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July 2007, Volume 57, Issue 7

Original Article

Prevalence and Factors Associated with Postpartum Vaginal infection in the Khyber Agency Federally Administered Tribal Areas, Pakistan

Nasreen GhaniI  ( Faculty, Post graduate Collage of Nursing )
Rafat Jan Rukanuddin  ( School of Nursing )
Tazeen S. Ali  ( Department of Community Health Sciences3, Aga Khan University, Karachi. )

Abstract

Objective:To estimate the prevalence and to identify the factors associated with vaginal infection among the married women between the ages of 15-49 years residing in the Khyber Agency (FATA), Pakistan.  Methods:Across-sectional study was conducted in the month of July 2005 on 1084 mothers by using random sampling strategy in Khyber Agency Pakistan by trained nurses. The descriptive and multivariate statistics were computed.Results:The multivariate analysis showed that the associated factors with vaginal infection were the use of unhygienic material to soak up the lochia [aOR=3.45, 95% CI (1.36, 8.75)], bathing after 40 days [aOR=2.10,95% CI (1.55, 3.14)], and women who did not receive antenatal care [OR=3.87, 95% CI (1.93, 7.75)]. Also women who did not have medical facilities available [OR=2.45, 95% CI (1.23, 5.06)] reported of vaginal infection.Conclusions:This study concluded that there is considerable need for health education among women and the entire community for the maintenance of hygiene, safe delivery through medical personnel and improvement inthe mobility of mothers and female education

Introduction

Vaginal infection is the occurrence of foul smell ingvaginal discharge, along with concomitant fever.  This vaginal discharge is different from lochia, the normal vaginal discharge during postpartum. According to a studyin Bangladesh, mothers perceive vaginal infection during the postpartum period to be a result of physical weakness.According to a multi-center study, conducted in fourcountries, the prevalence of utero- vaginal, or uterineinfection, in India was 0.5%, Egypt 9.8%, Bangladesh 10.2% and Indonesia 4.5%.1Predisposing factors for puerperalgenital infections are prolonged labour, prelabour rupture ofthe membranes, frequent vaginal examination, internal(vaginal) electronic foetal monitoring and caesarean section.2Following this culture of predominance of traditional values, beliefs and practices related to pregnancies and childbirth, Pakistan has a specific traditional culture of childbirth in its rural areas. Thus, highlevels of maternal mortality and morbidity in Pakistan are adirect result of the interplay between a variety of factors,such as low status of women in society; poor nutrition; asignificant proportion of high-risk pregnancies (such asthose to grand-multiparous women); lack of family planning, poor access to health services, deliveries conducted by non professionals, lack of antenatal and postnatal care, poverty, and illiteracy.Women's health is a neglected area in developing countries. Despite at least 50% maternal deaths occurring during the postpartum period,3very limited research has been carried out to assess morbidities.  In developing countries, the role of traditional health practitioners and their practices have a strong influence during the antepartum, and postpartum period. In Pakistan, nearly 5.3million births occur annually.2According to a Ministry of Health report, nearly 80% of the mothers deliver at home,with 82% of them being assisted by a traditional birth attendant.4In Karachi, a base-line survey of squatter settlements approximated that nearly 50% of the mothersdelivered at home with 80% of the deliveries beingconducted by traditional birth attendants.  During the antepartum period, it is estimated that nearly 54% of the mothers seek medical advice, which reduces to only 19%during the postpartum period.5More over, although research has been conducted inthe different provinces of Pakistan, to study the factors associated with maternal mortality, no research has been done to determine the factors associated with maternal morbidity. Hence this study would help mothers, the locality, and the society in general. The findings of the study will help to identify some specific morbidity likevaginal infection. Agreat understanding of this morbidity can help in preventing it.The Khyber Agency observes a strict cultural valueof purdah among the women. Most of the women are illiterate and the purdah sets limits to their mobility in the Agency. The women are never involved in decision-makingof any kind. The parents of the boys and girls arrange the marriages when they are between 15 and 25 years of age.6No research has been conducted in the FATA by any health professional. This makes it a dire need to learn what the exact needs and available facilities are to implement preventive and curative programmes to improve the health status of  women.The principal objective of this study was to estimate the prevalence and identify the factors associated with postpartum vaginal infection among the married women between the ages of 15-45 years in Khyber Agency FATAPakistan.

Methodology

Khyber Agency is one of the federally Administered Tribal Area, under FATA. The Khyber Agency is made up of Tehsils Bara, Jumrud and Landi Kotal. Each Tehsil has apopulation of 2 86184, 96188, and 144741 respectively. The total population of the Khyber Agency is 534,383, and the annual growth rate is 3.9%. The literacy ratio for males and females is 39.9% and 2.5% respectively.7 Pashto is the native language of the Khyber Agency, with Urdu as the national and official language.A quantitative study with a cross sectional design was planned on a population of married women between 15to 49 years, who were either pregnant or in postpartum period. Verbal consent was obtained from all women.Unmarried or infertile women were excluded from the study. Simple random sampling method was used to collect the data. Alist of all the women who fulfilled the inclusion criteria was made with the help of FATA directorate.Through epi Info version 4 a random number of 1084 women were selected. The data collector went to all the selected houses and from each household one woman was interviewed. If any woman refused to participate anotherone was identified from the list in the Bara, Jumrud and Landi Kotal Tehsil.  The questionnaire for data collection was developed and pre-tested in Karachi. Small modifications were done after pre-testing at Khyber Agency.5The questions were related to demographic characteristics and potential factors for maternal morbidity. Subsequently, the questionnaire was translated in Urdu and then again in English to see whether the consistency of each question had been preserved. Urduversion of the questionnaire was administered to collect the required data. Data collection started after formal consent of the Director Health of FATA from 1st July, 2005 and continuedto 31st July 2005. Further, permission was taken from the head of the family mostly the males before start of the interview. The data was collected by Pashto trained nurses of Peshawar,who received 2 days training on the procedure and supervised by principle investigator. Information was obtained on demographic variables,socio-economic status, previous obstetrical historyincluding ante-partum, partum and post partumhaemorrhage.Vaginal infection was defined, as the perceived foul smelling vaginal discharge, fever, lower abdominal painduring postpartum period. This was the dependent variable. Information was collected on the study participants'sage, her husband's occupation, the area of residency andethnicity, family status (joint or nuclear) and educational,employment, socio-economic, status. To assess there productive behaviour, information was acquired on the duration of marriages, age of mother at marriage, total number of pregnancies, number of living children(currently), number of abortions, and any complications,during the previous three stages of pregnancy. The details ofthe recent pregnancy included duration of  labour, antenatal care received, type of antenatal care provider, place of delivery and person who conducted the delivery, and breastfeeding counseling received by health care personal during antenatal care.Information was also collected about the mother'smobility within the house and decision-making regarding domestic problems. Questions were asked about intravaginal herbal  home made remedies and restriction on the fluid intake; number of days before the initiation of normal diet; number of days before the post delivery bath, practicesof rinsing of the perineum with antiseptic, material used to soak up lochia, and antibiotic application on perineum.Information was collected on other social factors including the mother's mobility to visit a clinic and her independence to spend household earning.The questionnaire was pre tested for appropriateness in a 10% of sample size in the Khyber Agency, prior toinitiating the study. Amendments were made where required.Data quality was maintained through, intensivetraining of field staff, daily editing of the questionnaire;double entry of data to ensure accuracy, and surprise visitsof the investigator at the data collection sites. Furthermore,crosschecking of two questions for similar information was also done.Double data entry was done using EPI-info version6.04, and analyzed by Statistical Package for SocialSciences (SPSS) version 10. To describe the demographic profile of the married women enrolled in the study,descriptive statistics, including frequency, percent distribution, mean and their standard deviation, were obtained. Multiple logistic regression analysis was performed to identify factors independently associated withvaginal infection.  Variables that were selected in theunivariate analysis were entered in the model simultaneously.

Results

 Out of 1084 women, 1000 were successfully interviewed with a response rate of 91.6 %. The reasons for refusal to participate in the study were traditional norms or not being allowed by the husbands. The analysis therefore included 1000 participants. The non-participating women were of a similar socioeconomic status.The results revealed the association of vaginal infection as univariate (independent association), and multivariate (adjusted association) factors. Table 1 shows the demographic characteristics of thestudy subjects. The mean age was 30.8 ± 6.6 years with amean duration of marriage being 14.7 ±  4.6 years.According to the ethnic distribution, most were Pathans(99.9%) and Muslims (99.9%). Alarge number were uneducated, unemployed and living in extended families.At the time of the interview, the women had 7 ± 3pregnancies, and 436 (43.6%) had at least one abortion.Only about 4% had received antenatal care with the majority from Traditional Birth Attendant (TBA). There maining had gone to health care centers, clinics and hospitals. The most common place of delivery for the previous pregnancy was the participant's home, followed by TBA's home, hospital, maternity homes, health centres,TBAclinics , doctors/nurses/LHVclinics, and mother'shome. The deliveries were mainly conducted by TBAs andin-laws/mother and few were delivered by neighbours,nurses/doctors, and LHV/ Midwives.  Table 2 shows that women who are at a lower socio-economic status [OR=1.14 95% CI (1.10, 1.27)], have notreceived antenatal care [OR=4.56, 95% CI (2.35, 8.85)],restricted bathing  [OR=2.33, 95% CI (1.66, 3.28)], did nothave medical facilities available [OR=2.45, 95% CI (1.21,4.99)], did not use hygienic materials to soak lochia[OR=3.45, 95% CI (1.36, 8.75)] were more likely todevelop vaginal infection. Further, significant result of ourstudy showed at 5% level that the odds of women having atimely delivery of the placenta among women having vaginal infection was 2.54 times as compared to thos ewomen who did not [OR=2.54, 95% CI (1.26, 5.12)] havevaginal infection.The variables in the final multivariate logistic

Table 1. Socio-demographic and reproductive characteristics of married women in Khyber agency -July 2005.

Characteristics

n=1,000 (%)

Mean (+SD)

Age of the women

30.8 (6.6),

Duration of marriage (years)

14.7 (4.6)

Ethnicity

 

Pathan

999 (99.9)

Punjabi

1 (0.1)

Religion

 

Muslim

996 (99.6)

Hindu / Christian

4(0.4)

Education

 

Illiterate (including madrasa education)

998 (99.8)

Can just read a newspaper

1 (0.1)

Technical diploma

1 (0.1)

Occupation

 

House wife

669 (66.9)

Farmer

284 (28.4)

Technical and related work

47(4.7)

Kinds of Family

 

Combined /extended

963 (96.3)

Nuclear

37(3.7)

Parity

7.0+3.0

Histroy of abortion

 

Yes

436 (43.6)

No

564 (56.4)

Antenatal Care Checkups

 

Traditional Birth Attendant

600 (60.)

Health Center

150 (15.0)

Clinic

130 (13.0)

Hospital

120 (12.0)

Place of Delivery

 

Self Home

827 (82.7)

TBA Home

71 (7.1)

Hospital

26(2.6)

Maternity Home

24(2.4)

TBA Clinic

17(l.7)

Health Center

18(l.8)

Doctor/Nurse/LHV

13 (1.3)

Mother Home

04(0.4)

Delivery Conduct By

 

TBA

587 (58.7)

In-Laws / mother

266 (26.6)

Neighbor hood   88(8.8)

Nurses/Doctors   48(4.8)

regression analysis included bathing during the post partumperiod, lack of antenatal care, medical facilities availableand not using hygienic materials to soak up lochia. Asshown in table 6, while having other variables in the model,the women who reported vaginal infection were more likely

Table 2. Uni-variates model of factors associated with vaginal infection among married women n the Khyber Agency (FATA) July 2005 (n=1000).

 

VI + n (%)

VI- n (%)

OR

95.0% C.Lfor

OR Lower

House hold items at

4.09 +1.46

4.42+1.68

1.14

(1.10 - 1.27)

home

       

Antenatal Care

       

Received

17(10.5)

21 (2.5)

1

 

Not received

145(89.5)

817(97.5)

4.56

(2.35- 8.85)

Bath during

       

postpartum period

       

Yes

68(42.0)

526 (62.8)

1

 

No

94(58.0)

312(37.2)

2.33

(1.66- 3.28)

Medical facilities

       

available on Panel

       

Yes

9(5.6)

109 (13.0)

1

 

No

153(94.4)

729 (87.0)

2.45

(1.21-4.99)

Hygienic material

       

used to soke up

       

lochia

       

Yes

5 (3.1)

69(8.2)

1

 

No

157 (96.9)

769 (91.8)

3.45

(1.36- 8.75)

Timely delivery of

       

placenta

       

Yes

133 (82.1)

738 (88.1)

1

 

No

29 (17.9)

100 (11.9)

2.54

(1.26- 5.12)

Prolonged duration

       

of Labor

0.94+0.23

0.87 +0.34

1.04

(1.01-1.07)

Table 3. Multivariate logistic regression model of factors associated with vaginal infection among married women n the Khyber Agency (FATA) July 2005 (n=1000).

aOR

Hygienic material used to soak lochia

   

Yes

1

 

No

3.45

(1.36- 8.75)

Bath during postpartum period

   

Yes

1

 

No

2.10

(1.55- 3.14)

Antenatal Care

   

Received

1

 

Not received

3.87

(1.93- 7.75)

Medical facilities available on Panel

   

Yes

1

 

No

2.45

(1.23- 5.06)

not to use hygienic materials

[aOR=3.45, 95% CI (1.36, 8.75)], were unlikely to have

to soak up the lochia

bathed during the 40 day postpartum period. [aOR=2.10,95% CI (1.55, 3.14)], would not have had medical facilities available [OR=2.45, 95% CI (1.23, 5.06)], and would nothave received antenatal care (3.87 times the chance ofdeveloping vaginal infections) [OR=3.87, 95% CI (1.93,7.75)].

Discussion

 The proportion of vaginal infection during the postpartum period, reported by our study subjects was16.2%, which is significantly high. The results of a similar study done in some of Karachi's squatter settlements showed 5.1%.5 According to a multi-centre study conductedin India, Egypt, Bangladesh and Indonesia, the prevalence of uterine- vaginal, or uterine infections were 0.5%, 9.8%,10.2%, and 4.5 % respectively.8Another study in Sri Lanka reported a 3.9% prevalence of vaginal infection.9The percentage of vaginal infection is high in our study because the women do not seek care for it. The reasons attributed are non-availability of services or their inaccessibility or inferior quality which is often a deterrent.Another important constraint may be a woman's lack of autonomy in her own health care management. Most women tend to endure obstetric and gynaecologic almorbidity as a fact of life and are shy to reveal these conditions, or acknowledge their problems. For the Khyber agency, the results of the multiple regression analysis showed the association of vaginal infection among married women with not using hygienic material used to soak up lochia, lack of antenatal and postnatal care, not bathing during the postpartum period,and a deficiency of medical facilities. The lack of health care facilities or their utilization is significantly associated with vaginal infection. In our studyonly 3.8% of the women sought health care, which is much lower than other developing countries, such as, India (40%),Philippines (58%), and Indonesia (72%). This differencecould be because of the higher national female literacy rateand the GDP.2 Moreover, the cultural aspect, as requiring your family's permission to visit a clinic, and the husband'sand wife's education levels strongly influence the attitude sand beliefs regarding health seeking behavior.10 The advantage of antenatal care (decreasing theprenatal morbidity and mortality rate), has been consistently demonstrated in a number of studies in the developed anddeveloping countries.11,12One beneficial effect of antenatal care is that it leads to early diagnosis and treatment of pregnancy complications, such as anaemia; maternal infections of the vagina and the urinary tract; and antepartum haemorrhage or cervical incompetence.  Routineante natal visits may raise awareness about the need for care at delivery and give women and their families a chance tobecome familiar with health facilities, which will enable them to seek help more efficiently during a crisis.13 Retrospective studies in Ethiopia found a lack of antenatalcare which was an important risk factor related to vaginaland urinary tract infections, ante partum hemorrhage, and maternal death.14Studies in India,15Nigeria,16Senegal17,and Zimbabwe18 have also yielded similar results.In our culture, due to poverty, people use old pieces of clothes in place of sanitary pads during the earlypostpartum period (first 7-10 days), when a mother's cervixis dilated. This is an unhygienic practice, which leads to the introduction of infections into the vagina. In addition,without treatment, micro-organisms from the lower genitaltract may ascend to the upper genital tract, causing infections of the oviduct and the uterus.19,20Not taking a bath during the purperium period is atraditional practice in our culture as bathing during that timeis believed to weaken the mother's bones. Taking a hot bathregularly has been identified as a popular practice among Thai women after delivery.21However its association withthe risk of vaginal infection has not been studied. This unhygienic practice may increase the risk of vaginal infection as identified in our study; however we were unable to find any other published papers addressing this issue. Limitations of the study:The perceived morbidity condition was revealed through the interview however due to the unavailability of health records the results were not matched or validated with them. Furthermore, the physical examination of the vagina was not performed due to the cultural norms at the community level. Therefore there are chances that women might have either over or under reported the presence of vaginal infection.  This might have introduced an information bias. As the study was cross-sectional, information of morbidities and associated factors were collected at the same time.

Conclusion

 The results of this study revealed a set of factors that contribute to the vaginal infection of women residing inthe Khyber Agency FATA, Pakistan and provide directions for the safe motherhood policy and programmatic strategies.

Recommendations

 This study recommends that there is a need for proper health education of women in the Khyber agency.Low cost and high quality health services in the antenatal,natal and postnatal periods is necessary. This should be made available at basic and tertiary health care units at Khyber Agency FATA, Pakistan.

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