WOMEN'S HEALTH CARE NEEDS

SELECTED ANNOTATIONS


1. A community study of gynaecological disease in Indian villages

Author                    : Bang R. and Bang A.
Source                    :Learning about Sexuality – A Practical Beginning,The Population Council
Place of study        : Gadchiroli, Maharashtra
Location                 : Rural
Period of study       : 1986
Type of Research  : Empirical, Exploratory, Community-based

Aim: To share the experiences of the researchers who conducted a community-based study on gynaecological morbidity. The study was sought to determine 1) the prevalence, types and distribution of gynaecological diseases in rural woman, 2) the awareness and perception of the women about their gynaecological and sexual disorders and 3) the proportion of women who have access to gynecological care.

Methodology: Two representative villages, from the work area of SEARCH, were selected. All women, regardless of whether they had symptoms or not were examined in order to estimate true prevalence of gynaecological morbidity. Medical examinations were done in the respective villages in the hospital setting. Each woman was to visit five units, registration, interview by a female social worker, history and examination by a female and gynaecologist, pathology laboratory, and dispensary. Privacy was ensured during interview and examination.

Findings: In this paper, researchers have documented their personal experiences while conducting this study with the hope that it may be useful to evolve more relevant methodology for further research in this field. The article reveals how interactions with the study community should be made for their better cooperation.

It was found that 92 per cent of the women had gynaecological disorders. Each woman had an average of 3.6 diseases, but only 7 per cent of the women had ever sought medical care. This study generated interest among public health personnel in various parts of the world as it projected women's gynecological diseases as an important public health problem.

The study also invites our attention to the fact that the existing taboo and inhibitions regarding sexual health prevent women from securing an easy access to medical care. Also, women found overemphasis on Family Planning in our health care services as a hindrance in utilisation of health services. Therefore, though 92 per cent of the women were found suffering from gynaecological problems, only 7 per cent of the women had ever sought medical care.

Reviewer's note: This article also details as to how to approach a new community for studying sensitive topics.

Key words: Sexuality, Gynaecological Morbidity.

2. Unwanted adolescent pregnancy: Its present status

Author                     : Behera R.C. and Padte K.
Source                     : Journal of Obstetrics and Gynaecology of India, 1991
Place of study         : Pune, Maharashtra; Panji, Goa
Location                  : Not Applicable
Period of study        : 1982-84 and 1985-88
Type of research     : Empirical, Descriptive, Health Centre-based

Aim: To determine the factors leading to unwanted pregnancy and highlighting possible preventive measures.

Methodology: Two hundred women seeking abortion care were interviewed at the two hospitals over 3 years each in sequence. Data collection was done using a specially designed proforma.

Findings: Demonstrated higher percentage of unwanted adolescent pregnancies among middle and late adolescents, with 45 and 54 per cent respectively. A high incidence of unwanted pregnancy was found among rural population (68%), housewife (69%), under matriculate (53%), and lower economic group (67%). Causes included out-of-wedlock (15%), quick succession or pregnancies (34%), small family norm (15%), failure of contraception (5%), recent marriage (6%), education and career consciousness (6%), medical grounds (7%), marital mal-adjustment (2%) and drugs taken (10%). Ninety two per cent of the cases had inadequate sex education, and 84 per cent did not use contraception.

The women seeking abortion were counselled for not going ahead with induced abortion, but it was highly unsuccessful (90%), whereas post-abortive contraceptive counselling was quite successful (78%).

It concludes that unwanted adolescent pregnancy has taken a new dimension due to rapid changes in socio-economic environment and changes in the philosophy of life. The author states that legalisation or liberalisation is not the solution for unwanted adolescent pregnancies but prevention of pregnancies through extensive sex education and effective contraception is required.

Reviewer's note: Conclusions derived reflect constraints of hospital-based studies. In absence of any statistics on adolescent pregnancies in the past, attributing it to changing socio-economic environment and to the change in life philosophy is a little far fetched. The unwanted adolescent pregnancies perhaps are more visible than before for more women are seeking abortion care from the hospitals than before and a good indication.

Key words: Unwanted Adolescent Pregnancy, Indications for Abortion, Preventive Measure.


3. Outcome of teenage pregnancy


Author                    : Bhalerao A.R., Desai S.V., Dastur N.A., et al.
Source                    : Journal of Postgraduate Medicine, 1990
Place of study        : Mumbai, Maharashtra
Location                 : Not Applicable
Period of study       :1988
Type of research    : Empirical, Descriptive, Retrospective, Health Centre-based

Aim: To collect data about the pregnant teenagers and to compare the incidences of various complications and outcomes of teenage pregnancy with those of teenage pregnancies reported in the literature.

Methodology: Two hundred consecutive cases upto age of 19 years of the total 3,150 confinements during the period under review - July 1988 to October 1988 - constituted the sample. Medical, obstetric and socio-economic aspects of the pregnant girls were studied.

Findings: The incidence of teenage pregnancy was 6.3 per cent. Most belonged to poor or lower middle class families and were housewives. Six (3%) were unmarried, 173 (86.5%) were nullipara. Antenatal complications occurred were anaemia (25.5%), pre-eclampsia (8.5%), eclampsia (1.5%), premature opening of os (3.0%), VDRL positive (1.5%), intrauterine foetal death (2.0%), antepartum haemorrhage (1.0%). There were 8 per cent spontaneous abortions, 16 per cent premature vaginal deliveries as against overall incidence of 10 per cent in the hospital, 58.5 per cent full term normal deliveries.

The disaggregated data for the age group of 15-17 years indicated that outcome of pregnancy becomes worst in this age group compared to the age group 17-19 years. Low birth weight (LBW) incidence was 46.2 per cent for the teenage as compared to 30 per cent for the overall incidence in the hospital. LBW incidence for the age group of 15-17 years was 71.5 per cent and for age group of 17-19 years it was 44.1 per cent. Perinatal mortality was 65.2 per 1,000 total births compared to 45 per 1,000 total births in the hospital.

It concludes that teenagers are definitely at greater risk, requiring additional efforts and resources to serve and protect their health. More attention needs to be paid for prevention and treatment of antenatal complications, prematurity and LBW.

Reviewer's note: Study of socio-economic aspects as correlates of incidence of teenage pregnancies and other related aspects would have been insightful.

Key words: Teenage Pregnancy, Outcome.

4. Self-reported symptoms of gynaecological morbidity and their treatment in South India

Author                 : Bhatia J.C. and Cleland J.
Source                 : Studies in Family Planning, 1995
Place of study     : Karnataka
Location              : Rural
Period of study    : 1993
Type of research :
Empirical, Descriptive, Community-based

Aim:
To conduct a community-based study on reproductive morbidity and its determinants. The study was part of the major research effort to investigate the pathways through which a mother's education influences her child survival.

Methodology: The main study had several components - anthropological studies; investigation of primary schools in three states of India; a cross-sectional survey; and a prospective study. The conduct of the study was designed in such way that inputs of the in-depth qualitative studies could be fed into the subsequent quantitative studies. The intricate inter-linkages between child's survival and that of mother's health were noticed. Therefore, detailed information was collected in the cross-sectional and prospective study on different aspects of mothers' health.

This study was conducted in a sub-district with 293 villages and a small town, because it was typical of rural Karnataka and within reasonable distance of the capital city. The study population comprised of women who were less than 35 year old and had at least one child under five year of age. The achieved sample size was 3,600 (2,400 in rural and 1,200 from the town). No representative sample was pursued for the survey was exploratory. All eligible women in the town and 48 villages having a population of at least 500 persons were included in the sample. Female interviewers conducted the interviews. Extensive training, enough time for rapport establishment before starting the work, support of the experienced survey specialists in the field, daily interactions of the work characterized the study.

The questions on reproductive morbidity were framed based on the comprehensive list of reproductive morbidities along with details of symptoms and everyday terminology prepared by an experienced female obstetrician/ gynaecologist. Four groups of independent variables conceived were socio-economic, demographic, factors related to last live-birth and cognitive and behavioral factors.

Findings: Approximately one-third of the women included in this study reported current symptoms of at least one reason for reproductive morbidity. Ninety per cent of abortions were reported to be spontaneous. The causes of which may be outcome of prior infection or a cause of subsequent infection. Among others, menstrual problems (7.3%), symptoms of lower reproductive tract infections (16.9%), anaemia (23.4%), and symptoms of acute PID (5.2%) were reported. Prolapse, urinary tract infections, infertility (secondary), haemorrhoids were less frequently reported.

Analysis of the determinants was limited to menstrual problems, lower reproductive tract infection, acute PID and anaemia. Bivariate analysis revealed socio-economic differentials. Among demographic indicators, age at first pregnancy and total number of pregnancies were consistently related to all four morbid conditions. About 41 per cent reported disorders or problems were associated with their last live-births. With regard to cognitive and behavioural factor, personal hygiene, household environment and sanitation, and exposure to health education were related to reported morbidity. Analysis also demonstrated relationship with socio-economic variables, health education and autonomy in addition to duration of problem and age of the respondent. Experience of obstetric problems and complications associated with the last live-birth, place of last delivery were found to have strong and pervasive influence on reported gynaecological morbidity. Most importantly, reporting of the symptoms indicative of lower reproductive tract infections, acute PID and anaemia were significantly higher among tubectomised women than among those who were not using any method of contraception or were using a reversible method.

The most common source of treatment was private medical practitioner. Women rarely used PHCs and sub-centres. Better-educated women from more affluent households sought more treatment for symptoms of gynaecological problems than their less privileged counterparts, although the difference between the two was not statistically significant. Exposure to health education emerged as a major predictor of therapy-seeking behaviour.

The results strongly suggest that the quality of care and, in particular, hygienic conditions, may be poorer in government hospitals than in private hospitals and clinics. The data show that delivery in a government hospital may offer little advantage over home delivery in terms of protection against infection.

According to the authors, the results of the study, if substantiated by clinical examinations, will have far-reaching implications for India's family planning programme. It is stated that obstetric problems can act as a warning sign of more persistent problems of reproductive illhealth. Therefore, health services targeting follow-up diagnosis and treatment for these women should be made feasible. The authors were of the view that a radical review of facilities available under the primary health care system is required along with a more systematic evaluation of the private medical sector.

Key words:
Reproductive Health, Morbidity, Utilisation, Prevalence.


5. Caesarean section: How safe is it?

Author                     : Bhide A.G.
Source                     : Journal of Obstetrics and Gynaecology of India, 1991
Place of study         : Mumbai, Maharashtra
Location                  : Not applicable
Period of study       : 1981-90
Type of research    : Empirical, Descriptive, Retrospective, Health Centre-based

Aim:
To project the mortality due to caesarean sections in one of the Bombay's leading teaching institutions and compare it with the data available from the literature.

Methodology: All cases delivered at Nowrosjee Wadia Maternity Hospital during the reference period of 1981-90 were studied. The mortality occurring in the cases of caesarian section (CS) was reviewed.

Findings: The data show that there was a progressive increase in incidence of CS in recent years from 6.5 per cent in 1981-82 to 9.0 per cent in 1989-90. Mortality from CS has declined from 321.5/100,000 in 1981-82 to 190.8/100,000 in 1989-90. It was attributed to advances in medical technology, which have made it easier to take a decision in favour of CS. Though on decline, mortality and morbidity associated with CSs is nowhere comparable to that following a vaginal delivery.

The indications for CS have also widened. They include repeat CS, foetal distress (both remained about the same over the decade), breech presentation (increased by about 6%), antepartum haemorrhage (decreased by about 2%), cephalo-pelvic disproportion (decreased by about 8%), high risk pregnancies (increased by about 11%). The main causes of post caesarean deaths were haemorrhage (9 in 10 yrs), sepsis (4), embolism (2), medical disorder (2), anaesthesia (1). Increase of 11 per cent in CSs for an indication of high risk pregnancy is attributed to early diagnosis of obstetric complications and medical disorders associated with pregnancy. Higher maternal mortality in case of CSs compared to vaginal delivery is attributed partly to the complications that lead to CSs and partly to the risks inherent in the abdominal route of delivery.

It is suggested that each case must be reviewed before resorting to CS. There is a need for good prenatal care, better knowledge of medical disorders and well supervised intranatal care with the help of good anaesthesiologist, so as to minimise maternal mortality due to CS.

Reviewer's note: It has not studied the socio-economic profile of women undergoing CSs, which may have been insightful. Gives a clear comparative statistics on CS and vaginal deliveries and the respective mortality rate. Despite a large sample size, being a tertiary-level hospital based study it has its own constraints. It indicates the need for community-based incidence study to provide better insights into women's health status and the incidence of CSs.

Key words: Caesarean Section, Mortality.

6. Perinatal outcome in teenage mothers

Author                 : Chhabra S.
Source                 : Journal of Obstetrics and Gynaecology of India, 1991
Place of study     : Wardha, Maharashtra
Location              : Not Applicable
Period of study   : Not Stated
Type of research: Empirical, Descriptive, Prospective, Health Centre-based

Aim:
To study perinatal outcome in teenage mothers.

Methodology: The study was conducted in one of the rural medical centres, which drains most of the abnormal cases from nearby villages and townships. Teenage mothers constituted around 11 per cent of all deliveries, around 75 per cent of them were primigravidae. Four hundred cases were analysed in each of the two groups of teenage mothers and controls in age group 20-29 years.

Findings: Total of 400 teenage pregnancies were studied. Of these mothers, 5 per cent were below the age of 15 years and 87 per cent were between the age 18 to 19 years. Anaemia was prevalent in 70 per cent and toxaemia of pregnancy occurred in 14 per cent. In the study group 70 per cent had normal delivery, 73.7 per cent cases with breech presentation required CSs. In the control group, 38.8 per cent of the breech presentations required caesarean sections. In the study group and the control group, CS rate were 21.5 per cent and 19.5 per cent, mothers with low birth weight were 11 per cent and 7 per cent; perinatal loss was 77.5 per 1000 births and 57.5 per 1, 000 births; maternal mortality was 520.8 and 257.1 per 100,000 live-births. In 43 per cent women from the study group and in 29 per cent from the control group, labour lasted for more than 12 hours.

It concludes that young mothers are at higher risk of some pregnancy problems and adverse perinatal outcome. The author cites an example of another study, which found that poor care than age is important factor in primigravidae. Teenage and subsequent pregnancies should be discouraged to reduce perinatal and maternal risks. This group requires high priority services.

Key words:
Teenage Mothers, Perinatal Outcome.


7. Morbidity in Tamil Nadu: Levels, differentials and determinants

Author                   : Duraisamy P.
Source                   : This paper is based on the project, "Morbidity, Utilisation of and Expenditure on Medical Services in                                   Tamil Nadu", 1997
Place of study        : Tamil Nadu
Location                 : Not Applicable
Period of study      : 1973-74 to 1986-87
Type of research   : Empirical, Analysis of Data from NSS 42nd Round

Aim: To study the levels, trends, differentials and determinants of morbidity in Tamil Nadu.

Findings:
Author details and discusses the concept and issues involved in defining and measuring prevalence and incidence of morbidity. Further, he explains the nature of data on morbidity in different rounds of NSS and the problems and issues as regards comparability of the data for analytical purpose. Using individual data, the difference in the morbidity pattern across socio-economic and economic characteristic of the population was studied. Age-sex specific distributions of type of illness were examined. The determinants of morbidity were estimated using regression techniques. Reasons for not seeking treatment were also analysed.

The morbidity prevalence rates for the years 1980-81 and 1986-87 were comparable and estimates indicated that the overall morbidity prevalence rate has increased during the period. The overall morbidity prevalence rate was 28 and 32 per 1,000 in rural and urban areas of Tamil Nadu. Overall, the morbidity prevalence rate was higher among males (29 per 1,000) compared to females (27 per 1,000). The untreated illnesses were found to be higher in females than in males. Distribution of type of illness among age-sex groups suggested that the communicable diseases were concentrated in the younger age while the aged people suffer more from non-communicable ailments. The female headed households experienced a higher morbidity compared to male headed households. The data on morbidity prevalence showed that males had a higher risk of being sick compared to females. Increase in age increased the risk of being sick. As the level of education increased, the morbidity risk reduced. The effect of per capita consumption expenditure was positive and consistently significant in all the morbidity functions. More than 50 per cent of the untreated cases report that the ailment was not serious enough to seek medical treatment. About 20 per cent of the cases did not seek treatment due to financial constraints.

The analysis points to the need for targeted health interventions to reduce the morbidity among children and elderly persons. In general, improvement in education would reduce the extent of sickness among people. The high prevalence rate of cardiovascular diseases needs attention and measures to reduce the burden of treatment of the poor and needy are necessary.

Key words:
Morbidity, Gender Specificity.


8. Voices from the silent zone

Author               : Dubey V., Prakash S. and Gupta A.
Source               : The RAHI Findings, 1998
Place of study   : Delhi, Bombay, Madras, Calcutta and Goa
Location            : Urban
Period of study  : 1997
Type of research: Empirical, Descriptive, Community-based

Aim:
To document child sexual abuse and to look into the impact of incest on woman's adult life; to establish incest and child sexual abuse also as a middle and upper middle class Indian phenomenon.

Methodology: The study was carried out amongst English speaking middle and upper class women currently living in Delhi, Bombay, Madras, Calcutta and Goa. The majority of them were graduate and undergraduate students. Respondents also included housewives and employed women. Questionnaires were used for data collection. The majority of the questionnaires were administered to women after making them aware of the purpose of the survey. Others were distributed at random with the help of the network of resource people. The study was based on 600 questionnaires out of 1,000.

Findings: About 76 per cent of the respondents had experienced sexual abuse in childhood or adolescence. In case of 71 per cent of the respondents, abusers were either relatives or others they knew.

For many respondents, filling up the questionnaire has been of therapeutic value as it was a non-threatening way to collect information on such a sensitive issue. This study also gives valuable information about family system and people's peception of the issue in general and the kind of action required for effective prevention of sexual violence. The study brings into light a range of misconceptions in the area of sexual abuse and perceptions regarding its effect on women's life.

Difficulties in expressing the complexities of experiences in English language, difficulties in accuracy of interpretation of the responses to such a sensitive subject, time constraint for rapport establishing with the women were some of the limitations of the study as articulated by authors. It recommends areas of research on the subject of incest and child sexual abuse.

Reviewer's note:
The high prevalence of sexual abuse revealed through this study needs to be seen in the light of the fact that it was a self selected sample from among the upper class. As high as 40 per cent non-response needs to be taken into account while interpreting the data. There is no clear mention of the way the universe was defined. Though generalisation cannot be drawn, the study certainly brings to light the possible magnitude of sexual abuse and incest.

Key words:
Child Sexual Abuse.


9. Too far, too little, too late: A community-based case-control study of maternal mortality in rural west Maharshtra, India

Author               : Ganatra B.R., Coyaji K.J. and Rao V.N.
Source               : Bulletin of the WHO, 1998
Place of study    : Pune, Aurangabad and Ahmednagar, Maharashtra
Location             : Rural
Period of study   : 1993-95
Type of research: Empirical, Descriptive, Prospective, Community-based

Aim:
To study the events from the onset of a complication to death/recovery and to delineate the factors that determine survival in women who develop a complication.

Methodology: This was a population-based, matched case-control study. It covered 400 villages, with a total population of 686,000 spread over well-delineated but noncontiguous rural areas in Pune, Aurangabad and Ahmednagar districts of Maharashtra. The public health infrastructure in the study area was similar to that of the rest of the state. Cases were enrolled prospectively over the period 15 January 1993 to 15 December 1995. All deaths were screened to determine whether they were maternal. All identified maternal deaths were enrolled in the study without exception. The ICD-10 definition of maternal death was used as the case definition. The control and cases were drawn from the same population base. Information was obtained from several sources such as vital registration records, primary health centre registers, public and private medical facilities serving the study area. These potential controls were divided into two groups - women with normal pregnancies and women with serious pregnancy related complication.

Each maternal death was matched to two or more women with the same bio-medical complications (complication-matched control) and to one normal pregnancy from the same village (geographical control). All controls were randomly selected from the control pool.

Data collection included a structured interview as well as histories taken from the husband's family and the woman's own family, interviews with health care providers and a review of available medical records. Families were followed up one year later to ascertain the fate of the live born children of the maternal deaths.

Findings: Of the 570 deaths identified, 121 (21.2%) deaths fitted the definition of maternal death. Direct obstetric causes accounted for 71.9 per cent of the maternal deaths. It was found that logistic difficulties in obtaining transport or money played a role in 45 per cent of the deaths, inadequate medical management at hospital level in 25 per cent of the cases and shortages of blood and other essential drugs in 28 per cent of the deaths. Domestic violence was the second-largest cause of pregnancy related mortality, exceeded only by post-partum haemorrhage.

The medical causes of maternal mortality in this study were similar to the picture seen worldwide, but the proportion of post-abortion deaths was surprisingly lower than has been reported elsewhere. This coupled with the fact that not a single death was due to septic abortion suggests that in the study area, abortions (whether legal or illegal) were being performed in relatively 'safe' circumstances. The study has demonstrated that existing services were often too remote or have too little to offer and that patients, logistics and health service factors combine to result in a medical intervention for a maternal illness being instituted far too late to be effective. Delays in seeking treatment were obscured by critical health service delays that operate after a woman had made her first health contact. The inability of most health facilities (both private and government) to deal with obstetric complications and unwillingness to accept potentially serious cases leads to patients being shunted from one facility to another. The stepwise hierarchical referral system further increases misreferrals.

The findings that have been quantified for the first time highlight the need for inclusion of prompt and accessible medical management as an essential component of maternal mortality prevention programmes. Redesigning the referral system to include bypassing inappropriate referrals, and identifying and strengthening area-specific institutions (government and non-government) which are potentially capable of providing obstetric care, would be an effective way of reducing the time spent in reaching appropriate health care facility. In addition to it, ways to increase the time between onset of a complication and possible death also need to be explored.

Reviewer's note: A large sample community-based study conducted using a sound methodology makes this reasearch significant.

Key words: Prevalence, Complication, Maternal Mortality, Health Care Interventions.

10. Induced abortions in a rural community in Western Maharashtra: Prevalence and patterns

Author                    : Ganatra B.R., Hirve S.S., Walawalkar S., et. al.
Source                    : Working Paper of Ford Foundation, 1998
Place of study        : Pune, Ahmadnagar, Auragabad, Maharashtra
Location                 : Rural
Period of study      : 1994-96
Type of research   : Empirical, Descriptive, Prospective, Community-based

Aim:
To study mortality rate of post-abortion complications. To study women's considerations while choosing an abortion service provider. To understand women's expectations about and experience of abortion services.

Methodology: The study area covered 139 villages with a total population of 324,431. Most of the study area was situated within a distance of 20-80 km of a large town or a city. All the district hospitals, a few PHCs and some rural hospitals including small private hospitals provided MTP services in the study area.

Multiple sources and informants were used for case-finding. Information was collated from self-reporting, snow-ball sampling, community women's groups, school teachers and health functionaries within the community to identify women who had undergone induced abortion during the study period of 18 months. Potential ethical problems in the use of such information were overcome by adopting a study design that enrolled cases prospectively over the study period.

A total of 1,950 induced abortion occurred in 1,853 women who were identified from the study population. The identified women were categorised as currently married or currently not married. A structured interview schedule with open- and close-ended probes was used for the married group and an in-depth unstructured interview schedule was used for the 'out-of-wedlock' women. Dummy interviews using the same tools were simultaneously administered to other women so that the respondents were not singled out.

Findings: Calculated through indirect ways, the induced abortion rate in the study population in the period of 12 months was 19.1 per 1,000 women in the age group of 15-45 years. About 74.1 per cent of the pregnancies were terminated as they were unwanted. It indicates the vast unmet need for contraceptive services. It was found that about one in every six pregnancy terminations among married women were sex-selective; about two-thirds of the women complained of a problem that was severe enough to disrupt their routine work. Post-abortion care was found lacking. The median gestation at which pregnancies were terminated was 10.9 weeks, with 70.9 per cent first trimester abortions. About 3.4 per cent pregnancies were terminated after 20 weeks, that is the legally permissible limit for termination. Knowledge of legality was low even among abortion seekers. Women not currently married constitute a special group of abortion seekers who had different needs and who behaved differently from married women.

About 81 per cent of the pregnancies were terminated in the private sector. About 45.9 per cent of all abortions were terminated illegally. Traditional practitioners were used by only 2 per cent of the married women, whereas the use was significantly higher by the women who were not currently married. This suggests that the group is socially marginalised and is exposed to exploitation and insensitivity of service providers. The most common reasons mentioned by married women for choosing a provider were that the provider was experienced in conducting abortions, was patient and good-natured, explained the procedure and answered their queries, and performed the abortion in a place where facilities like blood and oxygen were available. Nearly one-third of the respondents said that cost considerations played a role in their choice. About a third stated that it was important for them that the provider was female, and the same number said that they chose a particular provider because repeated visits and an overnight stay at the hospital were not required. Around 12 per cent stated that they chose a particular provider, as they did not insist on contraceptive use.

Reviewer's note: The large sample size marks the study. A large number of dummy interviews has been conducted. This communication does not make any reference to whether these data have been used for furthuring knowledge. In absence of any reference made it raises ethical issues vis-à-vis the time taken of the dummy respondents and the public funds expended for the same. The method of 'case-finding' for studying induced abortion incidence is also not ethically sound.

Key words: Induced Abortions, Morbidity, Contraceptives.


11. General and reproductive health of adolescent girls in rural South India

Author                  : Joseph G.A., Bhattacharji S., Joseph A., et. al.
Source                  : Indian Pediatrics, 1997
Place of study      : Arcot, Tamil Nadu
Location               : Rural
Period of study     : Not Stated
Type of research  : Empirical, Descriptive, Community-based

Aim:
To assess the general and reproductive health of female adolescents.

Methodology: Both quantitative and qualitative methods were used to assess the general and reproductive health of female adolescents in Arcot district of Tamil Nadu. The qualitative method of data collection included focus group discussions and key informant interviews. The quantitative survey was conducted by administering questionnaires. Objective checklist was used to determine knowledge. For the quantitative survey, 4 villages were randomly chosen based on presence or absence of high school and by population greater or less than 1,000. From the selected villages 50 adolescent girls were chosen randomly to be included in the sample. Anthropometry, blood pressures and other clinical examinations were also conducted for these girls to assess their health status.

Findings: In the focus group discussions, adolescents spoke of having headaches, body pains, and fatigue. There was reluctance to discuss sexual health problems, but many reported concerns about menstrual irregularities. Most girls stated that they would feel more comfortable attending a separate adolescent clinic run by female physicians. In interviews with 190 girls, the most frequently cited health complaints were fatigue, palpitations, frequent headaches, backache and abdominal pain. Over 20 per cent suffered from joint pains, weight loss, poor appetite and recurrent respiratory problems. Those with higher educational status had fewer health complaints. About 30 per cent were anaemic and their heights, weights and body mass indexes were typical of those found in chronically undernourished populations. Levels of knowledge about topics, such as, menstruation, contraception, nutrition, and AIDS were extremely low.

Female doctors were preferred for gynaecological check-ups. An overwhelming majority declared that specific health care facilities for adolescents were lacking. Overall, these findings indicate a need for both health education and special treatment services for girls who have suffered the health consequences of low economic status, unhygienic practices, and poor nutrition.

Key words: Adolescent Girls, Health Status, Health Care Services.

12. Induced abortions in rural society and need for peoples' awareness

Authors                : Mondal A.M.D.
Source                  : Journal of Obstetrics and Gynaecology, 1991
Place of study      : 24 Parganas, West Bengal
Location               : Rural
Period of study     : 1989-90
Type of research  : Empirical, Descriptive, Prospective, Health Centre-based

Aim:
To find out reasons for acceptance of induced abortions in rural areas, the reasons for approach to illegal abortionists, the magnitude and nature of complications thereof.

Methodology:
The study was carried out in Baduria PHC of 24 Parganas in West Bengal. From two adjoining villages 300 females with one or more abortions were identified within the stipulated study period. Histories of induced abortions along with socio-cultural and obstetric histories were taken.

Findings:
All the abortions performed by quacks and paramedicals had led to post-abortion complications. Out of the total cases aborted by MBBS private practitioners 45.8 per cent had led to complications. Reasons for these were improper aseptic techniques, lack of training, overconfidence and popularity in the area ignoring quality of care. Reasons for approaching quacks were secrecy, availability, affordability and accessibility of the abortion services. Lady doctors were preferred while choosing abortion service provider.

Contraceptive acceptance was far from the requirement. The authors expressed the need for more MTP facilities. Simultaneously, people also should be made aware of the available MTP services.

Key words:
Induced Abortion, Complications of Induced Abortion.

13. MTP programme in Uttar Pradesh

Authors                : Mukharji R.
Source                  : The Directorate of Family Welfare, Uttar Pradesh
Place of study      : Uttar Pradesh
Location               : Not Applicable
Period of study     : 1987-88 to 1991-92
Type of research  : Empirical, Analysis of Secondary Data

Aim: To analyse socio-economic scenario of MTP acceptors.

Findings: Five hundred and fifty four institutions and 1,208 doctors have been approved in Uttar Pradesh (UP) after 1976 to conduct MTPs. In UP, there was 1 MTP centre per 3 lakh population in 1987-88 and 1 MTP centre per 2.40 lakh population in the year 1991-1992. In the year 1991-92, there was 20 per cent increase in MTP cases. Women in the age group 25-29 years terminated the largest number of pregnancies. There were 6.9 per cent second trimester abortions. As regards post-MTP coverage, 13-22 per cent cases opted for sterilization and 7-19 per cent got IUD inserted.

Difficulties in the programme were found in terms of provision of funds for instruments; maintenance & repair of the apparatus; cultural inhibitions that women have; and under-reporting of private doctors.

It is suggested that IEC activities are undertaken in an area-specific approach manner for specific population groups like Muslim population. There is a need to use film/folk media/electronic media to expand the programme. Spacing methods should be encouraged through our health programmes to reduce morbidity and unplanned pregnancy. It is suggested that approval of doctors and institutions should be decentralised by the Director General of Health Services.

Reviewer's note: The objective stated does not seem to be pursued in the presentation. It is hard to find connection between the objective and body of the paper. It also does not adequately clarify as to why IEC should focus on Muslim population.

Key words: MTP Programme, MTP Services, MTP Incidence.

14. Gynaecological morbidity among women in a Bombay slum

Author                  : Parikh I., Taskar V., Dharap N., et al.
Source                  : Streehitkarini
Place of study      : Mumbai
Location               : Urban
Period of study     : 1989
Type of research  : Empirical, Descriptive, Community-based

Aim: To determine the levels, patterns and correlates of gynaecological morbidity in an urban slum, focusing on women's perceptions and assessment of their gynaecological health as well as the conclusions of medical assessments of laboratory tests.

Methodology: The study was undertaken in a slum area of Mumbai served by Streehitkarini, a health-based voluntary organsiation in Bombay. The survey comprised of socio-demographic survey of respondents including their reported symptoms and morbidity and reproductive histories; and clinical examination and laboratory tests.

A random sample of ten per cent (sample size = 1,500) of ever married women residing in slum was drawn. No replacement was attempted resulting into sample loss of 446 respondents. Of the remaining 1,054, 298 refused a gynaecological examination. Effective sample thus comprised of 756 women, representing an overall sample loss of 50 per cent and a refusal rate of 28 per cent.

Interviews were conducted by two trained extension workers at respondents' homes. They were requested to attend the Streehitakarini clinic for subsequent medical examination. Other qualitative data were also obtained through group discussions with health workers, informal interviews with health practitioners and 100 community women on their perceptions of disease patterns.

Findings: Over 70 per cent of all respondents reported gynaecological complaints; more than 70 per cent had clinical evidence of either vaginitis, cervicitis, prolapse or PID; and about 49 per cent had STD or an endogenous infection as assessed by laboratory test. Evidence of STD infections such as chlamydia and trichomoniasis was found in 15 per cent and 10 per cent of all cases. As many as 39 per cent and 21 per cent of all respondents reported low backache and lower abdominal pain respectively. Also, from among the 15 leading conditions listed duriing the 'free listing' exercise, eight reflect gynaecological conditions.

Associations between socio-economic indicators and morbidity were weak. It may be because the respondents with income level above the poverty line are more likely to report any gynaecological condition, and more likely to have a laboratory diagnosed STDs. Older and higher parity women are more likely to report low back or lower abdominal pain and menstrual problems. In contrast, the correlates of laboratory-detected morbidity suggest that older women are somewhat less likely than younger women to experience either STDs or any endogenous infections. Also evident was a consistent inverse relationship between infection and parity. Women currently using contraception reported higher morbidity. This indicates that socio-economic determinants drop out as significant predictors, and age and parity become more important correlates of clinically diagnosed morbidity.

Health workers reported that few women would resort to clinics or doctors for gynaecological problems. Gynaecological conditions were rarely taken seriously untill they became grave. Cost of treatment and male physician were said to act as further deterrents. Discussions with women revealed that health seeking for gynaecological complaints was minimal and though they were aware of home remedies they were rarely used.

The findings show high prevalence of gynaecological morbidity thus proving it a major public health problem. Gynaecological morbidity in the current health programmes have remained largely unaddressed. The report presents a forceful plea for greater attention to, and investment in reproductive health care needs of poor Indian women.

Reviewer's note: Profile of the non-respondents would have been useful given the 50 per cent 'no-response' rate.

Keywords:
Correlates of Gynaecological Morbidity, STD, RTI, Treatment Seeking Behaviour.

15. MTPs in Indian adolescents

Author                    : Salvi V., Damania K.R., Daftary S.N., et al.
Source                    : Journal of Obstetric and Gynaecology, 1991
Place of study        : Mumbai, Maharashtra
Location                 : Not Applicable
Period of study       : 1982-86
Type of research    : Empirical, Descriptive, Retrospective, Health Centre-based

Aim: To analyse MTPs in Indian adolescents.

Methodology: The study analysed 932 MTPs sought by adolescents (15-20 years) at the Nowrosjee Wadia Maternity Hospital, between the reference period of January 1, 1982 to December 31, 1986. Data on age, marital status, gestational age, the method of termination and the contraception accepted were analysed for adolescents and non-adolescents.

Findings: Of 932, 154 (16.6%) were below the age group of 18 years, 532 (57.1%) were primigravidae. The majority (78.8%) of those below 18 years were unmarried. Of all the adolescent MTP seekers about 48.8 per cent were unmarried. Younger the patient, later she presented to the clinic. Of the total patients attending the clinic only 21.2 per cent presented in the second trimester as compared to 34.9 per cent in the adolescent age group. The situation was worst in the youngest patients as 75 per cent of the 15 year old girls presented only in the second trimester. This was attributed to failure on part of the girls to realise that they were pregnant, concealment of pregnancy and conflicts with parents.

The younger patients had a higher incidence of the potentially more complicated procedures of second trimester method of termination (only 44.4% suction evacuations) as compared to the older girls (85.5% suction evacuation in the girls aged 20 years). About 38.9 per cent of the adolescents accepted IUCD as compared to 48.4 per cent of the total clinic population. Around 2.5 per cent of the adolescent patients even completed their child bearing and accepted sterilisation.

Reviewer's note: Disaggregated data on marital status and acceptance of contraception would have been insightful. It also points at the need to study the situations which lead adolescents to terminate pregnancies.

Key words:
MTP, Adolescents.

16. Health transition in India Part I - Differentials and determinants of morbidity in India : Disaggregated analysis Part II - Health scenario and public policy in India

Author                    : Shariff A.
Source                    : Working Paper, National Council of Applied Economic Research, 1995
Place of study        :
Nationwide
Location                 : Rural and Urban
Period of study       : 1993
Type of research    : Empirical, Descriptive, Community-based

Aim: Part I
: To study morbidity pattern and its determinants across the Indian states.
Part II: To critique the public health policy in India.

Methodology:
Part I
: A three-stage stratified sample design with varying probabilities in the first stage was adopted. District/towns, villages/urban blocks and the households were the sampling units in subsequent stages. For rural sample, 718 villages from 410 districts in the country were selected. Households listed in the villages were stratified into five income groups. Households from each strata were selected with equal probability using random number tables. For urban sample, the cities/towns with population exceeding five lakh were included in the sample. The remaining cities were grouped into six strata based on their population size and from each stratum a sample of towns was selected independently. The samples of blocks selected vary between 2 and 30, depending upon the size of the town. All households in the selected blocks were listed, stratified by income categories and then selected. A total of 6,354 rural and 12,339 urban households were covered.

The sample was representative of the respective rural and urban population but not adequate for disaggregate analysis at the state level. The methodology was detailed covering various aspects, such as, definition, reference period, date of survey; types and nature of illness categorisation; factors influencing the reporting of morbidity; measurement of income.

Part II: Not applicable

Findings: Part I -
Sex and age of individuals showed important associations with morbidity. The results highlight extremely high levels of morbidity prevalence among the very young (0-4 year) and the very old. A further disaggregation suggested that most of the male advantage in morbidity come from the age categories 15-34 years and 35-59 years thus pointing to a very high reproductive morbidity among the Indian women. Regional level disaggregation points to a substantial and significant female disadvantage in the three lower-central states namely Rajasthan, Madhya Pradesh and Orissa. Further, contrary to the expectation, the female disadvantage was high and significant in the urban areas.

Disaggregated analysis showed that the education of the household heads had large, positive and highly significant association with morbidity of children less than age of 5 years. Fairly negative and significant effects of household income on morbidity were seen. The magnitude of this association was larger and much stronger among the younger population. This highlights age and gender discrimination with regard to utilisation of hospitalisation services in rural and urban areas.

Public hospitals were preferred for hospitalisation. The rate of hospitalisation was significantly low in central and eastern parts and significantly high in western parts when compared with south India. In urban areas, the relative dependence on public markets was low and less variable than in rural areas. About 32 per cent and of those who reported sick had used public facilities for treatment. Women in productive ages had a tendency to resort to private health care in all parts of India. The public health care utilization was relatively high in case of Hindus, those living in eastern parts of India and those suffering from infectious sickness in rural and those from non-infectious in urban areas. As distance to the service centre increased, resort to public facilities declined compared to private services.

The survey has estimated a reported morbity prevalence rate of 104 for the rural and 101 per 1,000 for the urban areas for all India during the reference period of 30 days. The actual morbidity may be high. Author expressed the need to standardise the concepts, definitions and reference periods so as to estimate more accurate morbidity rates.

Part II - According to the author role of prevention in maintaining health was probably the most misunderstood aspect of health care schemes in the country both, at individual and policy level. At the policy level the emphasis has always been on curative medicine. Expanding the medical supply approach to include establishing and maintaining the health producing (disease inhibiting) infrastructure and services is essential.

The author expressed that in spite of concerted efforts the health infrastructure and supplies are inadequate and inaccessible to people. Besides, there exists a misplaced emphasis as far as the current policy is concerned which focuses on creating physical infrastructure and upgrading institutions through cosmetic changes. It is necessary to adopt epidemiological and target approach for reducing the deaths that have endemic and epidemic characteristics. The health services should be placed as close to the people as possible to ensure maximum benefit to the communities to be served. Making people depend less on the modern medicine and reorienting them in the attributes of traditional medicine and self-medication would increase the accessibility to health care. For example, as delivery mostly takes place at home, training birth attendants and providing them simple and inexpensive aseptic delivery kits on a mass scale could ensure safe delivery.

The national health programme should integrate and amalgamate the new health concepts largely originating from the allopathic system of medicine with the local concepts and practices. Indian health care programme should build a multi-type health care system. it is suggested that in order to improve access to reproductive health care services female medical practitioners are inducted at the services centres on the one hand and female health guides at the village level on the other.

The author states that the public policy in India is conceived and implemented as a partial approach. An integrated, holistic and people centered approach is missing in both conceptualization and propagation of policy. The approach is bureaucratic and there is a water tight compartment approach to policy. Public policy also appears to have a fire fighting approach, thus making its presence felt only in case of crisis which otherwise remains silent. The public policy also addresses only the short term, politically rewarding and often superfluous programmes. The current emphasis on involving the NGOs in health and welfare sectors does not necessarily amounts to the people's participation. There is a need to integrate local bodies like 'panchayats' in health care provision.

Keyword: Determinants, Health Care Utilisation, Health Care Expenditure, Morbidity, Prevalence.

17. Backpain, the feminine affliction


Author                    : Shatrugna V., Soundarajan N., Sunadaraiah P., et al.
Source                    : Economic and Political Weekly, 1990
Place of study         : Hyderabad, Andhra Pradesh
Location                  : Not Applicable
Period of study        : 1987
Type of research     :
Empirical, Descriptive, Retrospective, Health Centre-based

Aim:
To study incidence of various kinds of osteoporotic fractures in women.

Methodology: The study was carried out in two parts: a) retrospective and b) study of currently admitted women in the orthopaedic ward of the Osmania General Hospital. A total of 289 case sheets from 297 women of 18 years and above admitted in the hospital during the reference period of January and October 1987 were analysed. Also a 10 per cent (107) systematic sample of all men admitted during the same reference period was used to study the incidence of these fractures in the men's ward to get a comparative view. For the qualitative study 37 adult women admitted in the orthopaedic ward during the period of the study (Sept-Oct 1987) were interviewed. The reason for selection of women with osteoporosis fracture is very well justified by stating the limitation of identifying the calcium level, which was one of the important factors responsible for thinning of bone.

Findings: The authors highlight the importance of recognising backpain as an important health complaint in women's life. This complaint which otherwise remains delegitimised for doctors inflicts on women's bodies in a variety of ways throughout their lives. The causes of backpain and its correlation with working pattern and calcium deficiency have been explained.

The analysis showed differences in the pattern of utilisation of services and treatment seeking behavior among the women and the men for this specific illness. For various reasons women had to leave the hospitals before the completion of the course unlike men. The quality of services offered by hospital in terms of personnel, record keeping, interpersonal relationship were found less than satisfactory. The need for woman sensitive hospital set-up with increased sympathetic humanpower was brought out.

Recently medical scientists are engaged in finding quick solutions which have opened new areas of research. For example, there is need for further research in 'chronic calcium deficiency' and its role in osteoporosis or the need to study the role of bonesetters or doctors who did not insist on hospitalisation. To acknowledge and understand the services offered by these practitioners is important and significant for the speedy recovery of fractures in women in the context of utilisation of larger health care system. But these medical solutions deflect the question of osteoporosis into areas that do not have much relationship to women's day to day lives.

Incomplete record keeping on various important factors such as occupation, income, fertility history, periods of breast feeding, age of menopause, previous drugs used, dietary history in the case sheets limited the scope of study in terms of cross comparison and examining correlation of these various factors with osteoporotic fractures. Difficulties were also faced due to various reasons in retrieving the information on the various above mentioned factors in the cases from qualitative study. Also the number of women interviewed was very small for quantitative analysis.

Reviewer's note: The paper highlights the problem and difficulties faced while conducting this study. This would help researchers interested in taking up similar research in the future to pre-empt some of the problems.

Key words:
Backpain, Calcium Deficiency, Osteoporosis Fracture, Women, Diet, Incidence, Service Utilisation.

18. Research summary of STD prevalence study in Tamil Nadu


Author                 : Voluntary Health Services (VHS)
Source                 : Report of AIDS Prevention and Control Project
Place of study     : Tanjore, Ramanathapuram and Dindigul, Tamil Nadu
Location              : Rural and Urban
Period of study    : 1995
Type of research : Empirical, Descriptive, Community-based

Aim: To study the community prevalence of STD.

Methodology:
The entire state constituted the universe. A multi-stage sampling design was adopted. In the first stage, three districts were randomly selected. In the second stage, a population proportionate sampling of urban/rural clusters was used to select 30 clusters from each of the selected districts. A cluster was defined as a panchayat village or an urban ward as enumerated in the census. In the third stage, fifteen households were randomly selected from each of the clusters to form the unit of the study. All adults, including men and women in the age group of 15-45 years residing in these households formed the study subjects. A total of 20,975 people were examined in the medical camp.

A combination of survey and medical/clinical camp was used for data collection. Careful sampling, necessary pilot-testing and standardisation of medical camps, ethical clearance from the ethics committee mark the study. The HIV results were kept confidential and available only to the database manager.

Findings: The AIDS Prevention And Control Project (APAC) was focused at reducing the sexual mode of transmission of HIV/AIDS, as it is the major mode of transmission in the country accounting for 80 per cent of the HIV infections. The data revealed that most of the people with STDs go to private clinics and only 25 per cent go to PHC facilities. A very few (2% each) get attention at the secondary and tertiary level hospitals in the state. Only 52 per cent of people with STDs go to allopathic practitioners and the rest to who practice alternative system of medicines.

RTIs were very common in the community. Around 32 per cent (men and women included) complained of genital discharge. Vaginal discharge was observed in 42 per cent of women. The overall prevalence of STDs was 15.8 per cent in the community.

These data, according to the author, are very important for developing and implementing programmematic solutions to prevent STDs and HIV transmission in India. Estimates based on findings of this study show that for a population of 25 million about 2,425,000 people have any one of the six STDs measured in the study; about 1,325,000 people were infected with Hepatitis-B virus and carry the surface antigen; about 450,000 people were infected by HIV.

The programmatic solutions recommended to reduce STDs and HIV in the community include introduction of syndromatic management of STDs at PHC level through integration of RTI/STI; popularising syndromic treatment of STDs among private practitioners, strengthening government STD clinics and STD services; expansion of STD operational research; expansion of HIV diagnosis, support and care services in the rural area; and initiating ELISA (Hbs Ag) screening for high risk.

Key words: STD Prevalence, Health Care Services, HIV/AIDS.


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Centre for Enquiry into Health and Allied Themes