The majority of women in some areas of rural Gambia experience reproductive health problems, but few seek medical care for their symptoms, according to a cross-sectional study conducted among women in the Farafenni region.¹ Seventy percent of the study participants had at least one reproductive disorder: Bacterial infections and childbirth-related pelvic damage were especially common. However, fewer than half of the women with symptoms had sought care, often because of anxiety and lack of knowledge.

Investigators used a randomized cluster sampling design to select 20 villages for the study. Three of the villages were reluctant to participate and were replaced by three others in the area with similar demographic and geographic characteristics. All women between the ages of 15 and 54 years were eligible; 72% agreed to participate. The final sample included 1,348 women, who were interviewed between January and July 1999.

A female fieldworker visited participants at home and recorded their demographic characteristics. She also asked about their gynecologic and obstetric history, current reproductive symptoms and care-seeking behavior; these questions were later repeated by a female gynecologist in a clinical setting. The gynecologist also performed a physical examination, which included a vaginal speculum inspection for all women except those with intact hymens. Blood, vaginal swab, and cervical smear and swab samples were analyzed to detect the presence of reproductive tract infections, cervical abnormalities and anemia. Study staff offered appropriate care to all women found to have a treatable medical condition. Women wishing to know their HIV status were offered pretest and posttest counseling.

Thirty-six percent of the women were aged 15-24, while 50% were 25-44 and 15% were 45 or older. Fifty percent belonged to the Mandinka ethnic group, 33% were Wollof and 16% Fula. Eighty-six percent were married, including 54% who were in a polygynous marriage. Twenty-eight percent had 1-3 children, 38% 4-7 and 16% eight or more; 18% were childless. Very few women (3%) reported any formal education, and 95% listed either farming or household work as their main occupation.

Of the 739 sexually active women who were not pregnant, only 6% were using modern contraceptive methods such as the injectable (3%), oral contraceptives (2%) or sterilization (1%). Of the 695 sexually active women not using modern contraceptives, only 29% stated that the reason was a desire to conceive.

More than half of the women (58% of pregnant women and 51% of nonpregnant women) were anemic, and 2% had severe anemia. The majority (58%) had undergone female circumcision, ranging from 4% among Wollof women to 32% among Fula women and 98% among Mandinka women. The clitoris and all or part of the labia minora had been removed in 82% of circumcised women.

The most commonly reported reproductive symptoms were menstrual problems, abnormal vaginal discharge, vaginal itching or irritation, and infertility. Although only a quarter of participants (26%) reported reproductive symptoms to the fieldworker, more than half (53%) reported such symptoms to the gynecologist. In most symptom categories, fewer than half of women had sought treatment (range, 39-45%); the exceptions were inability to conceive (61%) and genital ulcers or sores (54%). The reasons the women cited most frequently for not seeking health care were that they did not think it would help (54%), that they were afraid or embarrassed (16%), that the problem was not serious enough (15%) and that care was too expensive (11%).

According to physical exam findings, laboratory results and questionnaire data collected by the gynecologist, 70% of the women in the study had at least one reproductive disorder. Almost half (47%) of the participants had one or more reproductive tract infections. Endogenous infections such as bacterial vaginosis and candidiasis were common (37% and 12%, respectively), and 32% of the women were seropositive for herpes simplex virus type 2. Three percent tested positive for syphilis, which was much more common among the Fula (16%) than in the other ethnic groups (1%). HIV seroprevalence was 2% overall.

Ten percent of the women examined had pelvic tenderness. Seven percent had cervical abnormalities or lesions. The gynecologic exam detected vulval or cervical masses in 16% of all participants, and uterine enlargement in 4% of nonpregnant women. Abnormalities suggesting childbirth-related damage were present in nearly half (46%) of the women; these abnormalities included displacement of genital organs (42% of women), urinary incontinence (7%) and functional damage to the anal sphincter (3%).

Of the 603 menstruating women who were not using a hormonal contraceptive, 34% reported at least one menstrual disorder, with 15% mentioning irregular cycles, 14% painful periods, 7% spotting and 4% prolonged or heavy bleeding. Ten percent of the 871 postmenarchal, premenopausal women younger than 45 years were classified as infertile.

Given that Gambian women often do not seek treatment for, or even report, their reproductive health problems, the authors warn that "the provision of services by itself will not overcome the culture of silence surrounding these disorders." They argue that "empowerment of women (and men) through education" is critical to the improvement of reproductive health.--A. Hirozawa

REFERENCE

1. Walraven G et al., The burden of reproductive-organ disease in rural women in the Gambia, West Africa, Lancet, 2001, 357(9263):1161-1167.