A Study on Selected Reproductive Health Morbidities among Women Visiting Reproductive Health Camps in Nepal Commissioned by Familly Health Division, supported financially and technically by UNFPA and carried out by CMDN 4th National Safe Motherhood Conference 15 Nov 2016
Outline of the presentation Objectives of the study Study methodology Data Collection Limitations of the study Key findings Way Forward Acknowledgment
Objectives of the study To determine the prevalence of selected RH morbidities among women of reproductive age groups (15-49 years) in Nepal: - Pelvic Organ Prolapse (POP) - Obstetric Fistula (OF) - Cervical cancer - Human Papillomavirus (HPV) types 16 and 18. Specific Objectives: To map the selected RH morbidities by urban or rural residence, developmental regions and ecological zones. To determine factors associated with RH morbidities
Methodology Cross-sectional, camp-based study carried out from September 2014 to December 2015 Study Population Women of reproductive age group (15-49 years) Study Sites 15 sites; 1 site each in 15 districts Representations of 3 ecological regions and 5 development regions
Study Sites FWDR (2) Baitadi Kailali MWDR (3) WDR (2) Dolp a Myagdi Pyuthan and Dailekh Rupandehi CDR (4) Makawanpur and Kavre Parsa and Sarlahi EDR (4) Taplejung Okhaldhunga Morang and Siraha Mountain (2) Hill (7) Terai (6)
Structured Questionnaire Data Collection Clinical Examination - Visual inspection with Acetic Acid(VIA) and treatment by Cryotherapy for cervical pre-cancerous lesions - Cervical swab samples for HPV types (16 & 18) Key Informant Interviews Secondary Data Collection
Limitations Camp based study- cannot be generalized to the national level Difficulty in following up with some patients who had been referred to higher institutions for further management, especially for cervical cancer. Low number of OF cases especially due to stigma and isolation. Long waiting time in the RH camp leading to drop out for the clinical examination Laboratory investigations quite lengthy Geographical constraints and unfavourable weather conditions contributed to the delay in the completion of study
Key findings
Number Participants Enrollment Status 6000 5000 4000 3000 2000 1000 0 5555 Women Visited RH Camp (All age group) 4277 Enrolled in the Survey and Interviewed (15 49 years)
Percent 100 Age group of the Study Participants (N=4277) Median Age = 35 80 60 40 28.2 34.4 34.0 20 0 3.4 15-19 20-29 30-39 40-49
Marital Status of the Study Participants (N=4277) Divorced/S eparated 0.8% Widow 3.5% Unmarried 0.2% Married 95.5%
20 years and above 19.7% Age at Marriage (N=4268) Median age (Range) = 17 (8 48) Below 20 years 80.3%
Percent Knowledge on different RH Morbidities (N=4277) 100 79.1 80 60 42.9 40 20 5.4 0 Pelvic Organ Prolapse Obstretic Fistula Cervical Cancer
Source of Information about POP (N=3383) Relatives/Friends 79.5 Health Personnel/FCHV 58.9 Newspaper 9.3 Radio/Television 45.6 Multiple Responses 0 20 40 60 80 100 Percent
Source of Information about Cervical cancer (N=1836) Others School/Teacher Books/Training Aama Samuha[1] Relatives/Friends Doctor/Nurse/Health Camp Newspaper Television/Radio 0.1 0.5 1.1 0.2 13.6 49.8 56.1 72.3 0 20 40 60 80 100 Percent
Source of Information about OF (N=229) Books/Training 2.6 Relatives/Friends 40.2 Doctor/Nurse/Health Camp 66.8 Newspaper 20.5 Television/Radio 53.7 0 20 40 60 80 100 Percent
Percent 7 6 5 Prevalence of RH Morbidities 6.4 5.4 4 3 2 1.6 1 0 POP (N=4031) Cervical precancerous lesions(n=3831) HPV 16/18 (N=3464)
Key Findings Pelvic Organ Prolapse
Percent Prevalence of POP by Degrees (N=256) 10 Overall Prevalance - 6.4% 8 6 3.7 4 2 1.4 0.8 0.3 0 I Degree II Degree III Degree IV Degree
Mountain (N=516) Hill (N=1797) Terai (N=1718) Eastern Development Region (N=1094) Central Development Region (N=1134) Western Development Region (N=581) Mid-Western Development Region (N=719) Far Western Development Region (N=503) Rural (N=2457) Urban (N=1574) Percent 20 15 10 5 Prevalence of POP by Region and Place of Residence 4.8 6.5 6.6 8 4.6 3.4 5.3 11.3 5.9 7.1 0 Ecological Region Development Region Place of Residence
Below 20 years 20-29 years 30 and above Not pregnant yet Don't remember/know 1-2 times 3-4 times 5-7 times 8 or more times Percent 100 80 60 40 20 0 Fertility Related Information of Women diagnosed with POP 57.8 39.8 0.4 0 2 16 41.8 32.4 9.8 Age at First Pregnancy* Number of Pregnancies
Percent 100 80 60 40 20 0 17.2 Health facility Delivery Related Information of Women diagnosed with POP 82.8 At home 30.9 69.1 83 Yes No 1-3 years 12.4 3-5 years 4.6 More than 5 years Place of Last Delivery* Assisted by Health Worker During Last Delivery* Birth Interval of Last Child (N=241)*
Percent 40 Rest after delivery among women with POP 35.5 30 20 16.1 17.7 12.9 17.7 10 0 Less than 7 days 8-12 days 13-15 days 16-30 days More than 30 days
Key Findings Cervical Pre-Cancerous screening through VIA
Mountain (N=490) Hill (N=1715) Terai (N=1626) Eastern Development Region (N=1038) Central Development Region (N=1057) Western Development Region (N=561) Mid-Western Development Region (N=689) Far Western Development Region (N=486) Urban (N=2329) Rural (N=1502) Percent 5 4 3 2 1 0 Prevalence of Cervical Pre-cancerous Lesions 2 2.2 2.2 0.8 Prevalance=1.8% (n=60) 1.1 1.6 1.6 1 1.4 1.8 Ecological Region Development Region Place of Residence
Percent Fertility Related Information of Women with VIA Positive Result 100 75 80 60 40 20 0 Below 20 years 20 years and above Age at Marriage 25
Yes No Biopsy Pap smear test Unable to mention proper method Self Doctor/Nurse Husband/family member/neighbor Health worker/fchv Percent 100 80 60 Screening for Cervical Cancer 98.5 50.8 42.9 44.4 34.9 15.9 40 20 0 1.5 9.5 4.8 Ever screened for Method of Screening (n=63) Advised/Referred for Cervical Cancer Screening
Findings HPV
Percent Prevalence of HPV (N=3464) 6 5.4 5 4 3.6 3 2 1 0 HPV 16 HPV 18 HPV 16 or HPV 18 2 0.2 Co-infection (HPV 16 & 18)
Mountain (N=435) Hill (N=1540) Terai (N=1489) Eastern Development Region (N=927) Central Development Region (N=918) Western Development Region (N=516) Mid-Western Development Region (n=643) Far Western Development Region (N=460) Rural (2092) Urban (N=1372) Percent Prevalence of HPV 16 /18 7 6 5 4 3 2 1 0 3.2 5.3 6.2 4.2 5.9 6.8 6.7 3.7 5.3 5.6 Ecological Region Development Region Place of Residenc
15-19 years 20-29 years 30-39 years 40-49 years Illiterate Literate but no schooling Primary Secondary SLC and above Dalit Disadvantaged Janajati Disadvantaged non-dalit Terai Religious Minorities Relatively advantaged Janajatis Upper caste groups Precent 60 40 20 Socio-demographic Characteristics of women with HPV Positive Result 35.6 37.8 26.136.7 28.2 19.7 17.6 13.3 14.4 17.6 45.7 0 0.5 2.1 2.7 2.1 Age in Years Educational Status Caste/ethnicity
Way Forward Support SRHR, including for the most marginalized, focusing on delaying early marriage and pregnancy, access to contraceptive choices, access to skilled birth attendants and promote gender equality across sectors. Focused programmes to increase awareness on different morbidities, including available treatment and treatment sites. Expand and strengthen RH Morbidity related services to different level of Health facilities to increase access, including availability of trained human resources POP prevalence decreased from 10% in 2006 to 6.4% Still very high. Conservative management of POP needs to be prioritized equally to surgical management. Need for focused strategy to increase awareness and identify OF. women with Strengthen referral mechanisms from peripheral level Health facilities providing RH Morbidity services to higher centers, particularly for cervical cancer