MANAGEMENT OF

REPRODUCTIVE HEALTH:
INTERPLAY OF SOCIAL ENVIRONMENT







R.S.GOYAL
NEENA RAINA
SAULINA ARNOLD


















IIHMR
Occasional Paper









ABSTRACT

This paper analyses the interplay of socio-economic and cultural factors in shaping women's perceptions
and health care seeking for Reproductive Tract Infections (RTI) in certain rural communities in India.
The data are drawn from two operations research studies conducted in 1997 in one district in Haryana
and eight districts in Tamil Nadu under the USAID supported PVOH (Private Voluntary Organisations
in Health) project. Qualitative methods were used to collect the information.

Women reportedly suffering due to reproductive health (RH) problems were first identified either
through a community surveyor with the help of key informants. These women were then invited for a
detailed discussion on their problems and for a medical check-up at health camps, specially organised
for this purpose. Focus group discussions were also held with other women in the community, lay health
providers etc. Resource mapping was carried out to assess the women's awareness about the health care
facilities available in the community and the extent of their utilisation.

These two studies, though conducted in totally different socio-cultural settings, point towards a high
prevalence of RTI among rural women. The perceived causes of RTI are loaded with a lot of
misconceptions. RTI influences all aspects of women's well-being, be it physical, social economic or
psychological. Lack of support from husband and family further adds to women's suffering.


* Professor, IIHMR, Jaipur, India
** Director, SWACH Foundation, Chandigarh, India
*** Director, TNVHA, Chennai, India



















The health care seeking behaviour for RTI is still very primitive. There is a fatalistic approach towards
RTI, leading to considerable delay in recognising the problem and seeking treatment. The first order of
health care providers comprises traditional birth attendants, village health workers, non-qualified private
medical practitioners, self-proclaimed experts in indigenous treatment, etc. These people are obviously
not adequately equipped for this role, which further adds to the misery of the women. Utilisation of
government health care facilities is very poor.

The study calls for efforts to modify the prevailing fatalistic approach towards RTI, validate scientific
knowledge, improve availability of quality care, and encourage women to seek appropriate health
care through outreach health education and health promotion programmes.

BACKGROUND AND OBJECTIVES:

There is a growing recognition that reproductive health problems affect the life of most women in the
reproductive ages particularly in developing countries. Though no national prevalence data on
reproductive tract infections (RTI) in India are available, a few available studies point to an alarmingly
high number of women who have confirmed infection. Bang et.al., (1989) in a study of 650 tribal
women (aged 13 years and older) from two villages in Maharashtra, India, noted that during the course
of interviews 55 per cent women reported gynaecological complaints. On clinical examination and
testing, however, nearly 48 per cent women were found with infections - vaginitis, cervicitis and pelvic
inflamatory diseases. In another study of 3600 rural women from Karnataka, Bhatia and Cleland (1995)
found that 23.5 per cent women had self-reported symptoms of RTIs. Further, upon examining 756
women living in the slums of Mumbai (India), Parikh et.al. (1996) noted that 72.6 per cent women had
gynaecological disorders, and 52.1 per cent one or another RTI problem.

These studies further note that in less than 10 per cent cases the women have sought any treatment for
their RTI problems.


These studies were funded by USAID/Government of India and co-ordinated by
Technical Assistance Unit (headed by the first author) at IIHMR, Jaipur, India.





















A high prevalence of RTI, coupled with apathy or inability of women to seek treatment, suggests that
more concerted research efforts are needed not only to assess the level and pattern of RTIs, but also to
study their socio-cultural correlates (e.g. culture of silence, inability to seek treatment etc.), biological
determinants and health care seeking behaviour under different socio-economic and environmental
conditions of living.

This paper reports the findings of two operational research studies recently conducted (1996-97) in two
different regions of India. One study was carried out by SWACH Foundation in one district of Haryana
state (North India) and the other by Tamil Nadu Voluntary Health Association (TNVHA) in eight
districts of Tamil Nadu in South India. The broad objectives of these projects were to improve the
reproductive health of women living in rural areas by studying their perception, attitude and behaviour
towards RTI, and by undertaking intervention programmes for health education and health promotion.
In this paper, we shall deliberate on the findings of field studies, focusing on the following issues;

Women's awareness, perception and behaviour related to RTI.
Assessment of prevalence of RTI.
Health care seeking behaviour for RTI.

2. RATIONALE:

A high level prevalence of RTI among women is associated with a host of socio-economic and
biological determinants that operate synergistically in the lives of most women. The most important of
these is the status of women. The economic and social subordination of women to men, lessens the
control of women over their own sexuality and, often, men and women are not equal partners in marital
and sexual relationships. In such a situation, most women are married off at a young age, forcing them
into the web of early onset of maternity, higher fertility and high gynaecological disorders (Goyal,
1994).

Low level of education, particularly among women, and lack of health information, generally result in
misconceptions about many illnesses and their treatment, and discourage people from adopting
preventive measures.

In traditional societies like those of India, many local customs also influence the prevalence of RTIs. It
has been noted that during menses and prolonged periods of post-partum amenorrhea, sex is taboo. In
joint families, the mother-in-law controls the sexuality of the daughter-in-law in the sense that she
determines when the latter should sleep with her husband. It encourages men to seek sex outside the
marriage union. They may have multiple sex partners, either through legitimate polygamous marriages

















or through factually accepted casual contacts or encounters with prostitutes (Wassenheit; 1989). These
practices intensify the spread of STDs (including RTIs) or facilitate their spread. In India, a large
proportion of the population is in the intense sexually active age group (in 1991, nearly 30 per cent of
the population (254 million) were in the 20-40 years age group). In absolute terms, it reflects the large
dimensions of the problem. Further, all developing societies are characterised by rapid urbanisation,
which is usually dominated by reallocation of young men and women. This process often results in the
loosening of the cultural-moral hold of society on ethics and values governing sexual activities.

Morbidity of RTI in women is also affected by a number of other factors. Socio-cultural dictates
seriously constrain women's ability to seek health care, more particularly for genital problems.
Ignorance and the culture of silence and shame prevent women from even sharing their suffering with
family members. The non-availability of accurate diagnosis and appropriate therapy further aggravates
the suffering of women, more particularly in rural areas.

3. METHODOLOGY:

In any community-based study on RTI, research has to grapple with a number of methodological and
ethical issues. For example, what is the appropriate methodology for inquiring about such intimate
issues as reproductive morbidity and sexual behaviour in a way that it will elicit reliable responses,
while protecting the confidentiality of the information and the reputation of the individual? Can the
standard survey technique work? Does it need to be supplemented by qualitative techniques?

Against this backdrop, a combination of quantitative and qualitative methods were utilised to collect the
data in the present study. Though both the studies were aimed at studying the same phenomenon, i.e.
perception, attitude, prevalence and health care seeking behaviour of women for RTI., the basic
approaches adopted by the two were somewhat different. The following comparison would make it
clear:























Table 1 : A comparison between the research methodologies adopted in the two studies:


State
Parameters
Tamil Nadu Haryana
1. Project Area 8 Districts 1 District
2. Number of villages covered
3. Method
RTI prevalence
Clinical diagnosis and Lab tests

8. Health Camps
Only clinical diagnosis

Prevalence survey followed by
7 Health Camps
Clinical diagnosis and Lab
tests
4. Quantitative Data
KAP Survey

Not separately

Yes (N=200)
5. Qualitative Data:
* Key informant interview
* Focus group discussion
* Participatory rural appraisal of symptoms
and causes of RTI
* Free listing of names of illnesses
* Ranking/severity rating of diseases
* In-depth interview
* Past RTI history
* Facility survey
* Local terminology used

8
Yes (N=16)
In every village (N=15)

Yes (N=16)
Yes (N=16)
Provides (N=12)
No
No
Yes

6
No
No

Yes (N=41)
Yes (N=41)
Health functionaries
Yes
No
Yes



RTI Prevalence: Different approaches were adopted to assess the prevalence of RTIs in the two
communities under study. In Haryana, a complete enumeration of all the eligible women (age 20-40
years) in the study villages was carried out. Community women were asked about the key symptoms of
RTI, such as vaginal discharge, itching in genital region, genital ulcers, urinary complaints, pain in
lower abdomen and low backache. All the survey positive women (who gave history suggestive of RTI)
were called to health camps for detailed gynaecological examination and clinical tests. Women with
definite symptoms of RTI were considered for study and subjected to gynaecological examination and
laboratory tests.



















In Tamil Nadu, health camps were held in the study villages. These camps were open to all women.

Behavioural Studies: A series of behavioural studies were undertaken to determine the level of
awareness among the women about RTIs and their consequences, the local terms commonly used to
describe their symptoms, care seeking behaviour, preference for providers and reasons thereof. These
studies comprised ethnographic studies, focus group discussions, free listing and ranking, severity rating
of illness, in-depth interviews, participatory resource mapping, and key informant interviews.

Both the studies were initiated by interviewing and holding focus group discussions with the key
informants [these included traditional birth attendants (TBAs), school teachers, health workers, etc.}.
During the discussion, local terms used for the signs and symptoms of RTI were listed, health care
seeking behaviour of women was reviewed, and availability of health facilities for treatment of RTI was
assessed. This information was used to develop a protocol for RTI prevalence survey and behavioural
studies.

4. FINDINGS:

Prevalence of RTIs

More than 60 per cent of the women who participated in the two studies were diagnosed with some RTI.
However, these results must be used with caution as they may not represent the community at large.

In both settings, the camp approach was used to estimate the prevalence of RTIs. In Tamil Nadu, the
study was conducted in 8 villages containing a total of 1008 women who were eligible to attend the
camps. Of these, only 456 or 45.2 per cent did, in fact, attend the camp, and 266 or 60 per cent of them
were diagnosed with an RTI.

In Haryana, health camps were held in 7 villages and they were open only to those women who during
the community survey, reported symptoms of some RTI, or other gynaecological morbidity. These
women were screened at the camps, and those found with symptoms of gynaecological or other
morbidity, such as prolapse, etc., were excluded from the study. Among the 427 women who attended
the camps, only 274 (64.2 per cent) had RTI related complaints; 13.1 per cent had other gynaecological
problems; 12.4 per cent reported medical or surgical problems; and 10.3 per cent were either reluctant to
undergo pelvic examination or were not examined due to other reasons (unmarried, etc.).




















In both the studies, self-selected women with recognized, pre-existing gynaecological problems, formed
the sample. Many RTIs are symptomatic and hence, the exclusion of women with such infections from
the study gives rise to the problem of under-estimation. Secondly, the qualitative data in the two studies
indicate that there is a delay in recognising morbidity even among symptomatic women who have
sought treatment. So, in both the cases, women attending the health camps were those who not only had
some symptoms of RTI but also recognised that their symptoms were severe enough to require
treatment. This is a major methodological problem in community-based studies of gynaecological
morbidity. Self-selection leads to an over-estimation of the prevalence of gynaecological morbidity in
the community.

However, there are also reasons suggestive of considerable under-reporting of morbidity conditions. For
example, in qualitative analysis, symptoms such as low backache and excessive discharge are accepted
as "women's lot" and are not considered for treatment.

It is difficult to judge the combined effect of over-and under-reporting of gynaecological morbidity on
true prevalence of RTI. Can we assume that it is not far removed from its true value (over-estimation
and under-estimation nullifying each other)?

In both the studies, "vaginal discharge" emerged as the most commonly reported gynaecological
problem (over 90 per cent) among women with RTIs. A number of women reported other symptoms
such as low backache or pain in lower abdomen also (60 to 70 per cent). But these were also invariably
associated with vaginal discharge. The vaginal discharges experienced by women can be broadly
classified under the following categories;

White discharge, foul smelling white discharge, watery discharge, curdy/mucus discharge, green or
yellow coloured discharge, and blood-stained discharge.

In the focus group discussions, the community women also corroborated these findings by observing
that vaginal discharges are experienced by most women.























Importantly, not all the vaginal discharges were rated as severe or very severe. Only white discharge,
blood-stained discharge, green or yellow coloured discharge and foul smelling discharge were rated as
very severe or severe.

Vaginitis was the most common clinically diagnosed problem in these women, followed by its
combination with cervicitis or pelvic inflammatory diseases (pm). The laboratory tests (KDH - Whiffs
tests, Pap's smear, etc.) largely corroborated the clinical diagnosis of the doctor. Prior to coming to
health camps, only 11 per cent women had taken treatment for their RTI from a health provider.

Behavioural Studies

One of the major objectives of this study was to examine the perception, attitude and health care seeking
behaviour of women for RTI. In the two studies, vaginal discharges emerged as the most common RTI
among rural women. The qualitative tools used in the study were, therefore, concentrated on studying
the women's perception of and response to vaginal discharges.

Vaginal discharges are a common phenomenon among Indian women. These discharges are generally
perceived by women as "part of life" or "fate of women", and until the problem becomes acute,
treatment is not sought. A host of causes are associated with vaginal discharges. Table 2 presents the
more prominent of these causes.
































Table2: Perceived Causes, Consequences and Health Care seeking Behaviour for Vaginal
Discharges.


Study Region
Parameter

Tamil Nadu

Haryana
1. Most common condition Vaginal discharge of various types Vaginal discharge of various types
2. Perceived causes "Fate of women":
Watery and curdy discharge due to:
body heat and tubectomy.
Mucusy/blood stained discharge due to;
tubectomy, STD.
Discharge with itching due to:
'hot' food, immoral behaviour, Ulcer
etc. due to :
immoral behaviour, evil eye, evil spirit,
IUD, tubectomy, body heat.

"Fate of women";
White discharge due to :
weakness, hot foods eaten, lifting heavy
weights.
Itching associated with:
Unhygienic menstrual practices, more
heat inside body.
(NB: links to tubectomy, IUD not
mentioned)
Females survey:
RTI attributed to: weakness, body heat,
"unhygienic" practices, tubectomy,
'hot' food etc.
3. Links to husband's infidelity Recognised Recognised
4. Perceived consequences Weakness affects physical health,
affect sex life, results in painful sex,
social problems staining, dour,
stigma, economic problems, affects
work capacity, psychological
problems -guilt, helplessness.



Affects sex life
5. Communication with husband Fear violence, or counter-
accusations of infidelity, reluctant to
discuss with husband

Most likely to confide in husband
6. Treatment seeking Takes 3-4 months before symptoms are
recognised as abnormal
Detailed knowledge of home remedies;
preferred
Delay in treatment due to: condition not
serious,
too much work;
no money,
too shy,
fear stigmatization,
no confidence in treatment
Order of providers; TBA,
traditional healers,
village health nurse,
private practitioners (all sorts),
government hospitals
Poor quality of care at PHC, and
other government facilities deter
women from seeking institutional
health care
Delay in seeking treatment,
seek treatment only if symptoms persist
over time
Detailed knowledge of home
remedies;
preferred
Women not averse to pelvic
examination
Decision for women's treatment
taken by husband
Husband: person most likely to
accompany women to seek treatment








In both the study regions, Tamil Nadu and Haryana, large similarities were noted in perceived causes of
RTIs such as body heat, eating 'hot' food, sexually transmitted diseases, sex with more than one partner,
etc. In addition, women in Tamil Nadu also associated these with the effect of the "evil eye" or "evil
spirits" and use of family planning methods, particularly tubectomy and IUD. A large number of
women complained that women become weak after tubectomy and that, it results in vaginal discharges,
excessive bleeding, etc. To quote the perception of a trained birth attendant (TBA). ".You cut a vital
blood vessel which supplies pure blood to the body. Due to this the waste blood stagnates in the uterine
tract and results in all sorts of ailments ..".

According to a community woman, ".. child bearing is an important process in a woman's life. When
you prevent this, it spoils the whole body ". A large number of women share these perceptions.

These could be some of the compelling reasons for the women from Tamil Nadu preferring abortion to
tubectomy (in Tamil Nadu the number of women seeking abortion is very large) even though the
facilities for abortion either do not exist or are very primitive (women are reportedly using local herbs or
metalic things to cause abortion, further adding to their gynaecological problems).

Vaginal discharges are believed to affect almost all the aspects of women's life, be it physical, social,
cultural, psychological or economic. Some of the most cited effects are:

Vaginal discharges cause weakness, drain energy and cause illness.
Painful coitus and post-coital pain associated with RTIs discourage women from intercourse
resulting in misunderstandings and quarrels within the family.
Suspicion of immorality by the husband (particularly in Tamil Nadu) if the information is shared
with him.
Foul smelling discharges prevent women from mingling with others, more particularly on social
occasions.
Due to weakness, unable to go for work, causing serious economic hardship for the family.
Constant pain, discomfort, guilt and helplessness affect one's mental state - many RTI patients
observed that ".. they would prefer to die rather than endure a never ending illness .."

Importantly, there were remarkable similarities between the perception of RTI patients and those of
normal women about the adverse effect of RTIs on quality of life.

Women from Tamil Nadu observed that they hesitate to confine their problem to the husband due to fear
of poor treatment or suspicion on their character. However, women from Haryana did not face such
problems in sharing their problems with the husbands and taking the husbands' help in seeking
treatment for RTI. It speaks volumes for the helplessness of the women, particularly poor rural women
in Tamil Nadu, where they cannot even share their suffering with their husbands (though in most cases,
the husband himself had been the source of the disease). Taking the husband's help for treatment is a
distant dream only.

The health care seeking behaviour for RTI presents a classic case of neglect and associated suffering.
Non-availability of appropriate treatment or heavy dependence on indigenous medicines which are not
scientifically validated further aggravates the problem. The treatment is delayed for an average 3 to 4
months before a woman is able to identify the symptoms as abnormal (vaginal discharges are invariably
taken as part of life). Only if the symptoms persist or get aggravated further, home remedies are
attempted. Most women claimed that they knew a great deal about home remedies for gynaecological
disorders and initially preferred these remedies to treatment from a doctor. Moreover, in every
neighbourhood, there are a number of elderly women who are self-proclaimed experts in indigenuous
treatment for gynaecological morbidity and dispense treatment to everybody who seeks their advice. In
the first instance, most women consult them for treatment of their RTIs. Only when the problem
becomes too acute, professional help is sought. However, even then, first of all, the TBA or village
health worker or a non-qualified private medical practitioner in the village is consulted. Services of a
hospital or a qualified doctor are sought only when the problem becomes very acute or the people
consulted earlier advise them to do so (this is not done very easily because the health providers at the
local level do not want to lose their business).

Government hospitals are not preferred because of the poor quality of services rendered and lack of
personalised care.

The perception of health care providers closely corroborate the observations made by the women
regarding the care seeking pattern for RTIs. To quote a few;






















Very strong cultural beliefs were prevalent in the villages. In spite of our constant health
education, women still attribute reproductive health problems to acts of evil spirits, evil eye, heat etc.,
and follow treatments according to their own wishes. They still have faith in tanthrik (witch doctor)
healing. When we advise them to go to a hospital to get treatment for exessive bleeding, they only go to
the tanthrik healer ..".

" Women's personal hygiene is very poor. Many women do not bathe daily. They wear the same
dirty clothes for many days. It may be due to poverty, lack of availability of sanitary facilities, heavy
workload etc".

There are very harmful treatment practices prevalent in the village. Women with severe
infections come to hospital for treatment. When we examine them, we sometimes find shrunk or broken
pieces of woodapple (Feronia limonia), rubber balls etc. inside the uterus. They insert these items inside
the uterus as a treatment for uterine prolapse .

From these quotations it appears that government health care providers seem to have a negative or
indifferent attitude towards the poor women due to their uncleanliness and lack of hygiene. Also, there
is little sympathy for the ignorance and socio-cultural and economic compulsions of the women in their
poor management of RTI problems.

5. DISCUSSION:

The two studies, though conducted in totally different socio-cultural settings [Haryana (North India) and
Tamil Nadu (South India)] point towards a high prevalence of RTI among rural women. Vaginal
discharges are most common of these RTIs. The perceived causes of RTIs are loaded with a lot of
misconceptions. Firstly, these are considered as 'fate of women' and are also linked with heat in the
body, use of family planning methods, such as sterilisation and IUD, effect of evil eye or evil spirit.
Suffering due to RTIs is very large. RTIs not only affect women's physical, social and economical
wellbeing, they lead to a host of psychological problems. Lack of support from husbands, further adds
to women's suffering.






















The health care seeking behaviour for RTI is still very primitive. There is considerable delay in
recognising the problem and seeking the treatment. A fatalistic approach towards RTI is largely
responsible for this. Further, in every neighbourhood, there are a number of women who are self-
proclaimed experts in indigeneous treatment for gynaecological morbidity and dispense treatment to
everyone who seek their advite. Invaribaly, first treatment for RTIs is taken from these women only.

It has not been possible to establish effectiveness of treatment provided by these women. But there are
indications that most of the patients had to consult professional health providers after having taken
treatment from these women, which could only mean that indigenous health providers have had very
limited success in effective treatment of RTIs. The first order of health providers i.e., TBA, village
health workers, non-qualified private medical practitioners are shouldering the major responsibility of
providing health care for management of RTIs. Their effectiveness could be left to anybody's
imagination.

It is rather unfortunate that inspite of a large network of health care facilities, these are not utilised by
the people for the management of RTI. Poor quality of services provided, lack of personalised care and,
above all, a negative or indifferent attitude of doctors towards poor women and their problems are
apparently iresponsible for this apathy.

There are also several methodological issues involved in assessing the true prevalence of RTI. There is a
need to evolve an appropriate mix of strategies for its correct estimation. In the few available
community based studies, the estimate of prevalence of RTI in India falls within a range of 30-60 per
cent, a range which is too wide for a comfortable estimate. Perhaps, these estimates are influenced by
the socio-economic settings in which these studies were conducted. A method mix of qualitative and
quantitative data collection would perhaps be a better approach for estimating the prevalence of RTI.

The study suggests that there is a need to modify the fatalistic approach towards RTI, validate scientific
knowledge, improve availability of quality care, and encourage women to take appropriate health care
through outreaching health education and health promotion programmes.



REFERENCES

1. Bang; R.A. et.al., (1989) 'High Prevalence of Gynaecological Diseases in Rural Indian
Women'. The Lancet Jan. 14.
2. Bhatia, Jagdish C. and John Cleland (1995) 'Self Reported Symptoms of Gynecological
Morbidity and their Treatment in South India'. Studies in Family Planning, Vol. 26, No.
IX, July/August. PP.203.
3. Goyal, R.S. (1984) 'Dimensions of Adolescent Motherhood in India'. Social Biology,
Vol. 44, No.1 & 2.
4. Parikh, Indumati et.al., (1996) 'Gynecological Morbidity Among Women in Boundary
Slum'. Unpublished Paper.
5. SWACH Foundation (1997) 'Reproductive Tract Infections Amongst Women of Rural
Haryana'. SWACH Foundation, Chandigarh.
6. TNVHA (1997) 'Operational Research Study on Perception Attitude and Behaviour of
Women Regarding Reproductive Tract Infections'. Tamil Nadu Voluntary Health
Association, Chennai.
7. Wasserheit, Judit N. (1989) 'The Significance and Scope of Reproductive Tract Infections
among Third World Women'. International Journal of Gynecol Obstet. Suppl. 3:145-168.