous serious consequences among women such as infertility, ectopic pregnancy, preterm labor, miscarriage, stillbirth, pelvic inflammatory disease, cervical cancer, increased susceptibility to opportunistic infections and pregnancy associated complications [18]. Apart from these complications, presence of symptoms of RTIs/STIs is associated with significant psychological distress, due to embarrassment and fear of rejection and stigma [19]. They also constitute a substantial burden owing to their potential to disrupt daily activities and reduce women’s overall well-being. Women in the reproductive age group constitute 22.2% of the population in India [20]. Any morbidity in this group results in a huge burden on the socioeconomic and health status of the community. Thus, the prevention of RTIs/STIs and promotion of reproductive health of women is an issue that warrants high priority in a developing country like India. A major limitation of our study is that laboratory investigations were not used to confirm the diagnosis of RTIs/STIs. However, our study has the advantage of being community-based with a high response rate. Interview based measurement techniques for diagnosis of RTIs/STIs in community surveys has the merit of generalization to the source population given the population-based sampling frame and strategy [21]. Symptomatic diagnosis of RTIs/STIs based on a syndromic approach has also been supported by World Health Organization (WHO) and Center for Disease Control and Prevention (CDC) as an effective and inexpensive approach for diagnosis of RTIs/STIs in low resource settings [22, 23]. This study was small but significant attempt in identifying those suffering from RTIs/STIs in the study area, helping them achieve cure and equipping them with knowledge to protect themselves and their close community from RTIs/STIs.

Our study shows that RTIs/STIs, with a prevalence of 33.3%, continues to be a significant problem in rural areas in spite of the various measures adopted by the Indian government to reduce the transmission of RTIs/ STIs. Age of the participant, duration of marriage, contraceptive usage practices, and personal and menstrual hygiene practices were found to be significantly associated with symptoms of RTIs. Most of these factors are amenable to change by health education and counseling and this study stresses the need for awareness programs for women with a focus on these factors. Postponing the age of marriage to early twenties and creating awareness among young married women regarding contraceptive choices and use should be an important component of RTI/STI prevention programmes. Intrauterine contraceptive device insertion should be followed by proper post-insertion care. Condoms should be promoted not only as a barrier contraceptive but also to protect against RTIs/STIs. Those couples who have undergone permanent sterilization should be encouraged to use condoms for protection against RTIs/STIs. School health programs and health education sessions in antenatal and postnatal clinics should include promotion of proper personal and menstrual hygiene practices. Community based initiatives should be encouraged to promote the production and use of affordable, acceptable and safe sanitary pads.  Considering the high prevalence of RTIs/STIs, there is need for further community based studies to assess the burden and other possible risk factors.

 The author is grateful to Dr. A. K. Rajendran, Director, Institute of Community Medicine, Madras Medical College, and Dr. V. V. Anantharaman, Assistant Professor, Institute of Community Medicine, Madras Medical College (Tamil Nadu, India) for their guidance during the study.

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