International Institute for Population Sciences Deonar, Mumbai

Transcription

1 PSYCHOSOCIAL, CULTURAL AND SERVICE FACTORS AFFECTING REPRODUCTIVE MORBIDITY AMONG RURAL WOMEN IN MAHARASHTRA (SUMMARY REPORT) International Institute for Population Sciences Deonar, Mumbai

2 PSYCHOSOCIAL, CULTURAL AND SERVICE FACTORS AFFECTING REPRODUCTIVE MORBIDITY AMONG RURAL WOMEN IN MAHARASHTRA by S.K. Singh Rajiv Prasad Ravi K.Verma Arvind Pandey International Institute for Population Sciences Govandi Station Road, Deonar, Mumbai

3 Preface Reproductive health covers all aspects of women s health. It is an umbrella concept, consisting of several distinct, yet related issues such as abortion, childbirth, sexuality, contraception, and maternal mortality. Biological, social, cultural, economical, and behavioural factors play an important role in determination of reproductive health. Problems of reproductive health are particularly acute in developing nations. Nearly 90 percent of all the births in the world occur in developing countries. Reproductive health needs, especially in developing countries and particularly in India are poorly understood and ill served. Reproductive health addresses women s health, rights, and empowerment, but in India reproductive morbidity is an outcome of not just biological factors but also of women s poverty, powerlessness and lack of control over resources as well. The magnitude of woman s reproductive health problems in India is immense, ignored and marginalised and demands immediate attention. The main objective of the study is to determine the psychological, socio-cultural and service related factors, which affect reproductive morbidity among rural, married women of reproductive age in different parts of Maharashtra. The study has revealed several important findings that have implications for policy makers. It has also raised a number of issues, which need immediate attention for improvement in the effectiveness of overall reproductive health programme. We are grateful to the Indian Council of Medical Research (ICMR), New Delhi, for selecting the International Institute for Population Sciences (IIPS), Mumbai, to undertake this study. We express our sincere gratitude to Dr. R. N. Gupta, Deputy Director General and his colleagues for their constant support and valuable suggestions. We are thankful to Professor T. K. Roy, Director and Senior Professor, IIPS for his guidance and encouragement at different stages of this study. We acknowledge the sincere efforts put in by the Research staff and Assistant Research Officers Mrs. Shubhangi More, Ms. Papya Guha, Mr. Mohan Tiwary who extended their support in the data analysis and documentation work. We would fail in our duty if we do not acknowledge the contribution of women respondents who not only spared their valuable time but also provided us information on many sensitive issues as well as other necessary information required for this study. Last but not the least, we are grateful to district health officials of Nagpur, Kolhapur, Thane and Jalgaon for providing valuable help during various stages of data collection. Shri Kant Singh Rajiva Prasad Ravi Kumar Verma Arvind Pandey

4 Contents INTRODUCTION... 1 OBJECTIVES... 1 CONCEPTUAL FRAMEWORK... 1 STUDY DESIGN AND RESEARCH TOOLS... 2 PROFILE OF THE RESPONDENTS... 3 MENSTRUAL PROBLEM... 5 PROBLEMS OF RTIs /STIs AND TREATMENT SEEKING BEHAVIOUR... 7 GYNECOLOGICAL/OBSTETRIC HEALTH PROBLEMS CONTRACEPTIVE MORBIDITY... 13

5 List of Figures Prevalence of Reproductive Morbidities in Maharashtra... 4 Prevalence of RTI/STD related problem in different categories of hygiene... 5 Prevalence of Menstrual Problems in Maharashtra... Types of RTI/STD problems in Maharashtra Types of Gynaecological problems in Maharashtra Perceived reasons for Gynaecological/Obstetric problems Types of Contraceptive Morbidities in Maharashtra Perceptions about contraceptive morbidity among currently married women who are suffering from it Treatment seeking behaviour for contraceptive morbidity... 16

6 INTRODUCTION Reproductive health of women has recently become focus of attention due to its implications for women's own health, health of their children, family members, socioeconomic development of society, and population programmes. The reproductive health status of women, especially in the developing world including India, requires urgent attention. Over one-third of all healthy lives lost among adult women is due to reproductive health problems (WHO, 1995). Women are at risk of complications from menstruation, pregnancy and childbirth. They often deal with unwanted pregnancy, suffer due to unsafe abortions, problems arising out of contraception, risk of contracting reproductive tract infections (RTIs) and sexually transmitted diseases (STDs), including HIV infection. In India, though there are not many studies on women's reproductive morbidity, the available data indicate high reproductive morbidity in comparison to other developing and it's neighbouring countries. About 15 percent of the women attending routine gynaecological check-ups had chlamydial antigens (Joshi et al, 1994). From 9-30 percent of women attending STD clinics had some microbial organism (lyer et al, 1991). A cytological screening of women showed that Tricho-monas vaginalis was the most common infection (Sardana et al, 1994). Recently, a survey of reproductive health showed 38 percent women complaining of excessive vaginal discharge (ICMR, 1994 unpublished data). Bleeding, backache, weight gain, and menstrual irregularity are the main side effects experienced by women using IUDs and oral pills (ICMR, 1982). Infertility, both primary and secondary, has been reported to be about 10 percent (Gupta et al, 1986). The complications arising from abortion, particularly induced abortion, pose a serious reproductive health hazard more so when it is done by unauthorized and untrained personnel. The reported present abortion rate is as high as 45.2 per thousand live births (Chetna, 1994). The rate of induced abortion by unauthorized persons has been found to be 13.3 per thousand pregnancies as against 6.1 by authorized persons (ICMR, 1989). The available evidences regarding the level of reproductive morbidity are not comprehensive enough to give an accurate national picture. Biological factors alone do not explain women s disparate health burden. The psychological, socio-cultural and service-related factors have a major impact on women s reproductive health. Every culture and society has it s own system of defining and identifying a disease which may or may not overlap with the modern allopathic medical diagnosis (Lieban, 1977; Young, 1982). In addition to the cultural ideas and beliefs about any illness, individuals own perception is also important. Women as well as society perceive different reproductive morbidities differently. Whether treatment is sought and the type of treatment sought may largely depend on that perception (WHO, 1989). OBJECTIVES The main objective of the study is to determine the psychological, socio-cultural and service related factors, which affect reproductive morbidity among rural, married women of reproductive age in different parts of Maharashtra. The specific objectives of this study are: 1. To examine socio-economic and demographic characteristics of women, and cultural and service related factors affecting health/illness and treatment seeking behaviour related to different reproductive morbidity conditions. 2. To identify the factors affecting tolerance threshold and consultation lag for different reproductive morbidities. 3. To examine the relationship between different types of health behaviours and different reproductive morbidities. 4. To determine the relationship between health behaviour and severity level of a morbid condition. CONCEPTUAL FRAMEWORK Reproductive health/illness of women is affected by their treatment seeking behaviour. Whether treatment is sought or not, and when and what kind of treatment is sought for what kind of reproductive illness will determine the reproductive health status of women. Health seeking behaviour is governed by a multitude of factors. The beliefs and perceptions of different reproductive illnesses, availability and accessibly of treatment and quality of 1

7 service provided will affect treatment-seeking behaviour at different levels. The education, exposure, personal hygiene, socio-economic status and occupation will affect women s decision about treatment of reproductive illness. The cultural factors bear an important influence on individual behaviour through learned societal norms. The health behaviour of a woman will be affected by the cultural beliefs and prescribed coping mechanisms for different morbidities. The status of women in a society will determine their access to information and resources, which will affect their health behaviour. In addition to the above, the factors related to delivery of health services and their providers have a significant impact on women s reproductive health behaviour. The technical expertise and attitudes of providers towards their clients and their problems will affect women s health behaviour and consequently health status. The relationships of all these variables are shown in the following conceptual model, which has been followed in this study: CONCEPTUAL MODEL villages and from each stratum one village was selected randomly for the study. All currently married women of reproductive age groups (in the age group years) in the selected villages were considered eligible for the study. Thus, a total of 24 villages have been selected and eligible women were included for the study. Considering an average population of 2,000 in a village and about 170 women of reproductive age in a population of 1,000, so, there will be about 340 women of reproductive age in a village. Further, about 40 such women may be unmarried, divorced, widowed, or separated and non-available during the study survey. Thus, it is expected that only 300 women in a village will be available for study purpose. And for al the 24 villages in a state there will be approximately 7,200 women. Taking above consideration, in order to identify the women currently suffering or ever suffered from reproductive morbidity, initially all women are screened. Only those women who are currently suffering or have suffered within one year are included for psychosocial study. Psychological, Socio-economic and Demographic Characteristics Cultural Factors Health Behaviour Reproductive Morbidity Service Factors Independent Variables Proximate Variable Dependent Variable STUDY DESIGN AND RESEARCH TOOLS The research design consists of a random selection of four districts from Maharashtra followed by selection of two Primary Health Centres (PHCs) from each of the selected districts. In each PHC, the villages were stratified into PHC village, sub-centre villages and remote Now, considering 60 per cent prevalence rate of reproductive morbidity, there will be 180 women per village and about 4,300 women in 24 villages in one state. By taking 50 per cent random sample of the women having some reproductive morbidity, about 90 women per village and thus about 2,200 women for all the 24 villages in a state are available for the psychosocial study. 2

8 Total No. of women per village for initial screening Total No. of women in 24 villages for initial screening Total No. of women per village for psychosocial survey Total No. of women in 24 village for psychosocial survey = 300 = 7,200 = 90 = 2,200 In addition, 10 per cent random sample of women having no reproductive illness will also be taken for psychosocial survey. The number of women per village will be Hence for 24 villages it will be If the villages are small then more sub-center and remote villages, selected randomly, are taken in order to obtain the requisite sample size for the study. PROFILE OF THE RESPONDENTS The main objective of this chapter is to discuss in brief background characteristics of the respondents and prevalence of different types of reproductive morbidities. This chapter has been organized into two sections. First section deals with socio-economic and demographic profiles of 7133 respondents who were screened for the prevalence of any types of reproductive morbidities and also the variations in the prevalence of these morbidities by their background characteristics. However, the second section is devoted to analyse the variations in the reported morbidities among women selected for canvassing the survey instruments for the sample as a whole as well as each of the four districts included in the study. Present section deals with the socio-economic and demographic determinants of various types of reproductive health problems among 300 respondents screened from each of the 24 villages included in the study based on syndromic approach using a wellstructured screening performa. Current age, age at effective marriage, caste, religion, education, and occupation are some of the variables included for analysing the background characteristics of the women. Nearly half of the total respondents (48 percent) included in the screening were belonging to broad age group of years, which comprises of the most active childbearing ages. The pattern is by and large the same in all the four district included in the study with slight but insignificant variation. The proportion of married adolescent women is lower in all the four districts. Caste and religion have been considered as important determinants of lifestyle at aggregate level particularly in rural India. More than fourfifths of the respondents are Hindu, the proportion of Muslims and others are 6 and 8 percent respectively. Slightly less than half of the respondents (46 percent) belong to the category of OBCs followed by 34 percent in General category and 20 percent belong to SC/ST. Age at effective marriage is a determinant, which needs to be explored carefully while discussing about women s health problems. Slightly over three-fourths of the respondents reported to initiate their reproductive process somewhere between years of age. 84 percent of respondents reported their age at effective marriage on or before 19 years of age. Women s autonomy plays a vital role in determining the health status of women in ways more than one. Educational attainment and occupational status, largely govern the utilization of health care services. Almost half of the respondents (49 percent) have educational attainment up to primary or even below and only 8 percent reported to have education above secondary schools. The percentages of respondents working as skilled workers are very low irrespective of districts included in the study. The pattern of variation in the prevalence of reproductive health problems across four districts of Maharashtra included in the study. As explained earlier, out of seven types of reproductive morbidities explored in the study, RTI/STDs, menstrual problems, and contraceptive related problems are the leading reproductive health problems in Maharashtra with a considerable variation across districts. The findings on prevalence of reproductive health problems by background characteristics of respondents show that 42 percent of the eligible women for this study did not report any type of reproductive morbidity. Among those suffering from one or other types of reproductive health problems, a substantially higher 3

9 proportion (26 percent) reported to suffer from RTI/STD related problems followed by menstrual health problems (17 percent) and contraceptive related problems (9 percent). Prevalence of Reproductive Morbidities in Maharashtra No Menstural problems morbidities 42% 17% Delivery problems 1% Gynecologi cal morbidities 3% Contracepti ve morbidities 9% RTI/STIs 28% Menstruation related problem shows significant variations by education as well as occupation of the respondents. It is surprising to note that the respondents from PHC villages are more likely to suffer from menstruation related problem than among those staying in remote villages. This pattern is in contrast with the findings with prevalence of RTI/STDs, where respondents from sub centre villages and remote villages are more likely to suffer with RTI/STDs. There is a considerable variation in the prevalence of contraceptive morbidities by background characteristics of the respondents, particularly, religion, caste, age at effective marriage and type of villages. Almost every second currently married women who are suffering from any reproductive health problem in Maharashtra (47 percent) are likely to suffer from RTI/STD related problems followed by menstrual health problems (28 percent) and contraceptive related problems (14 percent). Prevalence of menstrual health problems is by and large uniform across different categories of predictors, which are background characteristics of the respondents, except educational attainment of women and type of their villages. Prevalence of RTI/STDs shows significant variations by religion, current age, age at effective marriage, education and type of villages of the respondents. Currently married women in the age group years in Maharashtra (53 percent) are more likely to suffer with RTI/STD related problems then among younger as well as older women. Muslim women, those belonging to general caste category and those having age at effective marriage above 25 years are more likely to suffer from RTI/STD related problems. Respondents from remote villages are more likely to suffer with RTI/STDs than others. There is a considerable variation in the prevalence of contraceptive morbidities by background characteristics particularly, religion, caste, age at effective marriage, education and occupation of the respondent. A higher prevalence rate of contraceptive morbidities among SC/STs, among illiterates, among those involved in unskilled works may be attributed to a poor quality contraceptive acceptance process with lagging knowledge about contraindication and side effects of different methods. Though the extent of reported gynaecological morbidities is low (4 percent) but currently married women in the age group years and those staying in remote areas are more likely to suffer with gynaecological problems. It is worthwhile to mention that adolescent mothers (currently married women in the age group and years), those educated above secondary schools, working as house wives and living in PHC villages are more likely to suffer with pregnancy related problems. There is a growing realization that lack of personal hygiene and sanitation is one of the important reasons of some common reproductive health problems among women. This section aims to analyze the extent of hygiene and sanitation among women in rural Maharashtra and also to examine the association between hygiene and reproductive morbidities. The extent of personal hygiene, menstrual hygiene and sexual hygiene have been determined by merging information on a number of dimensions like, washing hands before food, washing hand after defecation, taking bath during menses, regularly cleaning vagina during menses, washing of clothes used during menses, washing sex organs after intercourse etc. These variables are further classified into low, medium and high based on range of the variables. It is quite evident that there is wide variation in terms of personal and menstrual hygiene, which ranges in the scale from 0.3 percent in case of low menstrual hygiene to 94 percent for high menstrual hygiene. It is very interesting to note that a vast 4

10 majority of the respondents have reported to have high personal (88 percent) and menstrual hygiene (94 percent), and similar pattern is followed in all the four selected districts of Maharashtra. However, the situation is not encouraging in case of sexual hygiene for both women as well as their husband. Association between status of personal, menstrual, and sexual hygiene and prevalence of different types of reproductive morbidities reveals that there is a significant variation in RTI/STD related problems by the level of different types of hygiene. Menstrual hygiene seems to contribute the maximum differences in the reported prevalence of RTI/STD related diseases with a variation of more than 20 percent point from high to low menstrual hygiene levels. Prevalence of RTI/STD related problem in different categories of hygiene High Low Sexual Hygiene-Husband High Low Sexual Hygiene-Self High Low Menstrual Hygiene High Low Personal Hygiene MENSTRUAL PROBLEM Percentage of women The onset of menarche is well marked in almost every society. It is a significant milestone in every woman s life, which marks her capability for marriage and reproduction. Despite the fact that in many societies the onset of menarche is celebrated, menstruation has negative connotation related with its physical discomfort besides various societal and religious restrictions. The experience of menstruation varies from woman to woman. Some of the problems related to menstrual bleeding which women face are amenorrhea (no period), delayed period (oligomenorrhea), which may occur after use of contraceptive or by menstrual cycle in which no egg is produced, excessive bleeding and painful periods (dysmenorrhea), prolonged bleeding (menorrhagia) which may be caused by the use of IUD, by small, noncancerous growths in the womb known as fibroids, an infection of the womb or uterine tubes or a hormone imbalance, scanty bleeding (hypomenorrhea) etc. Since menstrual problems are not symptomatic and the pain goes off after couple of days, many women rarely signal it as an actual illness and do not take them as problems. Out of 7133 women screened for the study, 2048 women (29 percent) were screened having at least one menstrual problem. Painful period and scanty bleeding were the two leading problems reported by 13 and 11 percent of women respectively. Prevalence of different types of menstrual problems according to background characteristics show that problem of no period was reported more (4.32 percent) among women of age group 40-45, delayed problem was reported more (14.05 percent) among women belonging to age group compared to other age groups and problem of scanty bleeding was reported more (14.56 percent) among women of age group years. Women belonging to SC/ST category reported more (17.52 percent) cases of having painful period, delayed period (8.77 percent), and scanty bleeding (14.69 percent) compared to women of general and OBC category. By age of effective marriage, it is found that prevalence of no period and painful period and scanty bleeding increased with increase in age of effective marriage age. The prevalence of scanty bleeding was the highest (20.90 percent) among the age group 25 and above compared to other age groups. It is interesting to find out that, the prevalence of menstrual problem decreased with increase in education. The prevalence of no period, painful periods and delayed period is more among unskilled workers than skilled workers and housewives. Unskilled workers had more (12.41 percent) prevalence of scanty bleeding compared to others. Variations in the prevalence of menstrual problems by background characteristics of the respondents reveal that out of the total 7133 women, 6.9 percent of women in the age group and 6.6 percent of women in the age group years, reported having menstrual problem, 5

11 these age group represented high percentage compared to other age groups. Around 30 percent of Hindu women reported having menstrual problem, which predominates women from other religion categories. Considering education women whose educational level is secondary and above, they reported less (1.9 percent) on having menstrual problem which indicates that level of education helps in managing menstruation and menstrual problem as it is found that respondents with higher level of education, reported less in having menstrual problem. Similarly by work or occupational status, women who are skilled worker (1.0 percent) reported to have less menstrual problems compared to women who are housewives (18.5 percent). By type of village, there is not much variation in reported menstrual problems. Percentage of women Prevalence of Menstrual Problems in Maharashtra 13 No period 3 Painful period 4 Frequent Period 9 Delayed period 3 Prolonged bleeding 4 Excessive bleeding 2 Continuous bleeding Types of Menstrual Problems 11 Scanty bleeding 2 Inter-menstrual bleeding Menstrual problem was also analysed with the history of problem or prevalence of the problem whether the problem is current, had menstrual problem in the past one year and experienced menstrual problem both current and past. It is evident that among the 29 percent currently married women who reported to suffer from one or other morbidity slightly over 5 percent were having current menstrual problem, while 2.6 percent of them had menstrual problem during the last year, while the rest 21 percent of women reported having menstrual problem both currently and in the past year. Reporting of current menstrual problem was high on lower age groups and it decreased with increase in age. By religion, Muslim women reported more (7.4 percent) current menstrual problem compared to other religious group. Marriage at younger ages reported more in having current menstrual problem. It is also seen that with increase in education the reporting of current menstrual problem decreased. Analysis of variation in current as well as past problem for those experiencing menstrual problem reveals that, women in age group and years had the highest representation compared to other age groups. Compared to Hindu and Muslim women, women belonging to other religious group represented more (28. 4) in reporting menstrual problem. Also those belonging to SC/ST group had the highest representation compared to others (27.4). The menstrual problem by history and duration of problem reveal that among those who currently have problem of no period, more than 50 percent of women reported having problems slice last 2 to 3 months, and for duration of the problem from the last one-year, 46.2 percent reported having no period since 6-12 months. All the women have reported having problem for more than one year when history of the problem i.e. both current and past is taken into account. Cent percent of women having other menstrual problems were reported to be experiencing menstrual problem currently and in the last year and for a duration of more than one year. Perception about Menstrual problem and treatment seeking behaviour Treatment seeking behaviour for any disease is largely governed by people's perception about the disease, which of course varies by socio-economic characteristics of the person. This section deals with perception of respondents on different dimensions of reproductive health problems viz. whether they consider these problems as disease or not, their seriousness, whether they are shameful, whether there is any need for treatment, and perceived impact on social and sexual life etc. and variations in the perception by socio-economic and demographic characteristics of the respondents. Irrespective of the women s educational status, ethnicity, religion, household income, type of village, housing condition, occupation and type of family, more women 6

12 reported that menstrual morbidity requires treatment, followed by those who consider it as a disease and shameful. The perception of menstrual problem as very serious increased with increase in women s menstrual hygiene. However, it is found that the perception of menstrual problem as very serious decreased with increase in levels of sexual hygiene of both the spouse. Women of low (19.2) and high (19.7) personal hygiene considere menstrual problem as shameful. The perception as Treatment required decreased with increase in levels of menstrual hygiene, self-sexual hygiene, husband s sexual hygiene, husband s alcohol, pan masala, gutka consumption and the frequency of their smoking behaviour. The perception of the cause of menstrual problem of those women having menstrual problem by their background characteristics reveals that irrespective of background characteristics, majority of the women perceived anxiety as the cause of menstrual problem followed by other reasons. Variation in the perception about menstrual problem was also explored through FGDs. Ignorance about menstrual problems among majority of rural women was one of the important revelation. They do not consider no period as a menstrual problem. The most common problem they face during menstruation is pain in the abdomen, which they term as painful period. They also face the problem of scanty bleeding and sometimes the period is delayed. They opine that scanty bleeding might be a sign of beginning of menopause. But delayed period sometimes troubles them a lot. The women perceive that poor health of the women causes these problems. Looking at the treatment seeking behaviour, it has emerged from the study that both western and traditional medicines are sought for alleviating the menstrual problem. However traditional medicine (faith healing) was the most commonly reported treatment seeking behaviour irrespective of their background characteristics. Among those women (250) who have sought treatment, 53.6 percent sought faith healing, 42.4 percent sought allopathic treatment, 2.8 percent sought non-allopathic treatment and 0.8 percent sought selfmedication. More than half of women belonging to age group less than 35 years sought faith healing and half of women in age group 35 and above sought allopathic treatment. Increase allopathic treatment seeking behaviour in older women could be due to higher degree of autonomy in decision-making on treatment seeking and their greater freedom of mobility compared to younger women. By education, about two-third of illiterate women sought faith healing. It is also found that allopathic treatment seeking behaviour increases with increase in education. The level of education may help in creating awareness of menstrual problem and also the importance of getting treatment from skilled personnel. Irrespective of the presence of PHC or SC or be it a remote village, about half of the women sought faith healing. Allopathic treatment was more in remote villages compared to those villages, which has PHC/SC. This breaks the illusion that the availability of health facilities increases the utilization of health care. PROBLEMS OF RTI/STIs AND TREATMENT SEEKING BEHAVIOUR The way in which, reproductive health services are offered, has been undergoing considerable revision over the past few years in the wake of rising HIV epidemic in major parts of the developing world. The Programme of Action of the 1994 International Conference of Population and Development (ICPD) emphasized reorienting health care systems to enable women to obtain comprehensive and quality reproductive health services. Thus preventing RTIs including STIs becomes a high priority in the RCH Programmes. In light of this the present chapter examines the effect of psychological, socio-economic and demographic characteristics of women on their sexual health and their treatment seeking behaviour in Maharashtra. Prevalence of RTIs/STDs The prevalence of different types of RTI/STI problems according to background characteristics in Maharashtra shows women in the age group complain more about low backache (17 percent) followed by white discharge and pain during sexual intercourse (6.5 percent). Similar trends are found in all the other age groups. Overall it can be said that RTI/STI related problems are more in the older women in the age group of years (5.8 percent). Followed by younger cohort in the age group (2.3 percent). Around 40 percent Hindu women complained about some RTI/STIs problems and 7

13 most of them had low backache (26 percent). A negligible proportion of Muslims (0.3 percent) and women belonging to other religions (1.1 percent) had any problem. There are some variations in RTI/STI related problems according to caste groups Types of RTI/STD problems in Maharashtra 6 White Discharge Itching over vulva 2 1 Boils/Ulcers/ Warts a... 3 Pain in lower abdomen 27 Low Backache 3 Pain during intercourse Bleeding after intercourse 1 1 Swelling in the groin 6 Frequent/ Painful urin... While 16 percent belonging to general caste reported any problem, it is 21 percent and 10 percent for OBCs and SC/STs. Low backache is the most frequently cited problem by all the three caste groups. Women whose effective age at marriage is less than 20 years are more likely to have RTI/STIs (40 percent) than those whose effective age at marriage is more than 20 years (8 percent). Women who are educated up to primary level are having more RTI/STI related problems (23 percent) compared to women who are educated up to secondary level. Regarding occupational status of the respondents, RTI/STI problems are more among housewives (31 percent) followed by unskilled workers (15 percent). There is little difference in RTI/STI problems according to the types of villages in Maharashtra. The prevalence of RTI/STD related problems in Maharashtra by duration of the problem according to the background characteristics of the respondents have also been analyzed. Women in their twenties are facing RTI/STD problem more than their counterparts in other age groups. Thirty-one percent in the age group years and 24 percent in the age group years are reported to having RTI/STD problem at present. Almost one-third women in the age group and more than one-fifth women in the age group had past problems. Around 80 percent of Hindu women are currently having RTI/STD problem, while 83 percent had some problems in the past. Proportion of Muslim women who have current problem is much lesser (11 percent) and 9.3 percent of them said they had problem in the past. More than half of the women belonging to the general caste currently have RTI/STD problems, while it is 32 percent and 12 percent respectively for OBCs and SC/ST. Around 35 percent general caste women had the problem in the past while it is 43 and 22 percent for OBCs and SC/STs. Little less than half of all OBC women are either currently having problem or had the problem in the past. Women who are more educated are less likely to suffer from RTI/STDs. While 42 percent women with education up to primary and 48 percent with education up to secondary are having problems currently, only 11 percent women with education above secondary are currently suffering from RTI/STDs. Most of the housewives (80 percent) are suffering currently while it is 17 percent for unskilled workers and only three percent for skilled workers. There is no significant difference in the prevalence level among the women living in different types of villages. Percentage of women suffering from different types of RTI/STD problem by history as well as duration of the problems show that among 12 percent of the women who complained about white discharge 57 percent are having the problem during last 3 months, while 32 percent are having the problem for more than one year. Sixty two percent of the women reported to have itching over vulva during last three months while 22 percent are suffering for more than one year. Higher proportion (56 percent) are suffering from boils/ulcers around vulva for more than 6 months during last one year, while more than four-fifths are suffering for more than 6 months during the current year. Around three-fourths of women have pain in lower abdomen during the current year, while more than onethird had the problem for major part of the last year. Perception about problems and treatment seeking behaviour Percentage of women having RTI/STI problems according to their various perception about the disease 8

14 by background characteristics show around 25 percent of the illiterate women consider RTI/STIs as a disease and 13 percent and 23 percent respectively consider it very serious and shameful. Majority of them (77 percent) consider treatment is required for the same although very few consider it can affect social life (10 percent) or sexual relation (8 percent). Perception of educated women towards RTI/STIs is also quite similar. Most women belonging to various caste groups viz. general, OBC and SC/ST consider treatment is required for RTI/STIs. A sizeable proportion of women belonging to SC/ST (28 percent) consider it as shameful and believe it can affect sexual relation (17 percent). More than four-fifths of women belonging to other religion consider treatment is required while 74 percent of Muslims and 70 percent Hindus think in similar fashion. Surprisingly somewhat lower proportion of women (64 percent) belonging to high income households consider treatment is required than women belonging to middle income (71 percent) or low income (73 percent) households. Similarly 30 percent women belonging to low-income households consider RTI/STIs, as a disease while it is only 9 percent for highincome household women. There is not much difference in the perception of the women by type of villages. Percentage of women according to perceptions related RTI/STI problem by hygiene characteristics and risk behaviors show more women with low personal hygiene (77 percent) consider treatment is required than those with medium (62 percent) or high (73 percent) personal hygiene. Very few women (4.5 percent) belonging to medium personal hygiene consider RTI/STIs as very serious health problem, while it is 11.5 percent for high and 20 percent for low personal hygiene women. A relatively high proportion of women with low self-sexual hygiene (31 percent) consider RTI/STIs as a disease than those with medium (25 percent) or high (20 percent) self-sexual hygiene. A very few women (6 percent) with medium self sexual hygiene consider it very serious compare to high (13 percent) or low (14 percent) self sexual hygiene women. Similarly very few women (6 percent) consider RTI/STIs as very serious whose husband s sexual hygiene is medium. 80 percent of women whose husband s consume alcohol regularly consider treatment is required compared to those whose husband consume occasionally (65.7 percent) or never (72.5 percent). A lesser proportion of women whose husband s consume pan masala or ghutka occasionally (60 percent and 53 percent respectively) consider treatment is required than those whose husband s consume regularly or never. Percentage of women according to their various perceptions related to RTI/STI problems by some important background characteristics viz. age, pregnancy, contraceptive use, and sexual relationship reveal that 65 percent of women below age 20 years consider treatment is required for RTI/STI problems and also a relatively high proportion of them (22 percent) consider RTI/STIs affect sexual relations while only 10 percent women between years of age and 8 percent women of age 35 and above consider RTI/STIs can affect their sexual relationship. Percentage distribution of women having RTI/STIs problems, who consider it as a disease, according to their perceptions about treatment requirement by four important background characteristics show women who are less than 20 years, 91 percent of them consider treatment is required for RTI/STIs who perceived it as a disease, while only 58 percent consider treatment is required who did not perceived it as a disease. Among the women in the age group 20-35, 95 percent consider treatment is required who perceived it as a disease, while it is only 64 percent for those who did not perceive. It is similar for older age women (35 +). Around 94 percent of literate women who perceived it as a disease consider treatment is required, while only 70 percent think alike who do not perceived it as a disease. About 95 percent of educated women also think treatment is required who perceived it as a disease. Types of village do not have any significant difference regarding perceptions about treatment requirement. 96 percent women in the villages with PHCs consider treatment is required among those who perceived it as a disease, while it is 64 percent for those who do not perceived it as a disease. Almost similar trends are found in villages with sub-centers and remote villages. Perceived reasons for RTI/STI problems by some important background characteristics show among the younger women (< 20 years) a very high percentages (43 percent) think anxiety causes RTI/STIs while 16 percent think poor hygiene or diet is a main reason for having 9

15 RTI/STIs. Among the other reasons, 6.3 percent cited sexual contact, 3.2 percent said frequent birth and 1.1 percent cited use of contraception as a main reason for RTI/STIs problems. Fifty-three percent of all women belonging to age group 20 and above consider anxiety as a main reason for RTI/STIs. Among the women who are illiterate 68 percent consider anxiety as a reason for RTI/STIs followed by 6.8 percent who think poor hygiene and diet cause RTI/STIs. Women who are educated up to primary level, 48 percent cited anxiety followed by poor hygiene/diet (7 percent). Similar trend is found among women who are educated up to middle school and above. There is no significant difference in the perceived reasons according to type of villages. Majority considers anxiety as a main reason for RTI/STIs irrespective of the type of villages. Distribution of women who sought treatment for RTI/STIs problems according to their chosen type of treatment by some important background characteristics show that in Maharashtra a vast majority (58.5 percent) still depends on faith healing for RTI/STI problems. Women who are below 20 years of age, among them 54 percent depend on faith healing and only 44 percent goes for allopathic treatment in case of RTI/STI problems. In the age group even fewer chose allopathic treatment (32.2 percent). A relatively higher proportion of illiterate women (43 percent) depend on allopathic treatment for RTI/STI problems compared to 26 percent women who are educated up to primary level and 37.5 percent who have middle school and above education. Surprisingly, 41 percent women living in remote villages avail allopathic treatment for RTI/STIs compare to 31 percent in villages with PHC or sub-centers. Distribution of treatment seekers for RTI/STD problems according to reasons behind choosing a particular type of medication in four districts of Maharashtra show almost in all the four districts except Nagpur, allopathic medication seems to have better appeal either because of its easy availability and affordability or its usefulness. Distribution of different types of treatment seekers according to their status of relief received in four districts of Maharashtra reveals that only 31 percent women reportedly experienced complete relief after medication while 57 percent received partial relief and 12 percent felt no relief irrespective of the type of treatment taken. The women in this part of the country suffer mostly from low backache, white discharge and burning sensation and painful passage of urine. Some women suffer from frequent passage of urine. Prevalence of white discharge and low backache is more common among younger women while painful passage of urine and frequent passage of urine occurs more among adult women who are on the verge of menopause or who have completed the desired family size. Most women do not consider pain in the lower abdomen as an RTI/STD problem and feel that being women they have to bear all the complications that are related to the abdomen. It is a routine matter. They quite often get pain in abdomen during the menstrual cycle, so one should not worry for such ailments. All the women, young and old, feel that proper services of ANM are very much warranted. Many times due to lack of proper transport facility or poverty they have to forgo their own health care. GYNECOLOGICAL AND OBSTETRIC HEALTH PROBLEMS Complications of pregnancy and childbirth are often the leading causes of morbidity and mortality among women in childbearing ages in the developing countries. They are more serious in rural areas where substantial proportions of pregnant women don t go for complete ANC and most of the deliveries take place at home without being attended to by trained personnel. The problem gets further heightened when women don't perceive these morbidities important unless it becomes severe. As a result, National Population Policy 2000 as well as Draft National Health Policy 2002 has expressed its increasing concern to provide good quality Emergency Obstetric Care services to the poor. Our strategies for minimizing Gynaecological/Obstetric Health Problems should focus on individual, collective, and organizational as well as systemic transformation, to generate results, sustain them and institutionalise the required changes. The main objective of this chapter is to assess the prevalence of different types of Gynaecological and Obstetric Morbidities including, morbidities relating to pregnancy, abortion, childbirth, and etc. based on screening as well as sample women. This chapter is divided into two sections. First section deals with prevalence of Gynaecological problems and its variation by socio-economic, demographic and hygiene status of respondents. A similar analysis of obstetric morbidities, 10

16 including pregnancy, abortion, childbirth etc. has been presented in the second section of the chapter. Distribution and prevalence of gynecological problems in study area The prevalence of any gynecology morbidity in four districts of Maharashtra is 7.8 percent whereas among the specific gynecological problems, prevalence of involuntary escape of urine while coughing and sneezing is 4.1 percent, followed by swelling/lumps in breast (2.6 percent) and some mass coming out of vagina (0.9 percent). Prevalence of the problem of some mass coming out of vagina is slightly high (0.9 percent) in age group years, among the women of other religion, among women of general caste and among the women whose effective age at marriage was years. Prevalence of any involuntary escape of urine while coughing and sneezing is high among the women of age group (5.1 percent), high among the women of other religion (7.0 percent), followed by Muslim religion (5.4 percent). Prevalence is also high among the women who belongs to SC/ST (6.3 percent) and among those whose effective marriage age is below 15 years (6.4 percent). The problem of swelling/lumps in breast is reported high by the women of age 30 years and above (above 3.1 percent), among the women of other religion (3.9percent) who belong to SC/ST (4.0percent), whose effective marriage age is below 15 years (3.9 percent) and who are engaged in unskilled job (3.5 percent). Prevalence of currently facing problem is more than ever had any problems in all the socio-economic and demographic characteristics. Only 2.1 percent women are currently experiencing the gynecological problems whereas only 0.7 percent had this problem in past. Women who are in the age group of and have high prevalence of gynecological morbidity than the women of other age group (2.5 and 2.4 percent respectively). Muslim women have high prevalence of gynecological problems (3.3 percent). Prevalence is high among the general caste women and among those who s effective marriage age is below 15 year (3.2 percent). The prevalence of current problems and ever had any problem shows that the prevalence is high among the women who are of age 30 and above, are from other (9.7 percent) religion, among the SC/ST women (8.2 percent), among the women who are married below age 15 years, which is quite obvious, because this is the age a girl attains menarche and reached the puberty. It may also be due to early entry in reproduction. The prevalence is higher among the women who are literate up to primary, are unskilled worker (5.4 and 6.14 percent) and are from remote area (5.7 percent). Types of Gynaecological problems in Maharashtra 1% 4% 3% 92% Some mass coming out of vagina Involuntary escape of urine while coughing/sneezing Swelling/lumps in breast No problem Among the women who have faced gynaecological problems in last year, 37 percent had problem of some mass coming out of vagina (prolapsed uterus) for about 3 months, whereas 41 percent women had involuntary escape of urine (while coughing and Sneezing) for about 6-12 months. Swelling/lumps in breast was experienced by half of the women for up to 3 months. Prevalence of Obstetric Morbidities in Maharashtra Prevalence of pregnancy among women was 6.3 percent (currently pregnant) and prevalence of pregnancy during the last one year was (12.5 percent). Prevalence of currently pregnant women is high among the age group (19.7 percent), among Muslim women (10.7 percent), among the women with effective marriage age above 25 years (10.4 percent), and among those who have education up to middle and above, who are house wives (7.3 percent) and is highly reported by women whose village comes under PHC. Data on prevalence of pregnancy in last one year shows that it is high among the women who are in age group of 15-24, among the women who belongs to SC/ST (14.6 percent), among the women whose effective marriage age is (18.6 percent), who 11

17 are educated up to secondary and above (21.7 percent) and among those who are housewives (14.7 percent) whereas prevalence of total pregnancy shows it is high among the women of age group (11.0 percent), among the Hindu women (17.1 percent) among the women of OBC caste (9.6percent), whose effective marriage age was years (14.7 percent) and among those who are housewives (15.1 percent). Almost eight percent of women, who were pregnant currently or during last one year of the survey, reported any problem due to pregnancy. Though the overall prevalence is low but considerable number of women reported anaemia during pregnancy (309 women) followed by any other problem. Further, looking at variation in prevalence in pregnancy related problem by some selected background characteristics, it is evident that younger women, those who are educated more than secondary level and above and are staying in PHC or sub centre village are more likely to report pregnancy related problem than other women. This clearly reveals the extent of ignorance about these problems, which may be vital for ensuring safe motherhood programme. It is observed that prevalence of current pregnancy related problems is 2.5 percent, whereas prevalence of past problems is 4.9 percent. Distribution of current problems shows that prevalence is high among women who are in the age group of (6.8 percent), among those whose effective marriage age was 25 years and above (4.5 percent) and who are educated up to secondary and above (4.4 percent). Prevalence of past problem is high among the women of age group (11.2 percent), among the women of other religion with 7.2 percent, among women belonging to SC/STs (6.5 percent) among the women whose effective marriage age was between years (8.1 percent), among the women who are educated up to secondary and above (10 percent), among the women who are housewives (6.0 percent) and among the women whose residential area is under PHC. women with middle and above education (15.6percent). Around 23 percent SC/ST women reported gynaecological and obstetric problems as a disease, followed by OBC women (16.4 percent). About 18 percent women of other religion perceived it as a disease followed by Hindu women (16.8 percent). One-fifth of women whose income is more than Rs. 5000/- perceived is as a disease and those women (18 percent) whose HH income is less than Rs. 2000/-. Around 22 percent women of remote village told that they perceived it as a disease, may be due to lack of exposure or lack of knowledge, followed by the village which is situated in sub centre (15.0 percent). Looking at the variations in perception about disease by hygiene status and substance abuse, it is observed that those women whose personal hygiene is medium, 44 percent perceived it as a disease, whereas 37 percent of low hygiene woman said it affects their social life. Around 33 percent women with medium menstrual hygiene perceived it as a disease and 22 percent thinks it affects the social life. Among women with high menstrual hygiene 32 percent feels that it affects the sexual relation. Among the women with high sexual hygiene one fifth perceived it as a disease (19.8 percent) and thinks that suffering from it is a shameful thing (18.8 percent), 13 percent told that it affects the social life and 6 percent thinks it affects the sexual life, around 12 percent perceived it very serious. Among the low sexual hygiene of husband 19 percent women perceive it as a disease and very serious problem, 14 percent told that it affects the sexual life and 9 percent said it affects the sexual relation also. Majority of women reported that these problems require treatment. 28% Perceived reasons for Gynaecological/Obstetric problems 13% 1% 6% 2% Perception of women about the Gynaecological and Obstetric problems and treatment seeking behaviour Women were asked about their perception regarding gynaecological and obstetric problems, 21 percent women with education up to primary level reported these problems as a disease, followed by illiterate women (17 percent) and 8% Poor Hygiene/ diet Frequent births Anxiety Others 42% Use of Contraceptives Sexual contact Abuse 12