Estimating the burden of reproductive tract infections and its determinants amongst reproductive age group women residing in rural and urban settings in North India-a cross sectional comparative analysis

INTRODUCTION

Sexually transmitted infections (STIs) and reproductive tract infections (RTIs) continue to be a major public health problem despite the evidence-based treatment available for the illness.¹

Certain Demographic factors like population explosion, rural to urban migration undoubtedly contribute to increase in STDs but numerous social and behavioural factors are also involved in their spread. The stigma and hesitation toward the STIs/RTI are the leading factors for negligent attitude among women toward the symptoms in the early phase of the illness thereby advancing to complications like pelvic inflammatory disease (PID), infertility, cervical cancer, puerperal sepsis, chronic pelvic pain, and ectopic pregnancy.²

In India, 40 million new cases of RTI/STI emerge each year.³ Due to limited access and affordability of STI laboratory diagnosis at the primary level of care where majority of STI cases seek care, syndromic case management remains the cornerstone of STI control.

Syndromic approach is based on presence of signs and symptoms reported, and provides immediate treatment for the most common organisms causing the identified syndrome through the use of pre-packaged colour coded drug kits. Both type of STIs, that is ulcerative and non-ulcerative, are prevalent in India, however the profile of the patient varies with changes in socioeconomic, cultural, geographic, and environmental factors prevalent in different parts of the country.^4-11

The present study aims to analyse and compare the prevalence and determinants of STI/RTI symptoms in two different setting that is urban slum and rural population of women in their reproductive age group which would eventually help the health administrator in providing better services for its treatment and control.

MATERIAL & METHODS

RESULTS

Prevalence of sexually transmitted infection syndromes:

Majority of women in urban (46.3%) and rural (39.8%) area observed vaginal discharge. Lower abdominal pain was reported by 30.2% of urban and 29.1% of rural women. (Figure 1)

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FIGURE 1:

RTI SYMPTOMS DISTRIBUTION IN STUDY POPULATION

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DISCUSSION

In the present community-based study, the prevalence of RTI/STIs among women of reproductive age was found to be 46% in urban slum area and 40% in rural area, this was almost double than the prevalence among women in Haryana as reported in NFHS 4 (23% in women). There was varied prevalence of RTI as reported by researchers among rural and urban Indian women. It was 49% in a rural district of Agra (U.P.),⁵ whereas 70% in rural area of Haryana.⁶ Comparatively, low prevalence was observed in the slum and rural areas of Chandigarh (21.6% and 17.7%, respectively).^7,8 Prevalence in the rural community of West Bengal was 23.6%⁹ Latha et al.,¹⁰ in a multicentric study in rural West Bengal, Gujarat, urban Baroda, and Mumbai reported the prevalence of RTI, ranging from 19% to 71%. Another study done in urban slums of north east Delhi showed more than half of the study women (53.8%) had symptoms of RTI in the past.¹¹High prevalence of 67.8% was reported in urban slum of Mumbai.¹³Similar prevalence of 39.9% was reported from rural area of Nepal.¹⁴

Above studies prove that urban slum women are more hit by the illness. Contrastingly NFHS-4 reported that self-reported STI symptoms were not affected by residence, education or socioeconomic status of population.⁵The marginal increase in prevalence of reporting of symptoms in urban slums in current study may be due to densely populated residential areas and lack of basic amenities like sanitation, clean water supply, electricity etc., moreover lack of privacy in these congested areas make women prone for sexually transmitted diseases and infections. The COVID pandemic has hit STI prevention and care activities just like other health programmes all across the globe with dramatically decreased reporting as compared with 2019.¹⁵ The international community also shares the similar data with an estimated 67.6 million prevalent and 26.2 million incident STIs in the United States in 2018.¹⁶ Vaginal discharge and lower abdominal pain were the most consistent symptom of RTI/STI among both rural and urban women in our study whereas similar study done in rural community of Haryana showed genital itching and vaginal discharge as most common symptoms.¹⁷ Kafle et al., from Nepal however reported backache as common symptom followed by vaginal discharge.¹⁴

Menstrual practise of using cloth during menstruation showed higher probability of RTI symptoms. A similar finding was reported by Philip et al., wherein women using ordinary cloth showed higher prevalence of RTI.¹⁸ Use of cloth as absorbent during menstruation as in our study shows the lack of awareness, careless attitude and lack of facilities for reproductive health.

The prevalence of symptoms was found to be significantly associated with parity and low age of marriage. The prevalence of symptoms was found to be lowest among the nulliparous and highest among the women with parity of three or more. This finding is comparable to a study done Anjana et al., from Delhi.¹⁹ They also presented a significant finding proving that contraceptive users were found to have lesser prevalence of RTI/STI symptoms as compared to nonusers both in urban and rural areas.¹⁹ Non usage of condom by partner was significantly associated with higher risk of RTI symptoms in the current study. However, the proportion of women reporting use of condoms by partners was lower as compared to those reported by Anjana et al., from rural and urban Delhi. In a study from Udupi District of South India it was reported that only 5% (of the total of 108) of the respondents used condoms while indulging in sex with a new partner at the migrated place.²⁰ Male Condoms under National AIDS control programme are distributed free or through social marketing channels. It provides dual protection from STIs and conception. However, the prevalence of their use is still less than half. Patel V et al., in their study conducted in Goa reported condom use and oral contraceptive use associated with a reduced risk of RTI.²¹

The present study also reveals that prevalence was highest in those who had history of abortion in both urban and rural areas. Similar findings were reported by Rani et al.,²² and Philip et al.,¹⁸ where in prevalence was highest among the study subjects who had history of abortion. This can be attributed to the fact that operative procedures more so unsafe abortion practices as prevalent in India make women more prone to ascending infections.

LIMITATIONS

The study was limited by its nature of study design due to which temporal association cannot be established. Moreover, symptom-based prevalence is a proxy to the disease. We did not perform any laboratory investigations tests on women complaining of STI/RTI symptoms to know the exact prevalence of the disease, as the self-reported morbidity alone cannot be used to measure the burden of disease in the community. This study only catered to women hence the direct data of sexual behaviour of male partners were not available.

CONCLUSION

The study reveals that the prevalence of RTI/STI among women of reproductive age is quite high, with urban slum women being worse hit by the disease. Rapid urbanization without filling in basic amenities attribute to poor reproductive health. Menstrual practices, high birth order and number of abortions play a significant role in reproductive tract infections. Condom use among partners have a better edge of protection than other contraceptive users for RTI/STI.

RECOMMENDATIONS

Robust management and control of RTIs/STIs needs to be part of the primary health-care. First contact health workers should be reinforced to identify RTIs/STIs through the syndrome approach. There is need to educate women about their reproductive health issues and encourage them to seek treatment for them as well as their partners. Many infected persons may be unaware of their infections because STDs are often asymptomatic or unrecognized, being educated about reproductive health and using barrier methods can lower risk of contracting STIs. The stigma towards reproductive diseases can be alleviated through more awareness campaign and providing better facilities to the marginalized population of the community.

AUTHORS CONTRIBUTION

All authors contributed equally.