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Prevalence & Factors Associated with Chronic Obstetric Morbidities In Indian J Med Res 142, October 2015, pp 479-488 DOI:10.4103/0971-5916.169219 Prevalence & factors associated with chronic obstetric morbidities in Nashik district, Maharashtra, India Sanjay Chauhan, Ragini Kulkarni & Dinesh Agarwal* Department of Operational Research, National Institute for Research in Reproductive Health (ICMR), Mumbai & *United Nations Population Fund, New Delhi, India Received February 20, 2014 Background & objectives: In India, community based data on chronic obstetric morbidities (COM) are scanty and largely derived from hospital records. The main aim of the study was to assess the community based prevalence and the factors associated with the defined COM - obstetric fistula, genital prolapse, chronic pelvic inflammatory disease (PID) and secondary infertility among women in Nashik district of Maharashtra State, India. Methods: The study was cross-sectional with self-reports followed by clinical and gynaecological examination. Six primary health centre areas in Nashik district were selected by systematic random sampling. Six months were spent on rapport development with the community following which household interviews were conducted among 1560 women and they were mobilized to attend health facility for clinical examination. Results: Of the 1560 women interviewed at household level, 1167 women volunteered to undergo clinical examination giving a response rate of 75 per cent. The prevalence of defined COM among 1167 women was genital prolapse (7.1%), chronic PID (2.5%), secondary infertility (1.7%) and fistula (0.08%). Advancing age, illiteracy, high parity, conduction of deliveries by traditional birth attendants (TBAs) and obesity were significantly associated with the occurrence of genital prolapse. History of at least one abortion was significantly associated with secondary infertility. Chronic PID had no significant association with any of the socio-demographic or obstetric factors. Interpretation & conclusions: The study findings provided an insight in the magnitude of community- based prevalence of COM and the factors associated with it. The results showed that COM were prevalent among women which could be addressed by interventions at personal, social and health services delivery level. Key words Chronic obstetric morbidities - chronic PID - community-based prevalence - genital prolapse - obstetric fistula - secondary infertility 479 480 INDIAN J MED RES, OCTOBER 2015 Reproductive morbidities include gynaecologic girls married at age less than 18 yr, home deliveries and and obstetric morbidities. Gynaecologic morbidities institutional deliveries for 33 districts in Maharashtra include reproductive tract infections, menstrual state as per the District Level Household Survey disorders, reproductive endocrinal disorders and (DLHS III) conducted in 2002-200312. As per these primary infertility. Obstetric morbidities are related data, Nashik district had its indicators at mid-level and to pregnancy, delivery or treatment of conditions that hence was selected to represent the Maharashtra State. arise during pregnancy or delivery. These can be acute For appropriate representation of the rural population and chronic. The short term or acute morbidities occur from the district, the list of total 103 primary health during pregnancy, delivery or within six months of centres (PHCs) consisting of 52 tribal and 51 non-tribal delivery or abortion and include eclampsia, antepartum PHCs was obtained from the District Health Office. and postpartum haemorrhage, obstructed labour, sepsis Six PHC areas (3 each from tribal and non-tribal) and post abortion bleeding or sepsis. The long term or were selected by systematic random sampling. One chronic obstetric morbidities (COM) include obstetric village each from the PHC and subcentre was selected fistula (vesico-vaginal or recto-vaginal), genital and 130 women satisfying the inclusion criteria were prolapse, chronic pelvic inflammatory disease and selected by visiting households. Thus, from each PHC, secondary infertility1. 260 women leading to a total of 1560 women from six Many studies have been conducted to estimate PHCs were included in the study. the prevalence and determinants of gynaecological The existing data on prevalence from the morbidities globally and in India2-9. Data on self community-based studies conducted on chronic reported experiences on acute obstetric morbidities 13 in India are also available from the National Family obstetric morbidities in South-Asia was considered Health Survey conducted in 1998-199910 and 2005- for estimation of sample size in the study. Considering 2006 in the country11. However, chronic obstetric the lowest prevalent condition of obstetric fistula as morbidities (COM) is a neglected issue in India. The one per cent, the sample size for infinite population available data on COM are scanty and largely derived was calculated to be 1560 women. An expected sample from hospital records. Considering the need for such loss of 45 per cent was considered for calculation of information, the present study was undertaken to assess sample size. The studies conducted in India in rural the magnitude and the factors associated with defined setting had shown a response rate varying from 19-59 COM such as obstetric fistula, genital prolapse, chronic per cent3,5-7. Hence an anticipated sample loss of 45 per pelvic inflammatory disease (PID), and secondary cent was taken. infertility in Nashik district of Maharashtra State of Inclusion/exclusion criteria: The inclusion criteria for India. In addition, information on associated factors study participation were non-pregnant ever married such as demographic, socio-economic and factors women with proven fertility (had at least one abortion related to conduction of deliveries and abortions was or live birth or stillbirth) in the age group of 15-44 yr. also collected. Though the focus of the study was on The exclusion criteria were pregnant women, women COM, the opportunity was utilized for collecting data on gynaecological morbidities also. who had delivered or had abortion within last six months and women having history of hysterectomy. Material & Methods Tools including the women’s household interview The protocol of this community based cross- schedule and clinic schedule were drafted by the sectional study was approved from Institutional Ethics investigators; the draft was discussed and finalized Committee of the National Institute for Research with United Nations Population Fund - India (UNFPA) in Reproductive Health, Mumbai, India. Written technical advisory group members. Operational informed consent in local language was obtained from definitions with diagnostic clinical criteria for defined the respondent during household survey, facility based COM (obstetric fistula, genital prolapse, chronic PID survey and clinical examination. and secondary infertility) were framed14, discussed and The study was conducted during two years adopted during an expert group meeting at UNFPA, between January 2006 and December 2007 in Nashik Delhi (Annexure). Pre-testing of tools was done in the district of Maharashtra. Selection of district was done field areas and these were finalized in two expert group based on the data of indicators such as percentage of meetings. 481 INDIAN J MED RES, OCTOBER 2015 Data collection: Prior to data collection, rapport building The reasons for non-participation of 393 women efforts were done extensively in the community were asymptomatic women not willing to undergo for six months to create a conducive environment examination, not satisfied with treatment of PHC, busy to maximize women’s participation in the study. with work and women unwilling to lose their daily Close interaction with the government health staff, wages. Treatment was given to majority of women stakeholders such as local leaders including panchayat diagnosed with morbidities after conduction of clinical members and mahila mandals (women’s groups) and gynecological examination and wherever required was also done. Qualitative as well as quantitative women were advised investigations and were referred methods were used for data collection. Six focus to higher facilities for treatment with a back up of group discussions (FGDs) were conducted among follow up. ever married non-pregnant women in reproductive age Mean age of women at the time of household group one in each PHC area to explore the awareness, interview was 31 ± 7.09 yr, 249 (21.3% were between perceptions and experiences related to reproductive 15-24 yr age group; 518 (44.4%) between 25-34 yr morbidities, the coping mechanism and treatment age group; and 400 (34.3%) were above 35 yr. One seeking behaviour for these morbidities. FGDs also hundred and ninty six (94%) women were currently helped in understanding the local terminologies for married while the rest were widows, separated or these morbidities and designing the questionnaire. divorced. Fifty one per cent women were staying in This was followed by collection of quantitative data nuclear families and almost two third 823 (70.5%) by social investigators during household interviews households had monthly per capita income of less than among 1560 women. These women were mobilized by ` 500. Majority of women were Hindus 1119 (95.8%) special efforts in the community such as conducting and 623 (53.4%) belonged to scheduled tribes. About communication activities for maximum participation half 564 (48.4%) of the participants were illiterates, of women for undergoing clinical examination at the 154
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