Background: Reproductive tract infections (RTIs) is a global health problem including both sexually transmitted infections (STIs) and non-sexually transmitted infections (non-STIs) of the reproductive tract. The risk of RTIs in pregnant women includes post abortal and puerperal sepsis to fetal and perinatal deaths. Hence a community study was done in Hubli, in terms of active search of the cases among pregnant women with feasible laboratory tests for RTI and thereby providing treatment, counseling and follow-up. Objectives: 1. To know the prevalence of RTIs using feasible laboratory tests among reproductive age group, pregnant women. 2. To find the socio-demographic factors influencing RTIs in pregnant women. Materials and Methods: A cross-sectional study was done using a simple random sampling technique to select households. A pre-tested structured proforma was used to collect data on socio-demographic and reproductive characteristics. Specimens were collected for laboratory analyses of Gonorrhea, Trichomoniasis, Vaginal Candidiasis (VC), Bacterial vaginosis (BV) and Syphilis in Urban Health Training Centre (UHTC), attached to Karnataka Institute of Medical Sciences (KIMS), Hubli. Results: In all 51.3% of the women were diagnosed as having an RTI, including 8.9% with sexually transmitted infections. Endogenous infections were most prevalent (VC 35.9%, BV 6.4%), followed by Syphilis 5.1%, Trichomoniasis 3.8% and Gonorrhea 0%. Conclusion: In this study, the prevalence of RTI among pregnant women is high and steps should be taken for appropriate management of these cases, to reduce further risk of transmission of HIV/AIDS. This study suggests for integrating RTI/STI services into primary health care in order to know the true prevalence of RTI/STI in the community. The study also highlights the need for the introduction and/or strengthening of facilities for simple diagnostic tests for RTIs/STIs, especially at the peripheral healthcare level.
Keywords: Endogenous infections, laboratory tests, reproductive tract infections, sexually transmitted Infections
|How to cite this article:
Sangeetha S, Bendigeri. A study of reproductive tract infections among pregnant women in the reproductive age group, in Urban Field Practice Area in Hubli, Karnataka, India. Ann Trop Med Public Health 2012;5:209-13
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Sangeetha S, Bendigeri. A study of reproductive tract infections among pregnant women in the reproductive age group, in Urban Field Practice Area in Hubli, Karnataka, India. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Aug 5];5:209-13. Available from: https://www.atmph.org/text.asp?2012/5/3/209/98621
Reproductive tract infections (RTIs), including both sexually transmitted infections (STIs) and non sexually transmitted infections (non STIs) of the reproductive tract are responsible for major ill health throughout the world. 
WHO estimates that each year there are over 340 million new cases of sexually transmitted infections in which 75-85% occur in developing countries. In India alone, 40 million new cases emerge each year. 
RTIs are due to endogenous organisms, iatrogenic organisms and sexually transmitted organisms. Endogenous RTI are widespread among pregnant women, mainly due to overgrowth of organisms normally present in the vagina, as a result of hormonal changes. They can be readily treated, if not, they cause women varying degrees of discomfort from local irritation to pelvic inflammatory disease (PID). The consequences of RTI in pregnant women includes post abortal and puerperal sepsis, fetal and perinatal deaths, ectopic pregnancy, chronic pelvic pain, emotional distress and risk of HIV transmission. 
RTI in many cases are asymptomatic among women, making their detection and diagnosis difficult. Considering the often asymptomatic nature of RTIs among women, laboratory findings remain the most accurate method of biomedical diagnosis of RTI. 
An effort has been made on this regard to detect RTI cases among the pregnant women in the field practice area of Urban Health Training Centre (UHTC), Hubli, Karnataka.
|Materials and Methods|
The objective of the study was to know the prevalence of RTIs using feasible laboratory tests among reproductive age group pregnant women, and to find the socio-demographic factors influencing RTIs in pregnant women.
This study was undertaken in the field practice area of UHTC, Hubli, and reproductive age group pregnant women of 15-45 years were identified for study purpose.
It is a cross-sectional time bound, community-based study, conducted from September 2005 to August 2006. The sample size was calculated by taking into consideration 19% of women under 15-45 years in urban community, at 95% CI and 3% permissible error covering ±1.96 under normal curve.
Houses were selected on simple random sampling basis until 656 reproductive age group women were covered. All women were screened for pregnancy, by urine pregnancy test, examination and checking their antenatal card. Among 656 reproductive age group women, the number of recently pregnant women were 78 women in different periods of gestation.
A pre-tested structured proforma was used to interview the women about their antenatal history, socio-demographic, reproductive history, current and past RTI symptoms. They were encouraged after counseling to give samples for laboratory tests for RTI in UHTC.
The criteria used for laboratory diagnosis of RTI is presented in [Table 1].
|Table 1: Laboratory test performed and criteria used for diagnosis of reproductive tract infections
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In the center, per speculum examination was done, vaginal and endocervical swabs were taken for 78 pregnant women. Serological test for syphilis was done for every respondent after written consent and counseling.
Wet mount microscopy of vaginal secretions was done to detect Trichomonas vaginalis. Immediately after per speculum examination, the vaginal and endocervical swabs were sent to Microbiology department, KIMS, in cold box, gram-stained and inoculated in suitable media like chocolate agar and Thayer Martin medium for gonorrhea and Sabouraud dextrose agar (SDA) media for Candidiasis.
For diagnosis of Bacterial vaginosis (BV), any three out of four criteria were taken as positive: 
- Watery vaginal discharge
- Vaginal pH more than 4.5 using pH indicator paper
- Amine odour test positive (odour described as fishy after addition of 10% Potassium Hydroxide)
- Clue cells in Gram-staining smear
Analysis: Statistical tests like Proportions and Chi-square test were used.
Data was tabulated on Microsoft excel sheets and analyzed using SPSS software.
The prevalence of RTI was 51.3% among the pregnant women, which was diagnosed by using simple laboratory tests in the field. The prevalence of STI includes 8.9%.
Endogenous infections were most prevalent, Vaginal Candidiasis in 28 (35.9%) and Bacterial vaginosis in 5 (6.4%) women. This was followed by Syphilis in 4 (5.1%) and Trichomoniasis in 3 (3.8%) women. No Gonorrhea cases were detected among the study group (n = 78) [Table 2].
|Table 2: Laboratory diagnosis of the pregnant women with reproductive tract infections
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Among the RTI positive women, maximum number of pregnant women were suffering from Candidiasis 28(70%), followed by Bacterial vaginosis 05 (12.5%) (n = 40) [Table 2].
Among STI, Syphilis was commoner, seen in 04 (10%) women, Trichomoniasis 03 (7.5%) and Gonorrhea 0% (n = 40 )[Table 2].
10 (25%) women had mixed infections with Candidiasis, Bacterial vaginosis and Gram-negative organisms (n = 40) [Table 2].
Socio-demographic characteristics influencing reproductive tract infections
The present study revealed that 78 women were recently pregnant among the study group during the study period in different periods of gestation. The number of women in first trimester were 30 (38.5%), while 14 (17.9%) women were in second trimester and 34 (43.6%) women in third trimester (n = 78) [Table 3].
|Table 3: Socio-demographic profile of the pregnant women with reproductive tract infections
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[Table 3] shows the trend of positive findings of RTI in relation to age with maximum prevalence between 25-34 years age group of 64%. The difference was statistically significant (P < 0.001).
Divorcees and widows, (n = 6) pregnant women who were in small number did not report any non-marital sexual relationships and the prevalence of RTIs was less of 33.3% as compared with married women of 52.8%. There were no unmarried pregnant women in the study group [Table 3].
The prevalence of RTI was common among illiterate women of 77.1% and showed a decreased trend with an increase in level of education (P < 0.001) [Table 3].
It was found that 64.4% of women who were home makers had RTI against 33.3% of employed women, who were mainly working as laborers or housemaids (P < 0.001) [Table 3].
The prevalence of RTI was far less in women who had no children of 29.3% as compared with women who had children. A higher prevalence of 74.3% was found among women who had one or two children and it increased with increase in parity (P < 0.001) [Table 3].
About 73% of pregnant women were using contraceptive devices before conception, with majority using IUDs (intra uterine devices) after birth of one child. The women who were using IUDs,70% had RTI as compared to other methods (P < 0.001) [Table 3].
This study showed that prevalence of RTI varied in different periods of gestation, which increased from first trimester of 33.3%, in the second trimester to 57.1% and maximum prevalence in the third trimester of 64.7% (P < 0.05) [Table 3].
From this study, the prevalence of RTI among pregnant women was 51.3% based on the laboratory findings, with prevalence of STI being 8.9%.
Endogenous infections were most prevalent, Vaginal Candidiasis 28 (35.9%) and Bacterial vaginosis in 5 (6.4%) women. This was followed by Syphilis in 4 (5.1%) women, Trichomoniasis in 3 (3.8%) and Gonorrhea in 0%.
This is similar to study conducted in Vietnam, where the prevalence of RTI among pregnant women was 54.4%, with STI prevalence in 3.3%. Endogenous infections were most prevalent, Vaginal Candidiasis 34% and Bacterial vaginosis in 12% women. 
In our study, based on laboratory findings, 40 pregnant women were positive for RTI, with majority of women being positive for Candidiasis 28 (70%) (n = 40).
This study is in accordance with the observations made by Punjabi et al., where majority of pregnant women had Candidiasis (67%). 
It differs from observations made by Jeyasingh et al., where majority of pregnant women had Trichomoniasis of 47.2%. 
This study also differs from observations made by Begum et al., where majority of pregnant women had Bacterial vaginosis. 
The study showed the trend of RTI more in the age group of 25-34 age group. This age group is active reproductive age group with marital life, sexual activity, child-bearing and using contraceptive methods. Hence the risk of RTI is more in this group. 
It was found in the study that marital status and RTI are related to each other, as married women who are leading active sexual life are having more chance of getting RTI. 
Also with increased duration of married life, the risk of occurrence of RTI is more, due to enhanced sexual activity. 
The trend of increased RTI with decreased educational status of women shows that illiterate women were more ignorant about the occurrence of RTI with poor genital hygiene, poor living conditions, and their health seeking behavior is also low. 
It was found in the study that there is association between parity of women and occurrence of RTI, which is statistically significant. Women with more number of children are exposed to increased number of deliveries, contraceptive device and gynecological surgeries, which contribute to occurrence of RTI in women. 
This study is in accordance to Rathore et al., where 2.4% among nulliparous women had RTI as compared to 13% among primigravida and 28.5% among multigravida. 
It was observed that 70% of women among IUD users had RTI. This is in accordance to observation of Jasmine Helen Prasad et al, where maximum 67% women among IUD users had RTI. IUD users are at more risk of acquiring RTI as they are exposed to iatrogenic and exogenous infections. 
It was found that majority of women 64.7%, who were in third trimester of pregnancy had RTI as compared to women who were in first and second trimester of pregnancy. As pregnancy advances, due to hormonal changes, the occurrence of endogenous RTI is more common. 
This study highlights the need for community-based studies requiring laboratory investigations with feasible tests to know the exact prevalence of the disease, as self-reported morbidity alone cannot measure the burden of any disease in the community to necessitate proper prevention and control measures.
At present the syndromic approach is considered the most feasible approach at health centers in resource-poor settings in the management of common RTIs and STIs. It should be consistently supplemented by risk assessment in order to reduce under- and over-treatment. Microscopic diagnosis could be applied in primary care settings to achieve more accurate diagnoses.
In India, routine surveillance of these infections is not carried out and estimation of the total incidence/prevalence is quite difficult. Lack of laboratory diagnostic facilities, limited resources, poor recognition of reproductive tract infections (RTIs)/STIs by the medical profession as a major public health problem, stigma and discrimination associated with STIs and poor attendance of STI patients, especially women, in sexually transmitted disease (STD) clinics, are some of the main reasons for lack of RTI/STI data. Taking the above factors into consideration, it is meaningful to have comprehensive and reliable laboratory-based data on the incidence/prevalence of RTIs/STIs which our study provides.
Promotion of health education aiming at reducing RTI/STI prevalences is also an important tool in STI/HIV control program, along with routine screening and treatment for RTI/STI in pregnant women and their partners.
The authors are grateful to the Director, Principal and Medical Superintendent of KIMS Medical College, Hubli, for their permission to conduct the study and encouragement. They thank HOD and staff of Microbiology department for helping to conduct laboratory tests in the field and in giving timely reports. They are also grateful to the medico-social worker and staff nurse for assisting in collecting data. The authors wish to thank colleagues of Community Medicine department for their support and the community for their cooperation.
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Source of Support: Provision of vehicle for field data work and equipment’s for sample collection, by Karnataka Institute of Medical Sciences, Hubli, Karnataka, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]