Reproductive morbidity among Iranian women; issues often inappropriately addressed in health seeking behaviors

Background Reproductive morbidity has a huge impact on the health and quality of life of women. We aimed to determine the prevalence of reproductive morbidities and the health seeking behavior of a nationally representative sample of Iranian urban women. Methods A sample of 1252 women, aged 18-45 years, was selected using the multi stage, stratified probability sampling procedure. Data were collected through interviews and physical, gynecological and ultrasonographic examinations. Results Reproductive tract infection (RTIs), pelvic organ prolapse (POP) and menstrual dysfunction were the three main groups of morbidities with a prevalence of 37.6%, 41.4% and 30.1%., respectively. Our study demonstrated that 35.1, 34.5 and 9.6 percent of women experienced one, two or these reproductive organ disorders mentioned, respectively, while 20.6 percent of participants had none of these disorders. Findings also showed that the majority of women who suffered from reproductive morbidities (on average two out of three) had not sought appropriate care for these except for infertility. Conclusions Reproductive health morbidities impose a large burden among Iranian women and have negative impact on their reproductive health and wellbeing.


Background
The third millennium development program emphasized maternal health, which can be assessed by maternal mortality ratio. However, for every woman who dies, approximately twenty others face serious or long-lasting morbidities [1]. As a result, every year an estimated 50 million women are affected by maternal morbidity and for at least 18 million of them these morbidities become longterm and are often debilitating [2]. According to WHO estimates, reproductive ill health accounts for 33% of the total burden of disease in women as compared to 12.3% for men [3] Reproductive morbidity has defined as any condition or dysfunction of the reproductive tract, or any morbidity which is a consequence of reproductive behavior including pregnancy, abortion, childbirth, or sexual behavior [4]. Reproductive morbidity has a huge impact on the health and quality of life of women and it should be prioritized as such [5,6]. Although there are several hospitals based studies concerning maternal health, the number of community based studies is limited [7][8][9][10][11][12]. Reproductive morbidities may be overestimated in hospital based setting, as hospital attendants are usually those with health complaints. On the other hand, the burden of these morbidities can be influenced by the culture of silence surrounding these disorders, in particular, in countries with conservative backgrounds [7,13]. Besides that many women who suffered from reproductive organ disorders had not sought appropriate care and women's health seeking behavior is been influenced by many factors [14][15][16].
There is no information on the burden of reproductive health problems and health seeking behavior of the Iranian women except for one study on Qashqa'i women [17]. We aimed to assess the scale of reproductive morbidities and their health seeking behavior in a nationally representative sample of urban Iranian women.

Methods
This community-based descriptive study was performed between 2008 and 2010 to determine the prevalence of reproductive morbidity among Iranian women of reproductive age.
Sample size was calculated based on these parameters: P = 0.085 [5], α = 0.95, d = 0.025, cluster design effect = 2 and a non response rate = 0.15. A stratified, multistage probability cluster sampling method, with a probability in proportion to size procedure, was used. Otherwise, the subjects of the present study were recruited using cluster sampling method from 4 randomly selected provinces of Iran. For the selection of these provinces at first we divided the provinces to 4 geographic subgroups and after that one province from each of this subgroup was randomly selected. The selected provinces were Ghazvin, Kermanshah, Golestan and Hormozgan that located in central, west, north and south of Iran, respectively. Subsequently the proportion of required samples in each province was calculated using data available on the total number of women age 18-45 who lived in urban area of each of those provinces. We considered 7 household in each cluster; based on 1 day performance capacity of the data collection group. The number of cluster in each province was calculated by dividing the total number of required samples in each province to 7. The household list is available in the health department of each province and usually updated annually. Using this list, the sampling interval (k) was calculated by dividing the total number of households to the requested number of cluster in each province. After that one number between 1-k was randomly selected, this number was the number of the 1 st selected household. Next household was picked out from the list by adding K to the number of 1 st recruited household. This process was continued till all of the requested clusters were selected. (selecting the cluster was made systematically.
A checklist questionnaire, based on the inclusion and exclusion criteria was completed at subjects' homes. Menopausal women and pregnant women were excluded, as a result of which 1236 women fulfilled our inclusion criteria and were invited to a referral clinic in each province for a comprehensive interview and physical exam. Of these eligible women 1117 complete our study procedure, while the reminder dropped out.
Pairs of trained staff members of local medical universities/schools served as interviewers, and a trained supervisor monitored the process in each district. A standard questionnaire including information on socio-demographic and reproductive variables as well as women's self reporting of particular signs and symptoms of lower reproductive tract infection (RTIs), pelvic organ prolapse (POP), menstrual dysfunction during the previous 6 months and their health seeking behavior was completed, during face-to-face interviews by trained midwives.
The content validity of the questionnaire was assessed by 15 gynecologists and reproductive health experts of Shahid Beheshti and Tehran Medical Science universities. The reliability of the questionnaire was assessed using test-retest and inter-rater methods, both confirmed by r = 0.91 and r = 0.85, respectively.
All participants underwent clinical examinations, where body weight, height, waist (WC), hip circumferences (HC) and blood pressure were measured. Gynecological assessment included a speculum examination and bimanual pelvic examination was carried out for all married women by a single gynecologist in each province. The external genitalia, perineum and anal sphincter function were examined. To improve validity and reliability of the medical examination the gynecologists used standard diagnostic protocols, developed during the pilot study by means of the standard protocol for assessment of pelvic organ prolapse and genital infection [18,19]. The long time primary infertility, dysmenorrheal, premenstrual syndrome, meno-metroragia and oligomenorrhea were defined according to the standard definition presented in table 1 [20][21][22][23][24]. Self treatment or treatments recommended by non specialists were defined as traditional interventions and standard treatment currently used was considered as modern interventions.
All of the study subjects were invited for transvaginal or transabdominal ultrasound scans of the ovaries, performed by an experienced sonographer in each province, using the 3.5-MHz transabdominal and 5-MHz transvaginal transducer; all scans were assessed by a single sonographer. The definition for each reproductive morbidity and their denominators for analysis were presented in table 1.
The ethical review board of Ministry of Health and Medical Education of Iran approved the study and informed consent was obtained from all subjects.

Statistical analysis
Data was analyzed using Stata software version 10. The prevalence of various reproductive morbidities and its 95% CI were calculated with adjustment for cluster sampling method.

Results
A study checklist was completed for 1252 women, aged 18-45 years, of whom 1236 met our inclusion criteria; of these eligible women 1117 ones completed the study procedure. The characteristics of the study subjects are summarized in table 2. Eighty-seven percent of participants were currently married, divorced or widowed, 85.1 percent of women were housewives and the remainder was employed (part-time or full-time); 26 percent of ever married participants had experienced miscarriage once or more and one percent of them had history of recurrent abortion. The prevalence of life time primary infertility was 8.3 percent (95% CI 6.6%-10.0%). Table 3 shows the finding on clinical and ultrasonographic examinations. The three most common diagnosed reproductive morbidities using standard definition were menstrual disorders, POP and RTIs with a prevalence of 41.4, 37.6 and 30.1 percent, respectively (Tables3 and 4). Results also demonstrated that 35.1, 34.5 and 9.6 percent of women experienced one, two or all of these three morbidities, respectively and only 20.6 percent of participants had none of these symptoms. In ultrasonographic report 5 percent of women had pelvic mass, with only one out of every five being correctly diagnosed during bimanual pelvic examinations. Table 4 demonstrates the proportion of women reporting reproductive organ symptoms, their diagnosis using standard protocol and their health seeking behavior. On average two out of three of women suffered from reproductive morbidities had not sought appropriate care except infertility, for which 61 out of 80 women with long time infertility had received current standard interventions (Table 4). Results demonstrated that 25 out of 151 women with stress incontinence sought standard interventions, whereas the others used traditional methods or ignored the symptom, considering to be a usual symptom for any women who had given birth (Table 4).

Discussion
This is the first community based study aiming to demonstrate the prevalence of reproductive morbidities and the health seeking behavior among Iranian reproductive aged women. The results revealed a high frequency of these morbidities and a culture of silence observed in the health seeking behavior of such women with ailments that need to be addressed appropriately in national health care screening program. Menstrual problems, pelvic organ prolapse and reproductive tract infections were the three most common morbidities, with 79.4 percent of the participants having at least one of these symptoms. The prevalence of RTIs was 37.6% in the present study, while it was 70% in China [8], 41% in Egypt [8] and 9% in rural areas of Lebanon [25]. The prevalence of lower RTIS and upper RTIs in Oman were 22 and 3.7 percent respectively [26]. The prevalence of RTIs not only depends on the biologic characteristics of the microorganism but it is highly influenced by the communities' sexual behavior, the recruitment of study subjects, type of the study and the method for identification of these infections. Therefore the differences in the reported prevalence in these various countries can be partly explained by the different methodologies and diverse sexual behaviors, e.g. in a small rural community premarital and extramarital sexual relations are not acceptable as a result of which the rate of reproductive RTIs is low [25]. Furthermore RTIs were defined using a symptomatic approach or diagnosed based on gynecological examination or microorganism observations in different studies, in the present study we diagnosed RTIs based on guidelines of syndromic approach for genital infections as a result this limits its comparability with those other studies that use other tools for identification of genital infections. A clear and contemporaneous method for screening and recognition of RTIs is essential for improving the comparability and potentially the value of published research [11,27,28]. The similarities between RTIs' symptoms and their own gynecological exam used in our study prove the suitability of using a simple questionnaire for screening of genital infections in a resource limited area, for prevention of their severe consequences, as it has been reported before [19,29,30]. In spite of the high prevalence of RTI in the present study, many women did not seek care or proper treatment, as reported elsewhere [29]. The prevalence of pelvic organ prolapse in our study was 41.4 percent; it was 56% in Egypt [7] and 10% in Oman [26]. Clinical based studies showed a prevalence of 75 percent of POP [31,32], this high prevalence may be due to referring of symptomatic women to the clinics, furthermore its prevalence is influenced by several demographic and reproductive factors [33]. A questionnaire was developed for assessment of POP and its sensitivity and specificity was investigated [32,34], in this study, its modified and simple form was used for assessment of POP at the community level and it appropriately diagnosed over two thirds of women suffering from POP. Active screening of POP at the community level is highly recommended as its mild type can be easily treated using simple interventions including pelvic floor muscle training with biofeedback and bladder training, which have a great impact on the quality of life women have [35].
Meno-metroragia is the leading cause of two third of hysterectomies [36]. Various studies demonstrate different prevalences of abnormal uterine bleeding, possibly because of disagreement in its definitions [37], type of the study and the recruitment of its study subjects. Our study demonstrated that although 21.1 percent of women had meno-metroragia, only one out of every ten of them seeking modern interventions. Active screening of these women and referring of complicated cases could significantly reduce secondary complications such as anemia, a major indirect cause of maternal mortality [38] In the present study, the majority of women with reproductive morbidities had not sought appropriate care except for infertility; this might be because such disorders were considered normal by these women as they were prevalent or because of they were not aware * Defined using the standard protocol for assessment of the genital infection (references no. [19]) ** defined using the standard protocol for assessment of pelvic organ prolapse (reference no. [18]) that the condition was curable. However the majority of our infertile women (76.1%) had sought care, which could be because of being infertile can socially stigmatize a women and cause marital problems, particularly in conservative communities where a woman's status depends directly on her fertility [20,39]. These infertile women commonly face severe socioeconomic problems and their marriages are threatened by divorce, forcing them to seek treatment to save their marriages. Many factors impact the reproductive care-or treatmentseeking behavior of women, such as lack of privacy in reproductive health care services in rural Ghana [16], fear of social discrimination or shying away from genital examinations in Laos [29] and the impact of these symptoms on quality of life in Egypt [40]. Demographic and clinical factors such as age, gender, severity of pain or disability influence help-seeking behavior for chronic diseases [41]. It has also been shown that psychosocial factors including past help seeking, outcome expectancy, age-related beliefs, social cost and social influence have great impact on individual seeking behavior [41]. A community awareness program could change our culture of silence on reproductive problems and as a result improve women's quality of life [5]. Ø women who used only traditional methods were considered as the users of traditional intervention; and women who used only modern methods or both traditional and modern methods were considered as the users of modern intervention * Defined according to the standard definition (references no. 20-24) ** Defined using the standard protocol for assessment of the genital infection (references no.19) *** Defined using the standard protocol for assessment of pelvic organ prolapse (reference no.18) ¥ Defined as Self treatment or treatments recommended by non specialists ¥¥ Defined as sing standard treatment protocol recommended by a specialist.
The main strength of the present study is its methodology, as it is a community based prevalence study carried out on an ethnically homogenous population and had an appropriate response rate of 88.8%. The similarity between the educational status and the prevalence of obesity in the present study and a national survey conducted by Janghorbani et al [42]could confirm our population as being representative of Iranian reproductive aged women. Reproductive morbidities in the present study were diagnosed through interviews in combination with physical examination and ultrasonography, making our results more reliable than those based on self reported questionnaires or interviews per se.
Our study does have some limitations; we did not use the menstrual diary to identify menstrual problems. Complementary laboratory methods were also not used for confirming diagnosis of pelvic infections due to cost containment. We did not have any information about the few women who refuse to participate in our study; however, considering our 90 percent response rate this could hardly affect our estimates.

Conclusion
Reproductive health morbidities impose a large burden among Iranian women and have negative impact on their reproductive health and wellbeing. The present study demonstrated that about one-third of Iranian women experienced at least one reproductive morbidity and a majority of them had not sought appropriate care. The challenge ahead is to modify and restructure the primary health care system based on modern concepts of reproductive health care that can accommodate the current needs of the community.