More than one in four women aged 18–45 in Goa, India, had a reproductive tract infection at the time of a 2001–2003 study of the prevalence and determinants of such infections.¹ Although STIs were present in relatively few women (4%), endogenous infections, such as bacterial vaginosis and candidiasis, were common (25%). Being older than 25 at marriage and using condoms or oral contraceptives had a protective effect against bacterial vaginosis, while having a verbally, physically or sexually abusive husband and being concerned about one's husband's habits (such as alcohol consumption) were associated with an increased risk. A low level of social integration, concern about a husband's extramarital relationships (an indicator of sexual risk), never having been pregnant and having been sterilized were associated with having an STI.

The data come from a population-based sample of women aged 18–50, who were randomly selected from a database of health department records and who resided in the north Goa district, spoke one of the study languages, did not have cognitive impairment and were not pregnant. Of the 3,000 eligible women contacted, 2,494 (83%) consented to participate. The majority of the respondents (75%) were Hindu, 14% were unable to read or write, 68% were homemakers and 36% lived in homes with no toilet facility. Some 33% of women's households were in debt, and 5% of women reported having gone hungry in the three months prior to the study. Data collection involved two stages: a semistructured interview to obtain information regarding participants' social and demographic characteristics, experiences with gender disadvantage, and sexual and reproductive health risk factors; and a gynecological examination to determine the presence of endogenous infections (bacterial vaginosis and candidiasis) and STIs (trichomoniasis and gonorrheal or chlamydial infections).

Overall, 28% of women had a reproductive tract infection; 4% of women had at least one STI, and 25% had an endogenous infection. Bacterial vaginosis, found among 18% of participants, was the most common reproductive tract infection.

The univariate analysis indicated that risk factors for STIs and bacterial vaginosis included being older, being married, having less education, having a small household, lacking a toilet in the home and being in debt (p<0.1). Having candidiasis was associated with being younger, being non-Muslim, having fewer than three children and not having tap water in the house.

In a multivariate analysis, having an STI was associated with being married (odds ratio, 2.3), being illiterate (1.8), having fewer than three children in the household (2.2), having no tap water in the home (1.5) and being in debt (1.4). The risk of having bacterial vaginosis increased with age and was associated being married (1.5), being a migrant (1.4) and living in a house with fewer rooms. The risk of having candidiasis increased with women's age and was associated with being non-Muslim (5.3), being unmarried (2.9), not having running water in the house (1.3) and having fewer than three children (1.7).

In further analyses that adjusted for socio-economic factors, the researchers examined the relationship between reproductive tract infections and risk factors related to gender disadvantage and reproductive health. STI was associated with a low level of social integration—a composite measure based on the degree to which women were able to socialize with friends and relatives and participate in activities outside the home. The odds of having bacterial vaginosis were negatively related to age at marriage. Risk factors for bacterial vaginosis included verbal, physical and sexual abuse by the husband (odds ratios, 1.4, 1.7 and 1.9, respectively), and concern about the husband's extramarital affairs (1.4).

Sexual and reproductive health factors associated with having an STI included never having been pregnant (2.7), having been sterilized (1.7), having a husband with white genital discharge (6.9) and being concerned about the husband's extramarital affairs (4.0). Women who had ever had an abortion were about half as likely as those who had not to receive an STI diagnosis (0.5). Women who reported using the pill or condoms as their main contraceptive method had a significantly lower risk of having bacterial vaginosis (0.2 and 0.6, respectively).

The researchers point out that the association between bacterial vaginosis and gender disadvantage "may reflect the lack of control women have over their hygiene and possible effects of stress on vaginal flora." The link between STIs and women's social isolation, reports of their husbands' genital discharge and concerns about their husbands' affairs further indicate that many women's reproductive health is contingent on their husbands' behaviors. Thus, the researchers suggest that increased focus on treating and preventing STIs in men "may prove to be an effective strategy in controlling the spread of STIs and reducing the burden in women."—H. Ball

REFERENCE

1. Patel V et al., The burden and determinants of reproductive tract infections in India: a population based study of women in Goa, India, Sexually Transmitted Infections, 2006, 82(3):243–249.