An Analytical Study of Clinical Profile of Gynecological Morbidity
Yogita Amit Hiwarkar1*,
Hina Kausar2, Amit
A Hiwarkar3
1,2 Assistant
Professor, Community Medicine, Dr. Ulhas Patil Medical
College, Jalgaon Kh.(MS)
3Assistant
Professor, Anaesthesiology, Dr. Ulhas
Patil Medical College,
Jalgaon Kh.(MS)
ABSTRACT:
Background: Among women of reproductive age (15-44 years), the burden of
reproductive ill-health is far greater than the disease burden from
tuberculosis, respiratory infections, motor vehicle injuries, homicide and
violence. One way to understand women’s health care needs is by understanding
the extent and type of illnesses they suffer from.
Objective: To study the prevalence of gyneacological morbidity among urban and rural women of
reproductive age group
Material and
methods: By
systematic random sampling, 220 women in urban slum and 132 women in rural area
were interviewed and asked to follow up in OPD for clinical examination. Per
speculum and per vaginal examination was done in women who followed up in OPD.
Results: On examination, 65.19% women in urban slum and 79.8% of women in rural area had one or more gynecological morbidity.The most common finding on clinical examination was vaginitis (21.54%) and cervicitis (12.15%) in urban area while vaginitis (21.15%), cervicitis (15.38%) and PID (14.42%) were most common finding in rural area.
KEYWORDS: Vaginitis, Cervicitis,
Gynacological morbidity.
INTRODUCTION:
Gynecology morbidity, covers any
condition, disease or dysfunction of the reproductive system that is not related
to pregnancy, abortion or childbirth, but may be related to sexual behaviour.Gynaecological morbidity, which is the focus in
this study, can further be divided into reproductive tract infections,
endocrine disorders, infertility, gynecological cancers, congenital
malformations or birth defects, injuries, sexual dysfunction, menopausal
symptoms and others(1).Gynecological problem include continuum of conditions
which range from inconvenience to disability or even death. Little is known
about how such morbidity affects women’s ability to fulfill a diverse and wide
range of expected roles- domestic responsibilities, economic productivity,
marital and sexual relationships as well as their own psychological well-being.
In addition, what are the main determinants of these morbidities (2). Most of
the knowledge regarding gynaecological morbidity in
India is based on hospital statistics; information available at community level
in India is rare. A few community based studies have focused on an entire range
of gynaecological morbidity and have shown the
prevalence ranging from 26% to 74 %.(3)
Keeping in mind the above facts and as per
recommendations of the WHO study group in 1957, that in order to obtain a
comprehensive picture of a health problem / disease, only vital statistics is
not sufficient, more and more such studies have to be undertaken, Garg Narendra K.(3) and Garg Narendra K.and
Sharma A.B.(4) , the authors have under taken this study with the objective to
analysis the clinical profile of gynecological morbidity in rural and urban
women..
MATERIALS AND METHOD:
STUDY AREA –
The present study was a
community based cross sectional study which was conducted in an Urban slum
which is a catchment area of Urban Health and Training Centre and in the field
practice area of Rural health training center of a Medical College in
Metropolitan city.
Urban: The area under study has a population around one lakh forty two thousand. Area constitutes different settlements
of slum dwellers. The area is divided geographically into seven zones as
follows:
|
Area
|
Population
|
Cumulative Population
|
|
A
|
3500
|
3500
|
|
B
|
5000
|
8500
|
|
C
|
11000
|
19500
|
|
D
|
85000
|
104500
|
|
E
|
2400
|
106900
|
|
F
|
11000
|
117900
|
|
G
|
24000
|
141900
|
|
Total
|
141900
|
|
Rural: The village is a tribal village and it consists of 15 padas. The total population of this village is 2711.
Study population: Reproductive age group
(15-45yrs) married women
Study period - September 2007 to November 2009.
Sampling
procedure and Sample Size:
Urban: Considering the average prevalence of gyneaecological morbidity as 50%, the sample size was calculated at allowable
error of 7.5% as follows:
Sample
size = 4 p q
L2
= 4x
50 x 50
7.5
x 7.5
= 177.
But
to overcome factors such as noncooperation, nonavailability
and refusal of internal examination, 25 % more women were interviewed giving
the total sample size of 220.
By
using simple random sampling one zone was selected consisting of total
population of 11000. As
per the national data of NFHS 3 the average household size for an urban area is
4.8. In the pilot study that was conducted the average household size for the
slum under study was found to be 5, therefore the number of households in the
area III were calculated as,
No. of households in Area III =
Total population of area III
Average family size
= 11000
5
= 2200
Every 10th house was
selected for the study purpose by systematic random sampling. The first
household was selected randomly by using the currency note technique, after
which every 10th household was included in the study. Whenever a
household was found to be locked or when there were no eligible study subjects
in a household the next household on the right was selected for the study
purpose. Randomly, only one woman in reproductive age group was selected from
each household.
Rural: Out of total
15 padas of the village, 3 padas
were selected by simple random technique. The total population and total number
of households in each pada were as follows:
|
PADA
|
No. of household
|
Total population
|
|
Pada1
|
65
|
362
|
|
Pada 2
|
35
|
175
|
|
Pada 3
|
56
|
304
|
|
Total
|
156
|
841
|
Percentage of reproductive age
group women in community is 19%. Applying this percentage to total population,
the number of reproductive age group women came out to be 159. But few women
were not fitting in eligibility criterias or they did
not give consent. So, the total sample size arrived was 132.
House to house survey:
Overall, 220 women in urban slum
and 132 women in rural area were interviewed and asked to follow up in OPD for
clinical examination. Out of the interviewed women, some did not turn up at
health center for examination. Therefore, the effective number of study
participants who were examined, was 181 in urban and 104 in rural area. Per
speculum and per vaginal examination was done in women who followed up.
Limitations of the study
(a). Unmarried women were not
included in the study as it is not possible to do Per Speculum examination in
them and due to cultural reasons.
(b). The gynecological
examination findings of the participants were not confirmed by laboratory
tests. Also the asymptomatic carrier women could have been detected by
laboratory tests which were missed on clinical examination.
Gynecological
morbidity on Clinical examination classified as-
(i)Vaginitis: inflammation of the vagina, with or without
visible discharge;
(ii). Cervicitis:
all diagnoses of acute cervicitis, endocervicitis and chronic cervicitis;
(iii). Pelvic inflammatory
disease (PID): tender, palpable, or thickened fornices
(iv). uterine prolapse: Descent of the cervix to the introitus
or below that as viewed through speculum.
OBSERVATIONS AND DISCUSSION:
On analysis of the collected
data it was noted that in urban area, 82.27% of the study participants followed
up in UHC for physical and gynecological examination. The sample loss was
17.7%.While in rural area, 78.79% of the participants followed up in RHTC and
the sample loss was 21.2% (Table-I).
Table-II, Figure-I shows that on
examination, 118 (65.19%) women in urban slum and 83(79.8%) of women in rural
area had one or more gynecological morbidity.
Table-III shows that higher
proportion of all type of gynecological morbidity except vaginitis
was noted in rural patients. Table further shows that the most common finding on
clinical examination was vaginitis (21.54%), cervicitis (12.15%) and PID (8.33%) in urban while in rural
vaginitis (21.15%), cervicitis
(15.38%) and PID (14.42%) was most common finding. 9.62 5 rural patients was
found suffering from cervical erosion in comparison to their 5.52% urban
counterparts. 2.88%, 3.84, 3.84, 5.76% and 1.92 % rural patients were found
suffering from Fibroids, prolaose uterus, cervical
polyp/ectopy, cervical growth and genital scabies
respectively in comparison to their 1.1%, 2.22%, 1.65%, 1.65% and 1.65% urban
patients. Table also revealed that 0.55% urban patients have vesicles over
genitalia in comparison to nil percentage of rural patients while in cases of
genital warts there were 0.96 % rural patients in comparison to nil percentage
of their urban counterparts.
Bang et al(5)in which 92 per cent of the women had gynecological disorders.
But the results are comparable to the study by Parikh et al(6) in which more than 70 per cent had clinical
evidence of vaginitis, cervicitis,
prolapse or PID.
According to metaanalysis
of Latha et al(7)marked variation was found in
levels of gynecological morbidity across the four sites -- ranging from 26 per
cent in the Baroda study to 43 per cent in the rural West Bengal and Gujarat
studies, to as high as 74 per cent in the Bombay study.
In present study morbidity rates
were higher when measured by examination than by history similar to the study
done by Parikh et al.(6) But
Morbidity rates were considerably lower when measured by examination than by
history the studies in three studies Baroda study rural West Bengal study,
rural Gujarat Latha et al(7).
These variations may be caused
by differences in sexual norms and practices, which may affect exposure to
RTIs, as well as by differences in willingness to report symptoms or be
examined. Women in urban setting may be more secluded and live in a more
conservative sexual milieu, by contrast, social values in tribal areas such as
they commonly allow women more freedom that is sexual.
The most common finding on
clinical examination was vaginitis (21.54 per cent)
and cervicitis (12.15 per cent), in urban area while vaginitis (21.15 per cent), cervicitis
(15.38 per cent) and PID (14.42 per cent) were most common finding in rural
area. RTI/STI was diagnosed in 51.38 per cent of participants in urban and 62.5
per cent of women in rural area. According to syndromic
case management, with prevalence of 39.2 per cent in urban and 45.19 percent in
rural area, the most common syndrome diagnosed was vaginal and cervical
discharge syndrome. About 1.6% of women in urban and 5.7% of women in rural
area were found to have visible cervical growth. 2.2% women in urban and 3.8 %
in rural area were having prolapse uterus.
In metaanalysis
by Latha et al (7) marked variation between
studies was evident for both cervicitis (ranging from
eight per cent in the rural Gujarat study to 40 per cent in the Bombay study)
and for cervical erosion (from two per cent in the rural West Bengal study to
over 20 per cent in the rural Gujarat and the Bombay studies). Vaginitis was also an important source of morbidity (10-15
per cent of women) in all but the rural West Bengal study. Rates of pelvic
inflammatory disease ranged between one per cent and 17 per cent in all
studies.
In study done by Savita Sharma et al (8) the most common
presentation among women was vaginal discharge (51.9 per cent) which is
comparable with the present study. Similarly, second most common syndrome was
lower abdominal pain and less than 2 per cent of women had genital ulcer
disease and inguinal lymphadenopathy.
Findings of various studies
conducted by various researchers were more or less in accordance the findings
of present study.
CONCLUSION:
From above observations and discussion, the authors reached to the
conclusion that rural women were found more sufferers in almost each type of
gynecology morbidity in comparision to their urban
counterparts.
TABLE-I
Percentage of study subjects who underwent Per Speculum
examination
|
Came for PS
|
Urban
|
Rural
|
|
Frequency
|
Percent
|
Frequency
|
Percent
|
|
Yes
|
181
|
82.27
|
104
|
78.79
|
|
No
|
39
|
17.73
|
28
|
21.21
|
|
Total
|
220
|
100
|
132
|
100
|
TABLE-II
Gynecological morbidity on clinical and per speculum & per
vaginal examination
|
Presence of gynecological morbidity
|
Urban
|
Rural
|
|
Frequency
|
Percent
|
Frequency
|
Percent
|
|
Yes
|
118
|
65.19
|
83
|
79.80
|
|
No
|
63
|
34.80
|
21
|
20.19
|
|
Total
|
181
|
100
|
104
|
100
|
TABLE-III
Profile of gynecological
morbidity on physical and gynecological examination
|
Findings on P/S and PV examination
|
Urban
|
Rural
|
|
Frequency
(n =181)
|
Percent**
|
Frequency
(n =104)
|
Percent**
|
|
Vaginitis
|
39
|
21.54
|
22
|
21.15
|
|
Cervicitis
|
22
|
12.15
|
16
|
15.38
|
|
Cervical erosions
|
10
|
5.52
|
10
|
9.62
|
|
PID
|
16
|
8.83
|
15
|
14.42
|
|
Ulcerative genital lesion
|
1
|
0.55
|
2
|
1.92
|
|
Vesicals over genitalia
|
1
|
0.55
|
0
|
0
|
|
Genital warts
|
0
|
0
|
1
|
0.96
|
|
Fibroids
|
2
|
1.1
|
3
|
2.88
|
|
Prolapse uterus
|
4
|
2.2
|
4
|
3.84
|
|
Cervical polyp/ectopy
|
3
|
1.65
|
4
|
3.84
|
|
Cervical growth
|
3
|
1.65
|
6
|
5.76
|
|
Genital Scabies
|
3
|
1.65
|
2
|
1.92
|
** Since participants had
multiple complaints the total percentage would add up to more than 100.
FIGURE-I
Gynecological morbidity on clinical and per speculum and per
vaginal examination
RECOMMENDATIONS:
LOCAL/ COMMUNITY LEVEL:
·
Women need accurate health
education about gynecological morbidity to reduce the stigma and
embarrassment.
·
In the study it was observed that women with gynecological
problems felt strong barrier to talk to anyone about their gynecological
symptoms. Women should be encouraged to
talk about their own health amongst each other and in their family. In
addition, good rapport between women and health workers is necessary.
·
Mahila mandal is a
type of community-based organization of women and they work at local level for
women empowerment issues. It provides a readymade structure for participation
of women in health promoting activities. This organization can be utilized for
raising self-concern in women and to talk about some aspect of reproductive
health. Health care provider can play a major role by participating actively in
the functions of mahila mandal.
Health workers should educate women to come forward for such problems instead
of enduring pain silently. Health worker can make women aware of nearby health
facilities and can promote its utilization. Special emphasis should be given to
avert the dangerous trends like self-medication and consulting to local
healers.
·
Haldi-kunku- One of the popular
functions celebrated by women. Such functions if attended by health personnel
will certainly help in development of good rapport between them.
·
Saving groups/ Bachat Gat: Next common and popular organization run by women in local areas
is saving or bishi groups. This organization is meant
for preventing future constraints with the help of little savings today. All
members gather once in a month and this group continues for 2-3 years. In the
village this group also do some small-scale business with the help of funds
raised e.g. to prepare khichadi for anganwadi. Health care personnel should create awareness
among homemakers about such activities that raise financial capacity and can
thus empower them. The better economic condition will automatically result in
affording all measures needed for good gynecological health of women.
SERVICE COMPONENT:
·
Services for women with gynecological morbidity need to be
coordinated to create a continuum of
care i.e. a system of care that meets the multiple and changing needs of
reproductive women and that extends from the home and the community to the
clinic or hospital and back again.
·
Health services should be improved
and made more accessible so that
women feel comfortable in seeking treatment and are not deterred by concerns
over privacy and confidentiality. Services should be delivered at times
according to convenience of women as many women stated that they could not go
to health center because of time constraint.
·
Health care personnel need to be trained to detect and treat gynecological diseases that commonly
occur in women of reproductive age with special emphasis on STI/RTIs.
·
Health personnel should routinely ask married women, attending
OPDs or immunization sessions, if they are experiencing gynecological symptoms,
as most women do not readily come to seek the treatment only for reproductive
morbidity. Even a single complaint related to gynecological morbidity should
not be ignored.
POLICY LEVEL
·
Primary prevention programmes for gynecological morbidity need to be designed and
Evaluated.
·
Reproductive health education should be given to secondary
school students, out-of-school youth and to young married couples.
·
Policy and service delivery need to address both prevention and
treatment of gynecological morbidity. Gynecological morbidity can be reduced
by: encouraging social changes that
promote the value of girls and delay marriage and first birth; encouraging
girls to complete education and become economically independent, ensuring rapid
access to trained personnel during labor and childbirth; and ensuring proper
spacing between two births.
REFERENCES:
1.
The right to
reproductive and sexual health, United Nations Department of Public Information--DPI/1877--February
1997
2. www.pdhre.org/rights/women_and_health.html
3. Garg Narendra K.:
Evaluation of the impact of emesis and emesis plus purgation Therapy; Research
J Pharmacology and Pharmacodynamics (2) March-April; 2010:201-202.
4. Garg Narendra K and
Sharma A.B.: Epidemiological profile of patients attending a tertiary care
hospital, Muktsar,Punjab (India); Research J
Pharmacology and Pharmacodynamics:3 ;6
5. Bang R,
lancet 1989, 85-7, A community study of gynecological disease in Indian
villages: some experiences and reflections. POPLINE Document Number: 113353
6. Parikh,
I., Taskar, V., Dharap, N.,
et al. (Undated): ‘Gynecological Morbidity Among Woman in a Bombay Slum’s, Draft
Report, Streehitakarini, Bombay
7. Latha, K; Kanani, S.
J; Maitra, N.: Prevalence of Clinically Detectable
Gynecological Morbidity in India: Results of Four Community Based Studies. The
Journal of Family Welfare. Dec 1997. 43(4). P.8-16
8. Savita Sharma, BP Gupta, The prevalence of
reproductive tract infections and sexually transmitted diseases among married
women in the reproductive age group in a rural area, Indian journal of
Community Medicine, Vol.34, issue 1, pg 62-64.