Reproductive morbidity among married Muslim women: a community-based study in an urban slum of Mumbai, India

INTRODUCTION

Addressing women's reproductive health problems is now on the global social agenda in the current century. Although reproductive morbidity occurs significantly more frequently and has a far more impact on women's lives, maternal mortality has long been the only indicator of their health.^1,2 Reproductive health is one of the crucial components of the general health and well‑being of women. It is important for women, especially during their reproductive years, as most of their reproductive health problems arise during that period.^3,4 Maternal morbidity affects an estimated 50 million women yearly with at least 18 million women experiencing long-term and often debilitating symptoms.⁵ Reproductive ill-health contributes to 33 % of the total disease burden in women, compared with 12.3 % in males.⁶

Reproductive morbidity includes the obstetric and gynecological conditions of ill-health related to the reproductive process during and outside the childbearing time. Gynecological morbidity includes conditions other than pregnancy-related events like menstrual disorders, reproductive tract infections, cervical cell changes, genital prolapse and other conditions like syphilis and urinary tract infections. Obstetric morbidity covers conditions during pregnancy, delivery and the postpartum period.^7,8 In this study, reproductive morbidity refers to gynecological morbidity with special reference to menstrual problems and RTI.

There are few studies in India on women’s reproductive morbidity in gynecological diseases. The available data indicate a high prevalence compared with other developing countries.⁹ Studies conducted in different part of Indian slums showed that the percentage of women complaining of gynecological problems varied from 35% cent to 58.9%.^2,10 Around 40% of married women in India have at least one reproductive health problem related to urination or vaginal discharge.¹¹ Almost half of the women have reproductive tract infections (RTIs).^12,13 Half of them had menstrual problems, and every tenth woman suffered from uterine prolapse.^14,15 Available studies on this topic are based on the hospital and clinic data. Still, the number of community-based studies are limited.^16,17 So, the results from hospitals or clinics do not reflect the magnitude of the disease burden. The hospitals’ statistics are based only on biomedical causes, but information on social, economic, and demographic determinants is scanty.⁸

Women’s reproductive health profile in any country closely relates to their socio-demographic background. In Indian society, the reproductive health problems of women are often neglected. There are many contributing factors to the high prevalence of reproductive morbidities such as lack of education, early marriage, working status of women, standard of living, contraceptive practices, knowledge about reproductive health problems, and menstrual hygiene practices. Conversely, stigma is attached to gynecological problems like reproductive tract infection. Misconceptions, cultural beliefs and taboos attached to gynecological problems force women to live with the morbidity silently which further affects their health-seeking behaviour.^18,19 Married women in India are reluctant to seek treatment due to the absence of female doctors, lack of privacy, cost of treatment and low social status.²⁰

More specifically, in the Islamic culture issues related to reproductive health are considered sensitive and do not get much attention.²¹ Several studies have covered many aspects of women's reproductive health. However, few studies have focused exclusively on Muslim women. Since widespread notions regarding the religious norms over sexual behaviour exist, the area of reproductive health morbidities among Muslim women in India has been little researched. A community-based study was undertaken among married Muslim women aged 15-49 in the urban slum of Kurla (sub-urban) in Mumbai, India.

METHODS

The community based cross-sectional study was conducted in the Kurla (sub-urban) area of Mumbai, India, from August, 2019 to December, 2019. The sample size for the study was determined based on the prevalence of mothers in Mumbai suburban who had at least four antenatal care visits. According the NFHS-4, the prevalence of at least four antenatal care visits among mothers in Mumbai suburban was 82%. The 95% confidence interval was considered for the study. After considering the 1.25 design effects and 3.84% non-response rate final sample size was taken as 312.

Multistage sampling was used to select the blocks from the Kurla sub-urban area. Two blocks (Jarimari and Safed-Bridge) were selected based on high concentration (85%) of the Muslim population and low socio-economic status. A total of thirty-six Anganwadi centres were in the two selected blocks. Of these, twelve Anganwadi centres were chosen by using systematic random sampling. Every third Anganwadi center was selected and approached. Finally, 312 married Muslim women in the reproductive age (15-49) were selected based on purposive sampling. Twelve incomplete forms were removed, and 300 sample sizes were considered for final analysis. Information on socio-demographic variables and questions regarding reproductive morbidities in last six months was collect using a structured questionnaire.

SPSS version 23.0 was used for the data analysis. The symptoms of reproductive morbidities were divided into two categories. The first category was menstrual problems which consisted of delayed, prolonged and painful period. White discharge, burning during urination, itching in genitals and boils/ulceration in genitals are grouped under the category of any RTI problem. Descriptive analysis has been done initially. Continuous variables were represented using mean and standard deviation, and categorical variables were summarized using proportion. The chi-square analysis was done for categorical variables and tested for significance.

Inclusion criteria

Muslim women who had given birth in the last two years in the reproductive age (15-49) group were included in the present study.

Exclusion criteria

Women those who were not Muslim. Women those who were widow and unmarried. Women whose age was below 15 years and above 49 years. Women those who did not have children

Ethical considerations

The ethical committee of Tata Institute of Social Sciences, Mumbai, approved the study. The respondents have given written consent. Personal identifiers were removed before data analysis.

RESULTS

Table 1 shows the socio-demographic profile of the respondents. The mean age of the respondents was 26.3±4.1 years, ranging from 18 to 38 years. About 20.7% of the respondents were married before the legal age of marriage (18 years). About 12.7% of the respondents started childbearing at the age of 18 years. About 46.3% of the respondents had three more children. The mean years of schooling were 8.1±4.1 years and among them 13% were illiterate. The mean number of pregnancies was 3.0±1.5, which ranges between 1 and 8, and 15% had more than four pregnancies. Use of the sanitary napkin as menstrual protection was higher (71%) among the respondents than cloths. Only 30% respondents mentioned that they have the freedom to go to a healthcare center. Only 46.3% respondents currently use contraceptives.

Among all the respondents, 135 (45%) suffered at least one reproductive morbidity. Among these, 26.7% had menstrual-related problems, while 35.7% suffered from RTI-related problems (Figure 1).

The present study revealed that in menstrual-related problems, a maximum (42%) of respondents had prolonged period problems, followed by a painful period (39.7%) and a delayed period (35.7%). Further, among the RTI-related issues, white discharge, burning during urination and itching genitals were the most common symptoms (Table 2).

A significant statistical association was found between age at marriage, age at first delivery, education, types of menstrual protection, freedom to health centre and reproductive health problems. The prevalence of any reproductive health problems decreased with increasing age at marriage and first delivery age. Educated respondents had fewer reproductive health problems than illiterate respondents, which was statistically significant. Further, reproductive health problems were lower among those who used sanitary napkins for menstrual protection and were free to go to health centers (Table 3).

(Any reproductive health problems include any menstrual and any RTIs related problem) [n=135 (45.0) as it includes those who had any reproductive related problems out of the total respondents of 300]. *p<0.05. **p<0.01. ***p<0.001.

Health care-seeking behavior

Respondents used institutional and non-institutional health care facilities for their reproductive morbidities. About 45.0% respondents had complained of either menstrual (26.7%) or RTI (35.7%) related problem. Among them, around 40% respondents attended health care facilities for treatment. Most respondents preferred to use home remedies to cure reproductive morbidities. Around 35% of them used home remedies to treat their menstrual problem. On the other side, almost 31% used home remedies to get relief from the problem related to RTI.

Government hospitals were used more than private hospitals for both types of morbidities. Further, almost 24% and 28% respondents who suffered from menstrual and RTI problems took treatment from traditional healers such as Bengali baba, kabir, or fakir respectively (Table 4).

Reason for not taking treatment

The primary reason, as mentioned by the respondents, for not taking any healthcare treatment for reproductive health problems was the absence of female doctors in the healthcare settings.

The reason ‘shyness to explore the problem’ was mentioned by 25.5% and 27% of respondents who had menstrual and RTI problems respectively. Further, 20 to 25% respondents feel ‘no need to take treatment’ for reproductive morbidities. About 14-18% respondents mentioned ‘fear of side effects’ as a reason for not taking any treatment for reproductive morbidities (Table 4).

DISCUSSION

Ours was a community-based cross-sectional study carried out in an urban slum of Mumbai, India. In its menstrual problems and problems related to RTI predominantly focused on reproductive morbidity. It has shown the prevalence of reproductive morbidity based on community settings and health-seeking behaviour among Muslim women.

This study found that 45% of the respondents had at least one reproductive morbidity. Similar studies were reported elsewhere in India where the magnitude of reproductive morbidities ranged from 33% to 92%.²² Comparable findings were obtained in the study carried out among married rural women in Karnataka.²³ Surveys carried out in other developing countries like Karachi, Pakistan found the same findings, i.e., around 55% of women reported having at least one reproductive morbidity.²⁴ In our study, the most common reproductive morbidities were RTI (35.7%) and menstrual problems (26.7%). Comparable results were observed in the study conducted in urban slums of Baroda, India, where the most common reproductive health problems were menstrual (21-32%) and RTI (27%).²⁵ Likewise, similar findings were found in the review of the seven urban and rural studies; the prevalence of menstrual disorders was 33-65% and that of RTI 13-57%.²⁶ Another two studies carried out in an urban slum of Mumbai found similar findings about the prevalence of reproductive morbidities.^27,28 In the present study, the most commonly diagnosed symptoms among the problems related to RTIs were “white discharge” (45%) and “itching in the genitals” (44.7%). Similar findings were corroborated by studies conducted in the Tirupati slum (Andhra) and Himachal Pradesh.^29,30

The high prevalence of such diseases among Muslim women may be due to illiteracy, early age at marriage and lack of freedom to go to health centers. The percentage of reproductive morbidities was higher among illiterate women than educated women, and it was statistically significant. Similar findings were found in the study in Agra and Kolkata.^31,32

In this study, women who married before the legal age (18 years) had a high prevalence of RTI symptoms. A similar finding was found in the study conducted in Shimla city. Early age marriage (>18) was found to be significantly related to reproductive morbidities.³³ Sociocultural background of Muslim women can be attributed to the early age of marriage. A higher percentage of women using clothes for menstrual protection (44.8%) suffered from RTI-related problems than those using sanitary napkins. Comparable findings were found in the study conducted in 2001 where there was a direct correlation between menstrual hygiene and reproductive morbidities.³⁴ At the time of the first delivery, respondents who were younger (up to 18 years) had more reproductive morbidities than respondents having a first child after 18 years. A statistically significant association between the age of first delivery and reproductive morbidities was found. A similar finding was noted in a cross-sectional study in Karnataka.³⁵

This study shows poor health-seeking behaviour for reproductive morbidity as only 43% respondents sought treatment for menstrual problems, while 47% respondents took treatment for problems of RTIs. This prevalence is lower than seen in similar findings in Kargil where 77.3% of symptomatic women did not seek treatment for reproductive morbidities.³⁶ Studies done in Tamil Nadu and Calcutta also showed poor health-seeking behaviour.^37,38

A majority of the respondents used home remedies to cure reproductive morbidities. Similar findings were recorded in the study by Srivastava et al. In Mevat (North India), around 67% of Muslim women adopted home remedies like Multani mitti (fuller’s earth) and leaves of neem tree (Melia azadirachta) to cure reproductive morbidities.¹⁹ However, the visits to government hospitals were more than to the private hospitals. Our findings are in contrast with the study carried out in Rajkot, where women preferred private hospitals.³⁹ Common reasons for not seeking treatment were shyness, a perception that there was no need to take treatment and the absence of female doctors. The results of this study corroborate those of studies carried out in India and other countries.⁴⁰

The chances of under reporting cannot be rule out about gynecological morbidities among respondents due to silence associated with the issue of reproductive health.

CONCLUSION

The study revealed a high prevalence of reproductive morbidities among married Muslim women in the urban slum of Mumbai. About 45% of respondents had at least one symptom of reproductive morbidity in the last six months. Painful periods and white discharge were the most common symptoms. Respondents’ age at marriage, age at first delivery, respondents’ education, type of menstrual protection, and freedom to go health center had a significant association with reproductive morbidities. Poor treatment-seeking behaviour was found among the respondents for reproductive morbidities. Most respondents preferred home remedies to treat reproductive morbidities, while the absence of female doctors was the more common reason for not seeking treatment. To promote morbidity-free healthy life, there is a need to create awareness about reproductive morbidities and provide health care education. Female religious leaders, ASHA, and Anganwadi workers need to be trained to create awareness and provide information about healthcare facilities.

ACKNOWLEDGEMENTS

My sincere thanks to all study respondents for their valuable times and information.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Graham WJ, Campbell OM. Maternal health and the measurement trap. Soc Sci Med. 1992;35(8):967-77.
2. 2. Gosalia VV, Verma PB, Doshi VG, Singh M, Rathod SK, Parmar MT. Gynecological morbidities in women of reproductive age group in urban slums of Bhavnagar city. Nat J Community Med. 2012;3(04):657-60.
3. 3. Inamdar IF, Sahu PC, Doibale MK. Gynaecological morbidities among ever married women: a community based study in Nanded city, India. IOSR J Dent Med Sci. 2013;7(6):5-11.
4. 4. Gopalakrishnan S, Eashwar VA, Kumar PM, Umadevi R. Reproductive health status of rural married women in Tamil Nadu: a descriptive cross-sectional study. J Fam Med Prim Care. 2019;8(11):3607-13.
5. 5. World Health Organization (WHO). Postpartum care of the mother and newborn: a practical guide: report of a technical working group (No. WHO/RHT/MSM/. 1998;98(3):1-89.
6. 6. World Health Organization (WHO). Report on the Regional Reproductive Health Strategy Workshop, South East Asia Region: Book Report on the Regional Reproductive Health Strategy Workshop, South East Asia Region City; 1995: 3.
7. 7. Zurayk HK, EL-Mouelhy NHY, Mohamed M, Mohamed F. Concepts and measures of reproductive morbidity. Health Transit Rev. 1993;3(1):17-39.
8. 8. Rahman MM, Kabir M, Shahidullah M. Adolescent self reported reproductive morbidity and health care seeking behaviour. J Ayub Med Coll Abbottabad. 2004;16(2):9-14.
9. 9. Singh KS, Prasad R, Verma BR, Pandey A. Psychosocial cultural and service factors affecting reproductive morbidity among rural women in Maharashtra. Int Inst Popul Sci. 1995;1-26.
10. 10. Kambo IP, Singh P, Saxena BN, Saxena NC. Self-reported gynaecological problems from twenty three districts of India (An ICMR Task Force Study). Indian J Community Med. 2003;28(2):67-73.
11. 11. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), Mumbai, India. 2021. Available from: https://iipsindia.ac.in/content/national-family-health-survey-nfhs-5-india-report. Accessed on 13 July 2024.
12. 12. Xia DY, Liao SS, He QY, Choi KH, Mandel JS. Self-reported symptoms of reproductive tract infections among rural women in Hainan, China: prevalence rates and risk factors. Sex Transmit Dis. 2004;31(11):643-9.
13. 13. Rathore M, Vyas L, Bhardwaj AK. Prevalence of reproductive tract infections amongst ever married women and sociocultural factors associated with it. J Indian Med Assoc. 2007;105(2):71-2.
14. 14. Patel V, Tanksale V, Sahasrabhojanee M, Gupte S, Nevrekar P. The burden and determinants of dysmenorrhoea: a population‐based survey of 2262 women in Goa, India. BJOG. 2006;113(4):453-63.
15. 15. Bang RA, Baitule M, Sarmukaddam S, Bang AT, Choudhary Y, Tale O. High prevalence of gynecological diseases in rural Indian women. Lancet. 1989;333(8629):85-8.
16. 16. Sadana R. Measuring reproductive health: review of community-based approaches to assessing morbidity. Bull World Health Organ. 2000;78(5):640-54.
17. 17. Mawajdeh S. Measuring reproductive morbidity: a community-based approach, Jordan. Health Care Women Int. 2003;24(7):635-49.
18. 18. Poornima S, Katti SM, Mallapur MD, Vinay M. Gynecological problems of married women in the reproductive age group of urban Belgaum, Karnataka. Al Ameen J Med Sci. 2013;6(3):226-30.
19. 19. Srivastava L. Reproductive tract infections among women of rural community in Mewat, India. J Health Manage. 2010;12(4):519-38.
20. 20. Barua A, Kurz K. Reproductive health-seeking by married adolescent girls in Maharashtra, India. Reprod Health Matters. 2001;9(17):53-62.
21. 21. Alomair N, Alageel S, Davies N, Bailey JV. Factors influencing sexual and reproductive health of Muslim women: a systematic review. Reprod Health. 2020;17(33):1-15.
22. 22. Patel P. Illness beliefs and health seeking behaviour of the Bhil women of Panchamahal District, Gujarat State. In: Gittelsohn J, Bentley ME, Pelto PJ, Nag M, Pachauri S, Harrison AD, et al, eds. Listening to women talk about their health: issues and evidence from India. 2nd edn. New Delhi: Har-Anand Publications; 1994:55-66.
23. 23. Mathew L, Francis J, Alma L. Prevalence of gynaecological morbidity and treatment seeking behaviour among married women in rural Karnataka: a cross sectional survey. J Krishna Inst Med Sci. 2017;6(3):85-93.
24. 24. Sajan F, Fikree FF. Perceived gynecological morbidity among young ever-married women living in squatter settlements of Karachi, Pakistan. J Pak Med Assoc. 1999;49(4):92-7.
25. 25. Das NP, Shah U. Understanding women’s reproductive health needs in urban slums in India: A rapid assessment. Population Research Center, Baroda. 2001.
26. 26. Koenig M, Jejeebhoy S, Singh S, Sridhar S. Undertaking community-based research on the prevalence of gynecological morbidity: lessons from India. In International Union for the Scientific Study of Population seminar on Innovative Approaches to the Assessment of Reproductive Health, Manila. 1996;24:27.
27. 27. Mulgaonkar VB. Reproductive health of women in urban slums of Bombay. Soc Change. 1996;26(3):137-56.
28. 28. Pandit D, Prabha R, Shanbhag S, Mayekar R. Morbidity pattern of women attending screening program in an urban slum in Mumbai. Indian J Community Med. 2005;30(4):134-.
29. 29. Devi BS, Swarnalatha N. Prevalence of RTI/STI among reproductive age women (15-49 years) in urban slums of Tirupati town, Andhra Pradesh. Health Popul Perspect Issues. 2007;30(1):56-70.
30. 30. Sharma S, Gupta BP. The prevalence of reproductive tract infections and sexually transmitted diseases among married women in the reproductive age group in a rural area. Indian J Community Med. 2009;34(1):62-4.
31. 31. Nandan D, Misra SK, Sharma A, Jain M. Estimation of prevalence of RTIs/STDs among women of reproductive age group in district Agra. Indian J Community Med. 2002;27(3):110-3.
32. 32. Aparajita D, Madhutandra S. A study on reproductive tract infections among married women in the reproductive age group (15-45 years) in a slum of Kolkata. J Obstet Gynecol India. 2008;58(6):518-22.
33. 33. Parashar A, Gupta BP, Bhardwaj AK, Sarin R. Prevalence of RTIs among women of reproductive age group in Shimla city. Indian J Community Med. 2006;31(1):27-38.
34. 34. Singh MM, Devi R, Garg S, Mehra M. Effectiveness of syndromic approach in management of reproductive tract infections in women. Indian J Med Sci. 2001;55(4):209-14.
35. 35. Bhatia JC, Cleland J, Bhagavan L, Rao NSN. Levels and determinants of gynecological morbidity in a district of south India. Stud Fam Plann. 1997;28(2):95-103.
36. 36. Gaash B, Kausar R, Bhan R, Bashir S, Ahmad M. Reproductive Tract Infections in Kargil: a community based study. Health Popul Perspect Issues. 2005;28(1):1-8.
37. 37. Prasad JH, Abraham S, Kurz KM, George V, Lalitha MK, John R, et al. Reproductive tract infections among young married women in Tamil Nadu, India. Int Fam Plann Perspect. 2005:73-82.
38. 38. Prasad JH, Abraham S, Kurz KM, George V, Lalitha MK, John R, et al. Reproductive tract infections among young married women in Tamil Nadu, India. Int Fam Plann Perspect. 2005:73-82.
39. 39. Bhanderi MN, Kannan S. Untreated reproductive morbidities among ever married women of slums of Rajkot City, Gujarat: the role of class, distance, provider attitudes, and perceived quality of care. J Urban Health. 2010;87(2):254-63.
40. 40. Ratnaprabha GK, Thimmaiah S, Johnson AR, Ramesh N. Prevalence and awareness of reproductive tract infections among women in select underprivileged areas of Bangalore city. Int J Med Sci Public Health. 2015;4(12):1691-6.