Reproductive morbidity a neglected issue? Report of clinical-based study in Far-Western Nepal.

Research Report.

SUMMARY: Background: According to WHO estimates, reproductive ill health accounts for 33% of the total disease burden in women as compared to 12.3% for males. Despite this significant, in many South-Asian countries the magnitude of reproductive morbidity bas not been adequate defined (WHO,1995). This paper describes the results of a study of reproductive morbidity in Nepal. The objective of the study was to obtain and proxy indicators on the prevalence of reproductive morbidity of women in Doti and Accham districts. Specific objectives were: • to identify the number and types of reproductive morbidity among women who attend the clinics; • to identify possible contributing factors of diseases; • to document physical and social conditions associated with reproductive morbidity; and • to gather information on the underlying socio-cultural aspects/traditions that influence women's reproductive health. Methodology : The study was based on data collected during the training of district-level female health care workers in diagnosing and managing uterus prolapsed, and providing screening and clinical services to women who attend the gynaecological clinics. Information was generated from four different sources: patient questionnaire, history form, physical examination form and laboratory form. The clinics were held in the district hospitals of Accham and Doti in February and March 2001 for the and seven days respectively. Results: Demographics 3820 women attended the clinics, of these,2705 presented with gynaecological complaints. The mean age of the patient population was married (91.6%) and a quarter reported currently using family planning . A marked difference was noted in the number of pregnancies among women who had attended school compared with those who had never attende school (2.1 vs 4.4 in Achham district, 2.5 vs 3.7 for Doti). General health status of women The health status of women in this part of the country is strongly influenced by socio-cultural habits. Food restrictions were widely observed in the study area, with 61.2% in the case of a death of a relative, followed by menstruation (47.5%) and the postpartum period (42.6%). Regarding domestic violence, more than 18% of the women reported to have been verbally abused, while 5.1% indicated to have been physically abused. Husbands were cited as the most frequent abusers, Child-related issues the most frequent reason. Weight was found to have a significant association with night blindness, and Doti women who reported following food restrictions ahd lower weights than those who did not. The main reasons mentioned for attending the clinic included RTI (33.6%) , pelvic organ prolapse (25%), menstrual disorders (22.9%) and infertility (14.4%0. Pelvic organ prolapsed(pop) One in four women complained of POP, and on in four were diagnosed with pop. There was a strong correlation between self-reported and diagnosed pop,95.1% of Achhami women and 98.3% of the Doti women who reported pop were also diagnosed with pop. Over one fifth o women reported the onset of prolapsed before the age of 20years,44.2% were between 20-29 years. The mean number of years suffering from pop was 10. Approximately 40% of the women reported only one completed pregnancy at the onset of the pop, while 58% had only completed two pregnancies. O those self-reporting pop,87% had no rest before delivery and 21% reported to have had less than 7 days rest after delivery. The impact of pop on the daily life is dramatic: 88.6% of women reported difficulty lifting, 82% difficulty sitting, 79% difficulty walking,65.5% difficulty standing. Other complaints included backache 955%), burning upon urination (49%) , and painful intercourse(41.1%). The data also suggest a potential association between prolapsed and nutrition. Infertility As with pop, there was a marked correlation between self- reported and diagnosed infertility. 14.1% of the study population complained of infertility and 17.1% were diagnosed infertile. An interesting finding of the study, though not originally included in the research protocol, was the fact that out of 89 semen tests carried out among husband of women complaining of infertility, 68.6% had oligospermia (deficiency in sperm and semen) and 18.1% azoospermia (absence of sperm). Reproductive tract and sexually transmitted infections In contrast to the high number of self-reported RTI/STI symptoms (33.6%), the number of cases diagnosed was much lower (20%). The laboratory findings were even lower, and ranges from trichomonas (3.8%), hepatitis B (1.8%) Syphilis (1.5%) to candidiasis (0.6%), neisseria gonorrhea (0.6%) and bacterial vaginosis (0.1%0). There was no association between women who were clinically diagnosed with a RTI/STI and those with a positive laboratory result. Menstrual disorders Overall 12.3% of the patient population was clinically diagnosed with some of menstrual disorder. The majority of clinical diagnosis related ti dysfunction uterine bleeding , DUB (3.6%) ,followed by Depo- induced DUB (3.4%) lactational amenorrhoea (2.3%) and dysmenorrhoea (2.1%) Recommendations:Establish regular gynaecological training and services Because so many women visited the clinics, it is imperative that gynaecological health services, particular management of reproductive morbidity, become available, consistent and removed from the arena of "special" services. It is therefore recommended to develop regular gynaecological training and clinics I rural districts. Such clinics may be able to play a critical role in detecting and managing reproductive morbidity in remote areas of Nepal. Introduce reproductive morbidity check-lists The findings assert that self-reported prolapse correlates highly with clinically diagnosed prolapse. Therefore, a short checklist should be developed and added to existing checklists used by district level health workers, particularly for family planning and antenatal patients. POP can be more efficiently managed when caught in its early stages. Advocate a focus on non-life -threatening reproductive conditions The findings clearly demonstrate that reproductive morbidity is a felt need for women in rural Nepal. Attention to non-life threatening conditions, but conditions that nonetheless jeopardize quality of life, should be heeded in medical curriculum development, IEC material development, school-based learning , NFE circles, etc. Approaching reproductive morbidity as a service will aid health care infrastructure in reaching a broader population. Women and families do not always see themselves as in danger of life-threatening conditions; however, many people seek answers to their daily discomfort. Increase counseling services As mentioned, many of the reproductive morbidity present in this study can be, at least initially, managed with counseling. Therefore, counseling services related to hygiene, particularly menstrual hygiene, menstruation , ovulation/conception, infertile, family planning, prevention and management of POP and prevention of RTI/STI should be developed and implemented immediately. Such services should be a routine and integrate part of all rural rotational gynaecological clinics. Continue to support social development Government, non-government and donor communities should continue their work in the alleviation of poverty and promotion of women' s status, particularly her right to education, and economic , social and legal freedom.