ORIGINAL PAPER

The Silent Epidemic of Reproductive Morbidity Among EverMarried Women (15–49 Years) in an Urban Area of Delhi

Nidhi Bhatnagar • Jyoti Khandekar •

Amarjeet Singh • Sonal Saxena

Published online: 12 September 2012

� Springer Science+Business Media, LLC 2012

Abstract Concept of reproductive health has long been

discussed and need to focus on reproductive morbidity as a

measure of reproductive health has evolved. There is poor

reproductive health with neglect of women’s own health.

Compounded with socio-cultural factors, the result is poor

treatment seeking and hence poor quality of life. This

community based study was conducted to find out the

magnitude, type of reproductive morbidity and treatment

seeking behavior for the same. Cross sectional study was

conducted in Palam Village among married women aged

15–49 years. 750 women were interviewed by visiting

every fifth house through systematic random sampling.

Symptomatic women were referred for gynecological

examination and investigations. The overall prevalence of

Reproductive Morbidity was found to be 46.3 %: Gynae-

cological morbidity in 31.3 % subjects, obstetric morbidity

in 43.4 % of the eligible women and contraceptive induced

morbidity in 11.2 % of the ever contraceptive users with

5 % reporting more than one symptom. Problem perception

and treatment compliance was poor for subjects with

gynecological morbidity as compared with contraceptive

and obstetric morbidity respectively. High self-reported

obstetric morbidity was observed with good treatment

seeking behavior as compared to poor treatment seeking

behavior in women with gynaecological morbidity. Con-

traceptive morbidity was reported by fewer subjects but

treatment seeking was good. There is a need to understand

the pattern of reporting and health seeking behavior among

women suffering from reproductive morbidity. The large

magnitude of reproductive morbidity warrants attention

and hints the poor quality of MCH care delivered to

women.

Keywords Community � Reproductive morbidity �Gynecological � Obstetric � Treatment seeking behavior

Introduction

It has been more than 25 years since WHO working group on

reproductive health drew attention of health care planners that

they should focus on women’s health (morbidity rather than

exclusively targeting mortality). It was followed by in-depth

studies on the issue of reproductive morbidity and discussion

evolved on ‘culture of silence’ and ‘concept of normality’ in

the process [1]. However, despite this paradigm shift, mater-

nal mortality and pre natal diagnostic techniques still remains

the focus of most of our women’s health related discussions.

Reproductive morbidity needs to be given due attention as it

affects quality of life of women profoundly.

The WHO working group (1989) defined reproductive

morbidity as ‘‘any morbidity or dysfunction of the repro-

ductive behavior including pregnancy, abortion, childbirth,

or sexual behavior and may include those of psychological

nature’’. The group is categorized into gynecological,

obstetric and morbidity related to contraceptive use [2].

However, there is lack of availability of such category wise

data on reproductive morbidity of women in India.

N. Bhatnagar (&) � A. Singh

School of Public Health, Post-graduate Institute of Medical

Education and Research, Sector 12, Chandigarh 60012, India

e-mail: nidsbhatnagar@yahoo.com

J. Khandekar

Department of Community Medicine, Lady Hardinge Medical

College, New Delhi, India

S. Saxena

Department of Microbiology, Lady Hardinge Medical College,

New Delhi, India

123

J Community Health (2013) 38:250–256

DOI 10.1007/s10900-012-9607-3

Efforts to estimate the magnitude of this problem have

been primarily based on hospital data. Many studies focus

on some specific morbidity. A comprehensive under-

standing of this issue needs a study of all the morbidities of

reproductive tract simultaneously. There is also a dearth of

information on treatment seeking behavior of women

related to reproductive morbidity with stigma and taboo

related to any discussion on this issue. Hence this study

was done in a community setting with the objective to

ascertain the magnitude and pattern of reproductive mor-

bidity among reproductive age women and their treatment

seeking behavior.

Methodology

This cross-sectional study was conducted from January

2009 and March 2010 among ever married women of

reproductive age (15–49 years) residing in Palam Village,

Delhi. Both Government and private health agencies cater

to the health care needs of the residents. People have access

to a multitude of secondary and tertiary healthcare facilities

in close vicinity to Palam. Overall 750 study subjects,

20 % of the eligible couples among the total population of

study area (23,500 with 3,700 eligible couples) were

selected by visiting every fifth house from a random start.

An informed consent was duly taken before enrolling them

into study. A predesigned semi-structured interview sche-

dule was used to gather data. It sought information on

socio-demographic characteristics, reproductive morbidity

and treatment seeking behavior. The reference period

selected for recording gynecological and contraceptive

morbidity was 3 months while obstetric morbidity was

recorded for women with most recent delivery in past

3 years. If found symptomatic on history respondent was

called to PHC (Primary Health Center) Palam for general

physical and gynecological examination which was con-

ducted in presence of a gynecologist. Relevant hemato-

logical and microbiological investigations were also done.

Vaginal smear of subjects complaining of vaginal dis-

charge was collected using aseptic techniques. Two swabs

were collected. One swab was examined by direct

microscopy and gram stain was prepared as per standard

methodology and analyzed in routine laboratory of PHC

Palam [3]. The second swab was used for culture. It was

inoculated on Blood agar, Chocolate agar and Mac-Con-

key’s agar. The plates were then transferred to Department

of Microbiology, Lady Hardinge Medical College.

Throughout the study subjects were ensured of privacy

and confidentiality. Statistical Analysis of data was done

with the help of SPSS 12. The study has been approved

from the institutional ethical committee of Lady Hardinge

Medical College, New Delhi.

Results

The demographic profile of the study subjects is shown in

Table 1. More than half (54 %) of the study subjects were

in age group of 25–34 years and mostly (95.3 %) Hindus.

A Large majority 712 (94.9 %) of women were home-

makers. Only 38 (5 %) women were employed as teachers,

clerks, sweepers, labourers and housemaids. Two third

(66 %) of women belonged to nuclear families. Majority of

women (75 %) belonged to the middle section of the

Kuppuswamy scale (Lower middle and upper lower).

Table 1 Socio-demographic profile of the subjects

Socio-demographic factors Number Percentage

Age in years

15–24 124 16.5

25–34 407 54.2

35–44 187 24.9

45–49 32 4.2

Socio-economic status (modified Kuppuswamy scalea)

Upper & upper middle 140 18.6

Lower middle & upper lower 563 75

Lower 47 6.2

Type of family

Nuclear 496 66

Joint 254 34.2

Parity

0–2 522 69.9

[2 228 30.4

Literacy status

Illiterate & just literate 149 19.8

Primary & middle 233 31.06

High school & senior secondary 257 34.2

Graduate & postgraduate 111 14.8

Modern contraceptive usageb

Oral pills 35 7.7

Copper T 52 11.4

Tubectomy 197 43.3

Emergency contraceptives 3 0.6

Injectable contraceptives 7 1.5

Non users 296 39.5

Religion

Hindu 715 95.3

Muslims 28 3.7

Others 7 0.9

Occupation

Homemaker 712 94.9

Others 38 5

a Kumar et al. [20]b Multiple response

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Approximately half (49.5 %) of the study subjects were

educated up to high school or more. One fifth of the study

subjects (19.8 %) were either illiterate or educated below

primary class (just literate). Mean parity of study subjects

was 2.07 with 69.9 % women having two or less than two

live children and 30.4 % of women with more than 2

children. Among 454 ever users of contraception nearly

420 were using it currently. Tubal ligation was most pre-

ferred method of contraception (43.3 %) followed by Cu T

(11.4 %) and oral pills (7.7 %). About 17.4 % of study

subjects used traditional methods of contraception. (with-

drawal method, calendar method, etc.)

Reproductive Morbidity was reported by nearly half

(46.4 %) of the study subjects: gynecological morbidity

was seen in 31.3 %, obstetric morbidity in 43.4 % and

contraceptive induced morbidity in 11.2 % of subjects. The

questionnaire of obstetric morbidity was subjected to

women who had delivered in past 3 years. The study

subjects subjected to obstetric morbidity questionnaire

were 265(35.37 %) and among those nearly 43.4 % women

reported morbidity. Similarly, only ever users of contra-

ceptive were considered eligible for interviewing on con-

traceptive morbidity. Out of 454 ever users in the study,

nearly 12 % women reported to have morbidity which they

related to contraceptive usage.

Nearly half of the study subjects (48.9 %) who reported

gynecological morbidity were suffering from menstrual

disorders followed by reproductive tract infections

(34.8 %). Dysmenorrhoea was the most common (16.5 %)

menstrual problem and candidal infection was most com-

mon (22 %) RTI in women. In obstetric morbidity bleeding

per vaginum was most frequently reported (8.6 %) fol-

lowed by pedal odema with high BP (5.6 %). Menstrual

problems were most commonly (4.6 %) reported morbidity

associated with contraceptive usage Table 2.

Nearly 188 women (54.02 %) reported to the health

center for examination. Some women were not ready to

visit the health center and others were not symptomatic at

the time of interview.

Most of study subjects with obstetric and contraceptive

morbidity (96.5 & 96.0 % respectively) perceived it as a

problem interfering in their routine work as compared to

subjects with gynecological morbidity (87.6 %). Out of

those women who perceived this as a problem, treatment

was initiated by 93.6 % subjects with obstetric morbidity

and 87.7 % subjects with contraceptive morbidity. How-

ever 42 % of women with gynecological morbidity did not

seek any treatment.

More women with contraceptive morbidity (67.44 %)

reported to government health care in contrast to subjects

with gynecological morbidity (68.3 %) consulting private

health services more. Women with obstetric morbidity

consulted both services in nearly equal proportions. Good

compliance to treatment was observed in women with

obstetric morbidity (97.1 %) whereas 35 % of women with

contraceptive morbidity and 34 % of subjects with gyne-

cological morbidity did not comply with the treatment

received Table 3.

Discussion

The prevalence of reproductive morbidity is found to range

from 30 % to as high as 60 % in some studies [4–6]. There

are several plausible reasons that can be attributed to the

wide variation observed. (Mode of interviewing, probing,

whether it was self-reported or based on examination

findings, reference time period of symptoms and the

inclusion criteria set for the study.) Socio-demographic and

cultural practices also effect the reported prevalence sig-

nificantly. As revealed in our study more than one third of

morbidity in women can be attributed to her non-pregnant

state. This is a large share and demand’s significant

attention by the health care planners. The more or less

exclusive focus of National Rural Health Mission (NRHM)

and Reproductive Child Health (RCH) program on preg-

nancy related morbidity needs to be revamped.

Nearly half (48.9 %) of the women reporting gyneco-

logical morbidity suffered from menstrual problems. Study

conducted by Sehgal et al. [7] reported morbidity due to

menstrual disorders in 32.4 % women. Similar studies

conducted in Nepal and Gambia reported morbidity in 22.9

and 34.1 % women [8, 9]. Menstruation is an important

monthly recurring event in reproductive life of a woman.

Any discomfort or disturbance associated with menstrua-

tion will naturally assume special significance in a

women’s life. This high percentage of morbidity attributed

to menstrual disorders seriously affects the quality of life of

women.

Reproductive tract infections were reported by one third

of respondents. However nearly half (46.3 %) of the samples

(cervical swabs) were reported as ‘‘sterile’’. The reason for

this finding can be attributed to high sensitivity of organisms

(Gonococci, Chlamydia, Trichomonous, Candida, etc.).

These organisms perish easily when exposed to temperature,

drying and use of anti-bacterials. Another reason for sterile

report of culture may be due to occurrence of physiological

discharge in women [10]. Further, it is usually difficult to

culture the micro-organisms (chlamydia, gonorrhea and

other viruses) owing to the limitation of optimum/adequate

investigation facilities in the periphery. Among the women

whose cultures were not sterile, Candida was the most fre-

quent finding (22 %). Bacterial Vaginosis and Trichomo-

nous were isolated in three samples. Study conducted in

cities of Maharashtra, India found prevalence of RTI to range

from 37 to 64 % [11]. Similar study on RTI in Sundernagar,

252 J Community Health (2013) 38:250–256

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Orissa found 39.2 % women symptomatic of RTI. 12In sharp

contrast a study in rural Haryana documented the morbidity

in 11.1 % of women [12].

Obstetric morbidity prevalence seen in present study

was 43.4 %. Various studies have reported a highly vari-

able prevalence of obstetric morbidity ranging from 21 to

64 % [13–16]. This again indicates that more attention

should be given to relief of problems associated with

morbidity in women rather than solely targeting maternal

mortality. There is also a need to study the link between

quality of care during antenatal, intra-natal and postnatal

period with prevalence of obstetric morbidity.

Table 2 Pattern of reproductive morbidity in study subjects

Gynaecological Morbidity 235(31.3%)

Obstetric Morbidity 115(43.4%)

Contraceptive Morbidity 51(11.2%)

Menstrual Problems -115 (48.9%)

Dysmenorrhoea 39 ( 33.9%)

Polymenorrhoea 13(11.3%)

Oligomenorrhoea 23( 20%)

Metrorrhagia 18(15.65%)

Menometrorrhagia 14(12.17%)

Menorrhagia 8(6.9%)

RTI - 82 (34.8%)

Candida 18 (21.9%)

Trichomonous 3(3.6%)

Bacterial Vaginosis 3 (3.6%)

Sterile culture 38 (46.3%)

Not investigated 32(39%)

Dyspareunia -8 (3.4%)

Infertility- 26 (11%)

Prolapse-27 (11.4%)

Bleeding per vaginum-23(8.6%)

Decreased foetal movement-16 (6%)

Pedal odema-15 (5.6%)

Vaginal Discharge 13 (4.9%)

Postdated pregnancy-13 (4.9%)

Excessive vomiting-13(4.9%)

High fever after delivery-8 (2.6%)

Leaking per vaginum-5 (1.8%)

Abnormal lie-6 (2.2%)

Bleeding after delivery-3(1.1%)

Menstrual Problems-21 (4.6%)

RTI-17 (3.7%)

Chronic Pelvic Pain-13 (2.8%)

Any Reproductive Morbidity

n=348(46.4%)

Women of reproductive age group

n=750

Eligible subjects for assessment of morbidity

n1=750 n2=265ban3=454c

a Total eligible study subjects; b Study subjects who had delivered in past 3 years; c Study subjects who are ever users of contraceptive

J Community Health (2013) 38:250–256 253

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In the present study, contraceptive morbidity was reported

among 11.2 % of ever users. Higher prevalence of contra-

ceptive related morbidity was reported by Rathore. Mor-

bidity in users of non-invasive methods was 73 % as

compared to 57 % in users of Invasive methods [17]. Singh

and Singh [11] reported 26 % of study subjects attributing

their morbidity to contraceptive usage. Studies conducted by

National Family Health Survey I (NFHS) (1992) found IUD

related morbidity among 19 % and tubectomy related mor-

bidity among 23.3 %. The lower prevalence of contraceptive

related morbidity in the present study might be attributed to

good network of health care providers, delivering quality

family planning services in the study area.

Out of all women, many perceive the morbidity and seek

treatment consultation but few comply with the treatment

received. Various factors are responsible for this situation.

Consultation rate was poor for gynecological morbidity as

compared to the obstetric and contraceptive morbidity. This

may be attributed to perceived acute nature of obstetric

morbidity. Moreover, in general any society is more con-

cerned about events related to childbirth henceforth it is

given more importance. Superimposed on it are the socio-

cultural factors which put a taboo on women seeking treat-

ment for gynecological condition. Gynecological morbidity

is often perceived as chronic and a part of women-hood. The

concept of normality makes it culturally acceptable. This

seems to add evidence to why women do not seek treatment

and comply with it for gynecological morbidities. More

consultations with government health care were seen in

subjects suffering from contraceptive morbidity. This can be

assumed to be due to public perception of family planning as

a government program. They feel that government should

assume responsibility to provide relief from contraception

related morbidity. Moreover, almost invariably an easy and

no cost access to family planning services is provided in most

government hospitals.

Table 3 Treatment seeking behavior of women with reproductive morbidity

Women of reproductive age group n=750

Reproductive Morbidity n=348

Gynae. Morbidity 235(31.3%)

Obstetric Morbidity 115(43.3%)

Contraceptive Morbidity 51(11.2%)

206(87.6%) 111(96.5%) 49(96%)

136(66%) 104 (90.4%) 43 (87.7%)

90 (66.1%) 101 (97.1%) 28, (65.1%)

Problem perception

Treatment Sought

Government

Private

Others

T/t Compliance

48(35.29%

93(68.3%)

12(8.8%)

51(49.03%

53(50.96%

29(67.44%)

14(32.55%)

Interview on type, duration, pattern & T/t seeking behavior

On History & Interview

38 women (5 %) had more than one morbidity in the study

254 J Community Health (2013) 38:250–256

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Treatment seeking behavior differed between the dif-

ferent types of reproductive morbidity. Nearly twice the

number of study subjects suffering from gynecological

morbidity reported to the private health care (68.3 %) as

compared to the government health care (35.29 %). Con-

cern for confidentiality, privacy and lesser waiting time

may explain the women’s preference of private health care.

Nearly equal number of study subjects suffering from

obstetric morbidity reported to government (49.03 %) and

private (50.96 %) health care facility. Availability of free

medicines and investigations under various RCH program

draws women with obstetric morbidity to the government

sector. Moreover government is encouraging institutional

delivery hence women’s preference for government health

services for obstetric morbidities is understandable. How-

ever in Palam, the study area, many private nursing homes

were delivering subsidized or no cost antenatal care under

public private partnership, explaining nearly equal con-

sultation rate for both sectors. Majority of subjects suffer-

ing from contraceptive morbidity (67.44 %) reported to

government health care as compared to private health care

(32.55 %) as consultations in government health centers

are done for contraceptive usage by most of the subjects.

Lesser compliance (66 %) to treatment was observed in

gynecological and contraceptive morbidity. Among the

subjects with contraceptive morbidity poor compliance was

a result of poor response to treatment. This might result due

to more frequent reporting of even insignificant symptoms

by women using contraceptives. Very good compliance

was observed in subjects with obstetric morbidity. The

present study reported better treatment seeking as com-

pared to other studies. This can be explained by better

education of study subjects and availability of health care

providers in the study area. Study conducted in Maha-

rashtra by Singh and Singh [11], reported that less than half

of the women with gynecological morbidity sought treat-

ment. Sehgal [18] found 40 % of women who accepted

their ill-health as a normal phenomenon and treatment

sought by only 47.2 % women. (88.2 % preferring allo-

pathic health care). Rangaiyan and Surender [19] reported

treatment seeking in 15 % of symptomatic women [19].

Das and Shah [15] found 25 % of women with gyneco-

logical symptoms not on treatment.

Limitations

There are several limitations in the study. First, the sample

size is small. Second, every woman self reporting the

symptoms of reproductive morbidity should have been

visiting the health center for further examination and

investigations. But this was not the case as only women

who were currently symptomatic and not receiving

treatment gave consent for the visit. The study also war-

rants robust diagnostic procedures for accurately assessing

the magnitude and etiology of reproductive tract infections.

Lastly, the findings need to be supported by a qualitative

study to find out the perceptions of women on reproductive

morbidity and the reasons for this pattern of health seeking.

Conclusion and Recommendations

Nearly half (46.3 %) of study subjects residing in Palam

Village suffered from reproductive morbidity. Consider-

ably large proportion of this was the gynecological mor-

bidity (31.4 %). Obstetric morbidity was reported in

43.4 % of the women who delivered in past 3 years and

contraceptive related morbidity in 12 % of the ever users.

This large share of reproductive morbidity effecting

women throughout the reproductive life span may severely

impair the quality of life and demands due attention. Policy

makers and program managers need to go beyond the rates

and ratios to improve the reproductive health of women.

The barriers in treatment seeking by women should be

identified and well addressed. Further qualitative in-depth

studies are required to understand the reproductive health

needs of women, the complex inter-relationships of social

and cultural factors in deciding women’s health their

morbidity profile and treatment seeking behavior.

Acknowledgments The author(s) received no financial support for

the research and/or authorship of this article.

Conflict of interest The author(s) declared no potential conflicts of

interests with respect to the authorship and/or publication of this article.

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