A Study on Selected Reproductive Health Morbidities among Women Visiting Reproductive Health Camps in Nepal Commissioned by Familly Health Division, supported financially and technically by UNFPA and carried out by CMDN 4th National Safe Motherhood Conference 15 Nov 2016
Outline of the presentation • Objectives of the study • Study methodology • Data Collection • Limitations of the study • Key findings • Way Forward • Acknowledgment
Objectives of the study • To determine the prevalence of selected RH morbidities among women of reproductive age groups (15-49 years) in Nepal: - Pelvic Organ Prolapse (POP) - Obstetric Fistula (OF) • - Cervical cancer - Human Papillomavirus (HPV) types 16 and 18. Specific Objectives: • To map the selected RH morbidities by urban or rural residence, developmental regions and ecological zones. • To determine factors associated with RH morbidities
Methodology • Cross-sectional, camp-based study carried out from September 2014 to December 2015 Study Population • Women of reproductive age group (15-49 years) Study Sites • 15 sites; 1 site each in 15 districts • Representations of 3 ecological regions and 5 development regions
Study Sites Baitadi Kailali FWDR (2) Dolp Pyuthan and Dailekh MWDR (3) a Myagdi Rupandehi WDR (2) Makawanpur and Kavre Parsa and Sarlahi CDR (4) Taplejung Okhaldhunga Morang and Siraha EDR (4) Mountain (2) Hill (7) Terai (6)
Data Collection • Structured Questionnaire • Clinical Examination - Visual inspection with Acetic Acid(VIA) and treatment by Cryotherapy for cervical pre-cancerous lesions - Cervical swab samples for HPV types (16 & 18) • Key Informant Interviews • Secondary Data Collection
Limitations • Camp based study- cannot be generalized to the national level • Difficulty in following up with some patients who had been referred to higher institutions for further management, especially for cervical cancer. • Low number of OF cases especially due to stigma and isolation. • Long waiting time in the RH camp leading to drop out for the clinical examination • Laboratory investigations quite lengthy • Geographical constraints and unfavourable weather conditions contributed to the delay in the completion of study
Key fin indings
Participants Enrollment Status 5555 6000 4277 5000 4000 Number 3000 2000 1000 0 Women Visited RH Enrolled in the Survey Camp (All age group) and Interviewed (15 – 49 years)
Age group of the Study Participants (N=4277) Median Age = 35 100 80 Percent 60 34.4 34.0 28.2 40 20 3.4 0 15-19 20-29 30-39 40-49
Marital Status of the Study Participants (N=4277) Widow 3.5% Unmarried Divorced/S 0.2% eparated 0.8% Married 95.5%
Age at Marriage (N=4268) 20 years and above 19.7% Below 20 years 80.3% Median age (Range) = 17 (8 – 48)
Knowledge on different RH Morbidities (N=4277) 100 79.1 80 42.9 Percent 60 40 5.4 20 0 Pelvic Organ Obstretic Fistula Cervical Cancer Prolapse
Source of Information about POP (N=3383) 79.5 Relatives/Friends 58.9 Health Personnel/FCHV 9.3 Newspaper 45.6 Radio/Television 0 20 40 60 80 100 Multiple Responses Percent
Source of Information about Cervical cancer (N=1836) 0.1 Others 0.5 School/Teacher 1.1 Books/Training 0.2 Aama Samuha[1] 72.3 Relatives/Friends 56.1 Doctor/Nurse/Health Camp 13.6 Newspaper 49.8 Television/Radio 0 20 40 60 80 100 Percent
Source of Information about OF (N=229) 2.6 Books/Training 40.2 Relatives/Friends 66.8 Doctor/Nurse/Health Camp 20.5 Newspaper 53.7 Television/Radio 0 20 40 60 80 100 Percent
Prevalence of RH Morbidities 7 6.4 6 5.4 5 Percent 4 3 1.6 2 1 0 POP (N=4031) Cervical pre- HPV 16/18 cancerous (N=3464) lesions(N=3831)
Key Findings Pelvic Organ Prolapse
Prevalence of POP by Degrees (N=256) Overall Prevalance - 6.4% 10 8 Percent 6 3.7 4 1.4 0.8 0.3 2 0 I Degree II Degree III Degree IV Degree
Percent 10 15 20 0 5 4.8 Mountain (N=516) Ecological Region 6.5 Hill (N=1797) Prevalence of POP by Region 6.6 Terai (N=1718) and Place of Residence Eastern Development 4.6 Region (N=1094) Central Development Development Region 8 Region (N=1134) Western Development 3.4 Region (N=581) Mid-Western Development 5.3 Region (N=719) 11.3 Far Western Development Region (N=503) 5.9 Rural (N=2457) Residence Place of 7.1 Urban (N=1574)
Fertility Related Information of Women diagnosed with POP 100 80 57.8 Percent 41.8 32.4 39.8 60 40 16 9.8 2 0.4 0 20 0 Below 20 years 20 - 29 years 30 and above Not pregnant yet remember/know 1- 2 times 3-4 times 5-7 times 8 or more times Don't Age at First Pregnancy* Number of Pregnancies
Delivery Related Information of Women diagnosed with POP 83 82.8 100 69.1 80 Percent 60 30.9 40 17.2 12.4 4.6 20 0 Health At Yes No 1-3 3-5 More facility home years years than 5 years Place of Last Assisted by Birth Interval of Last Child Delivery* Health Worker (N=241)* During Last Delivery*
Rest after delivery among women with POP 40 35.5 30 Percent 17.7 17.7 16.1 20 12.9 10 0 Less 8 - 12 13 - 15 16 - 30 More than 7 days days days than 30 days days
Key Findings Cervical Pre-Cancerous screening through VIA
Percent 0 1 2 3 4 5 Prevalence of Cervical Pre-cancerous Mountain (N=490) Ecological Region 2 0.8 Hill (N=1715) 2.2 Terai (N=1626) Eastern Development 2.2 Lesions Region (N=1038) Development Region Central Development 1.1 Region (N=1057) Western Development 1.6 Region (N=561) Prevalance=1.8% (n=60) Mid-Western Development 1.6 Region (N=689) Far Western Development 1 Region (N=486) Residence Urban (N=2329) 1.4 Place of Rural (N=1502) 1.8
Fertility Related Information of Women with VIA Positive Result 75 100 80 Percent 60 25 40 20 0 Below 20 years 20 years and above Age at Marriage
Screening for Cervical Cancer 98.5 100 80 50.8 42.9 44.4 34.9 Percent 60 40 15.9 9.5 4.8 1.5 20 0 Yes No Biopsy Unable to mention Doctor/Nurse member/neighbor Health worker/FCHV Husband/family Pap smear test Self proper method Ever Method of Advised/Referred for screened for Screening (n=63) Cervical Cancer Screening Cervical (n=63)
Findings HPV
Prevalence of HPV (N=3464) 5.4 6 5 3.6 4 Percent 3 2 2 0.2 1 0 HPV 16 HPV 18 HPV 16 or Co-infection HPV 18 (HPV 16 & 18)
Percent 0 1 2 3 4 5 6 7 3.2 Mountain (N=435) Ecological Region 5.3 Hill (N=1540) Prevalence of HPV 16 /18 6.2 Terai (N=1489) Eastern Development 4.2 Region (N=927) Central Development 5.9 Region (N=918) Development Region Western Development 6.8 Region (N=516) Mid-Western Development 6.7 Region (n=643) Far Western Development 3.7 Region (N=460) 5.3 Rural (2092) Place of Residence 5.6 Urban (N=1372)
Precent 20 40 60 0 0.5 15-19 years Age in Years 35.6 37.8 20-29 years of women with HPV Positive Result Socio-demographic Characteristics 30-39 years 26.1 40-49 years 36.7 Illiterate Educational Status 19.7 Literate but no schooling 13.3 Primary 28.2 Secondary 2.1 SLC and above 17.614.417.6 Dalit Disadvantaged Janajati Caste/ethnicity Disadvantaged non-dalit Terai… 2.7 2.1 Religious Minorities Relatively advantaged Janajatis 45.7 Upper caste groups
Way Forward • Support SRHR, including for the most marginalized, focusing on delaying early marriage and pregnancy, access to contraceptive choices, access to skilled birth attendants and promote gender equality across sectors. • Focused programmes to increase awareness on different morbidities, including available treatment and treatment sites. • Expand and strengthen RH Morbidity related services to different level of Health facilities to increase access, including availability of trained human resources • POP prevalence decreased from 10% in 2006 to 6.4% Still very high. Conservative management of POP needs to be prioritized equally to surgical management. • Need for focused strategy to increase awareness and identify women with OF. • Strengthen referral mechanisms from peripheral level Health facilities providing RH Morbidity services to higher centers, particularly for cervical cancer
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