ORIGINAL REPRODUCTIVE HEALTH STATUS OF MARRIED WOMEN PARTICIPATING IN CERVICAL CANCER SCREENING IN KATHMANDU

Background : Reproductive health of women has been the central agenda of Cairo conference since its inception in 1999. As a signatory country for Cairo Conference, Nepal government is also committed for reproductive rights for Nepalese women. Despite this, reproductive health challenges do exist in Nepal. This prompted us to determine the reproductive health status of married women attending in cervical cancer screening in Kath -mandu. Methods : Cross sectional study was designed to include retrospective data of married women, obtained during cervical cancer screening camp conducted by KIST Medical College at Laga Khala Clinic, Lagan, Kathmandu on 12-02- 2017. Among married women (131) attended cervical 100 wom en’s records with complete set of data for reproductive health variables required for the study were included in this study. Statistical analysis was done descriptively. Results : Participant’s age is between 21 years to 61years, 83% are liter ate and 46% are employed. Adolescence marriage and pregnancy were two main problems noted. Cervical examination in relation showed 3% (3) VIA positive, 33% (33) Cervicitis, 10% (10) cervical polyp, 7% (7) atrophic vaginitis, 4% (4) cervical erosion and 43% (43) healthy cervix. Regarding Knowledge about risk factor majority 92% (92) had either no knowledge or only some extent of knowledge. Conclusions : Married women who lives in Kathmandu has significant re productive health problem. Urban health program should address these issues.


INTRODUCTION
Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. 1 International conference for population and development (ICPD) was help in Cairo Egypt, in 1994 and the conference was the turning point that sexual and reproductive health was perceived holistically and right based approach was emphasized. Though many countries have attempted to implement recommendation of Cairo conference the progress has not been satisfactory. 2 Several other milestone took place for the sexual and reproductive health such as first World Health Organization (WHO) global strategy on reproductive health was endorsed by the 57.12 resolution of World Health Assembly in 2004. 3 This initiated to develop and implement activities for improving sexual and reproductive health in different countries. Also 2005 world summit committed to achieve universal access to reproductive health by 2015. 4 As a signatory country for Cairo Conference, Nepal government is also committed for reproductive rights for Nepalese women. Despite this, reproductive health challenges especially when it comes to adolescence marriage and adolescence pregnancy is serious problem in Nepal. 5 Considering these problem national Adolescence sexual and reproductive health program was designed in 2011 and implemented in several districts in Nepal but not in Kathmandu. 6 Therefore this study aimed to identify reproductive health status of married women in Kathmandu.

METHODS
Observational cross-sectional study was designed to use retrospective data collected during Cervical cancer screening camp conducted by KIST Medical College and Hospital (KISTMCH) at Laga Khala Clinic, Lagan, Kathmandu on 12-02-2017. On the camp Health education regarding cervical cancer was conducted by faculties of Community Medicine, KISTMCH. Prior conducting health education Participants knowledge was assessed. Married women who give consent to have cervix examined by Visual Inspection with Acetic acid (VIA) were examined by gynecologist. VIA is the simplest cervical cancer screening method recommended for resource poor countries and that includes our part of world. 7 Verbal consent was taken from Principal of KIST Medical College to use the data for study and ethical clearance was sought from Institutional review committee of KIST Medical College and Hospital. Pilot study was done by randomly selecting (lucky draw) 10 participants from total 131 participants of camp to see the status of variables required for the study. Sample size was calculated by taking 50% prevalence, based on prevalence of reproductive health problem among urban women in Mumbai. 8 Confidence Interval 95% and 10 % error of margin by using N= z2 P q/d2 formula. Required sample size was 96 but we used 100 records. Observational checklist was formulated based on our study objectives. Socio demographic, Reproductive health variables (Menarche, menopause, age at first marries, age at first pregnancy, number of live birth, number of pregnancy, number of abortion, cervical examination finding in relation to VIA, signs and symptoms related to reproductive health problem, knowledge about risk factors for cervical cancer, source of information and married women with ever cervix examined) were included in the study. Inclusion criteria were records with complete set of above-mentioned variables and records not torn or destroyed and written in understandable handwriting. Data entry was done and any missing data, outliers etc. were identified and corrections were made immediately. Double data entry was done to minimize the recording error. Data analysis was done descriptively using Statistical Package for social sciences (SPSS) version 20.   Among sign and symptoms of reproductive health problem lower abdominal pain and vaginal discharge and or itchiness were the most common. Symptoms of reproductive health problem reported were lower abdominal pain was 59(59%), vaginal discharge and or itchiness 53(53%), wart like growth 21 (21%) and genital ulcer 8(8%) ( Table 3).
In our study median age at marriage was 19 years, which is below than legal age for marriage. Legal age for marriage in Nepal is 20 is for both girls and boys. 12 However, with parental consent they can marry at the age of 18. Our study found 60 % (60) adolescence marriage. This showed either adolescent marriage is parents will or the implementation of law is poor in Nepal. Our study also showed high adolescent pregnancy 47(51.64%), participants with 3 or more than 3 live birth children 23 (26.43%) and at-least one abortion 31 (31%). However, we have not sought the cause of reproductive health problem but other study has shown unmet reproductive health problem in Nepal is high. 13 This may also apply for our case. So further research should be needed. When asked for number of pregnancies among participants 9 (9%) were never got pregnant. This may be due to infertility. This is similar with study done by Dangal G, on reproductive morbidity in Eastern Nepal. 14 Regarding Symptoms suggestive of reproductive health problem lower abdominal pain and vaginal discharge and or itchiness were the most common. Fifty-nine (59%) agreed to have experienced lower abdominal pain, 53(53%) vaginal discharge and or itchiness, 21 (21%) wart like growth and 8(8%) genital ulcer). This finding is similar with community based study conducted in Rupandehi, Nepal. 15 Cervical examination in relation with visual inspection with acetic acid (VIA) showed 53 (53%) had unhealthy cervix. Among them cervicitis was the most common. It is proven fact that the main cause of cervicitis is sexually transmitted infections and most often they are asymptomatic and if lead untreated it may lead reproductive morbidities.
Three (3) % of the participants were found VIA positive this indicates 3 of them may have precancerous lesions. Cancer mortality profile among female in Nepal showed that cervical cancer is the most common accounting 18.4% of all cancer. 16 Wart like growth in genital a is caused by Human Papilloma virus (HPV) and our study showed 21% had this problem. It is proven that High risk HPV is the main causative factors for causing cervical cancer. Our own study showed that HPV 16 and 18 is the HPV strain associated with cervical cancer. 17 Significant number of women had symptoms of reproductive health problem, cervicitis and wart like growth but only 46 % (46) had their cervix examined at least once. Low rate of cervical cancer screening among women in Nepal is also shown by other study conducted in Nepal. 18 Such kind of trend may lead negative impact on reproductive health of women in Nepal. So in depth study regarding the cause of women not having cervical examination must be carried out and intervention should be targeted to it to prevent morbidity and mortality related to it. Participant's knowledge of cervical cancer risk factors were also found unsatisfactory as only 8% (8) had very good knowledge and 74% (74) with some extent of knowledge and 18% (18) had no knowledge. This finding is supported by other study conducted in Nepal. 19 Majority of participant's source of information was from social network like friends and families Participant's source of information about cervical cancer risk factors are mostly from social network like friend and families 16(34.7%) and very few got information through health worker 8 (17.39%). This indicated that participants may not have got correct information and if this was the reality, reproductive right of women to get proper information may be jeopardized.

CONCLUSIONS
Adolescent marriage, pregnancy at adolescence age, reproductive health problems are the main problem noted among married women in Kathmandu. Despite having significant number of women with reproductive problems only few were noted having cervical examination done. Also, role of health worker in information dissemination was found very low. All of these factors may contribute poor reproductive health. So intervention should be targeted in these issues.