Findings of the survey on the reproductive health of women in some towns and rayons of Khatlon oblast, Republic of Tajikistan

MINISTRY OF HEALTH REPUBLIC OF TAJIKISTAN Obstetrics, Gynaecology and Paediatrics Scientific Research Institute Republican Centre for Reproductive Health FINDINGS OF THE SURVEY on the REPRODUCTIVE HEALTH OF WOMEN in some towns and rayons of KHATLON OBLAST Republic of Tajikistan UNFPA Division of Arab States and Europe WHO Regional Office for Europe Women’s and Reproductive Health Programme February 2000

iii ACKNOWLEDGEMENTS We would like to express our acknowledgements to: Ministry of Health of the Republic of Tajikistan Mr Alamkhon Ahmadov Minister of Health Republic of Tajikistan Mr Nasrullo Abdujabarov Deputy Minister of Health Republic of Tajikistan World Health Organization Regional Office for Europe Dr Assia Brandrup-Lukanow Regional Adviser for Women’s and Reproductive Health Dr Gayane Dolyan Technical Adviser for Women’s and Reproductive Health Dr Babill Stray-Pedersen WHO Consultant on Sexually Transmitted Diseases, Women’s and Reproductive Health WHO Office in Tajikistan Dr Nazira Artikova WHO Liaison Officer in Tajikistan Dr Muazama Jamalova WHO National Project Coordinator TAJ/96/PO2 iv PROJECT EXECUTORS Tajik Scientific Research Institute of Obstetrics, Gynaecology and Paediatrics Ministry of Health of the Republic of Tajikistan Republican Centre for Reproductive Health Mavjuda Kasimova Director Team leader of the survey “Abortion and its complications” Tajik Institute for Post Diploma Training of Medical Personnel Zarina Narzullaeva Assistant to the Obstetrics, Gynaecology Department Medical College of Dushanbe Olga Eylisova Head of the Cycle Commission for Obstetrics and Gynaecology Computer Data Processing Bakhtyar Yahyaev Engineer-programmer Republican Centre for Reproductive Health Translation Munavara Jalilova Head of Chair Tajik National University vLIST OF ABBREVIATIONS RT Republic of Tajikistan MoH Ministry of Health OGPSRI Obstetrics, Gynaecology and Paediatrics Scientific Research Institute RCRH Republican Centre for Reproductive Health RH Reproductive health FP Family planning STD Sexually transmitted diseases USI Ultrasound investigation IBM Index of body weight AC Alimentary canal SS Surgical sterilization DOMC Disorder of ovular menstrual cycle EGD Extragenital disorder HIV Human immunodeficiency virus AIDS Acquired immunodeficiency syndrome

vii CONTENTS Page Executive summary ..................................................................................................................................... ix Introduction ...................................................................................................................................................1 Background .........................................................................................................................................1 Survey objectives ................................................................................................................................1 Methodology .................................................................................................................................................1 Methods of investigation, characteristics of the surveyed group ........................................................1 A baseline of main parameters included in the survey questionnaire .................................................2 Methods of investigation.....................................................................................................................4 Review of the reproductive health.................................................................................................................6 Infant mortality ...................................................................................................................................8 Maternal mortality...............................................................................................................................9 Results of the survey ...................................................................................................................................10 Survey of reproductive functions ......................................................................................................13 Health status of respondents .............................................................................................................17 Conclusions and recommendations .............................................................................................................19 Survey on abortion prevalence and its consequences..................................................................................19 Characteristics of investigated women..............................................................................................21 Social aspects of reproductive behaviour of women.........................................................................21 Approach to abortion ........................................................................................................................24 Abortion complications.....................................................................................................................27 Awareness of contraceptive methods................................................................................................28 Conclusion ........................................................................................................................................31 Recommendations.............................................................................................................................31 Tasks .................................................................................................................................................31 Sexually transmitted diseases......................................................................................................................32 Situation in the republic of Tajikistan...............................................................................................34 Sexual behaviour and relations .........................................................................................................35 Awareness of sexually transmitted diseases......................................................................................35 Awareness of contraceptive methods................................................................................................37 Screening for sexually transmitted diseases......................................................................................38 Investigation of sexually transmitted disease patients ......................................................................40 Clinical forms of STD.......................................................................................................................40 Summary ...........................................................................................................................................45 Recommendations.............................................................................................................................45

ix FINDINGS OF THE SURVEYS ON THE REPRODUCTIVE AND SEXUAL HEALTH OF WOMEN IN SOME TOWNS AND RAYONS OF KHATLON OBLAST REPUBLIC OF TAJIKISTAN Executive summary An agreement on the implementation of the project “Improvement of the Reproductive Health and access to the Family Planning services” was signed between the United Nations Population Fund (UNFPA), the World Health Organization (WHO) and the Government of the Republic of Tajikistan in 1996. On the basis of that agreement the following three surveys were conducted: the reproductive health (RH) situation, abortion prevalence and its consequences, and sexually transmitted disease (STD) situation in the Kathlon oblast. Khatlon oblast is one of the biggest oblasts of the Republic of Tajikistan which has its specific climate, geography, socioeconomic, demographic and other features. The three surveys are presented in this document with all findings and reviews specific issues of reproductive and sexual health in the Kathlon oblast. In the RH survey, 400 women were examined and 3000 women of different age groups from Kathlon oblast were interviewed. Results shows that the majority of women have started sexual intercourse at the age of 19 and above. This reflects the necessity of developing educational programmes and awareness campaigns. Nearly 56% of women would like to have three to four children. As contraceptive knowledge, nearly 22% of respondents are not able to name at least one birth regulating method which indicates low awareness. The most popular method among current users is intrauterine device. A large portion of women (76.7%) are found with anaemia. The second survey showed that abortion remains a major means of birth regulation in Tajikistan. This survey shows that 47% of women who had abortion suffer from extra-genital and gynaecological diseases. Among the surveyed women, 31% had four to five abortions. It is strongly recommended to strengthen post-abortion counselling and information to avoid unwanted pregnancy and abortion. Lack of knowledge on STDs among surveyed women in the STD survey, is noticeable – 72% only have an idea of STDs. Nearly 29% of respondents do not use preventive measures and means against STDs. It is strongly recommended to launch a comprehensive public health and educational programme involving all sectors to combat STDs. Also there is a need for establishing the WHO syndrome approach in medical facilities without having to resort to hospital services for STDs. Family planning priority for the health protection of mothers and children has been acknowledged long ago. Taking into consideration the misunderstanding of the term “family planning” by many people we use the notion “reproductive health” with broader meaning – it is the state of physical, mental and social prosperity, it is the capacity of people to have responsibility for safe sex which gives satisfaction, reproductive opportunity and the freedom of making decision on the number of children in the family, when and how often they may have children. In 1997, Tajikistan approved a strategy up to year 2005 that is focused on the improvement of health of women and children. Currently this strategy is undergoing changes on the basis of HEALTH21, the updated policy for health for all in the 21st century, from the WHO Regional Office for Europe. Findings of the survey on reproductive health of women will provide the identification of priorities.

1Introduction Background In November 1996 the UNFPA and Government of the Republic of Tajikistan developed a project “Improvement of the Reproductive Health and Access to the Family Planning Services” (TAJ/96/PO2). One of the components was a survey to assess the reproductive health of women in Khatlon oblast. The survey was conducted by the Tajik Scientific Research Institute of Obstetrics, Gynaecology and Paediatrics and the Republican Centre for Reproductive Health with the technical assistance of the European Regional Office of WHO. Risk groups on abortion and sexually transmitted diseases (STD), frequency and the structure of extra-genital and genital pathology and also awareness and approach of various population groups’ to the contraceptive methods were identified on the basis of the survey findings. Measures on improving the quality of provided services and access to the reproductive health were identified. We hope that the obtained data will help to have access to the necessary data for design of an effective policy, strategy and coordination of measures directed to improve the reproductive health of population in the country. Survey objectives Strategy development of the reproductive health in the Republic through implementation of the following tasks: 1. the study of reproductive health in some towns and rayons of the population of Khatlon oblast; 2. the study of sexually transmitted diseases ratio; 3. contraceptive use; 4. abortion survey. Methodology Methods of investigation, characteristics of the surveyed group Anonymous questioning-interview was used for the sociological survey. Some 3109 people were interviewed including: 1000 respondents on reproductive health; 1068 respondents on sexually transmitted diseases; 1041 respondents on reproductive health of women using contraceptives after abortion. Interviews were conducted in place of residence of respondents, i.e. in Kulob, Kurgan-Tube, Bokhtar, Vose, Kulob rayons. The method of random selection was used in order to provide statistical conformity in the respective age group. 2Methods of questionnaire and interview was used. Some women answered personally to the interviewer’s questions, others filled in the questionnaire themselves. In order to guarantee the confidentiality of answers the interview was anonymous. In order to detect the structure of extra-genital and genital pathology, sexually transmitted diseases, 400 women employed in Kulob, Kurgan-Tube, Vose enterprises were examined clinically. Routine laboratory studies and special investigations were carried out which included:
 history taking
 physical examination
 additional methods of investigation. On the basis of the collected data reproductive health of the population of different strata was studied, some demographic data, medical-socio reasons, diseases that have an impact on the reproductive health were analysed; structure of extra-genital and genital pathology of sexually transmitted diseases, social behaviour, abortion and its consequences, responses of medical personnel and patients in the case of undesirable pregnancy was also studied. The survey was conducted on the basis of:
 identification of the reproductive health needs and rights of the patients
 medical facilities needs for additional services and coverage in reproductive health. A baseline of main parameters included in the survey questionnaire Sociological interview was conducted on the basis of the following subjects by the survey team:
 “Study of the Reproductive Health of Khatlon Oblast Population”
 “Study of Women’s Reproductive Health Using Contraceptives after Abortion”
 “Study of the Sexually Transmitted Diseases”
 Population–demographic parameters indicating women’s reproductive behaviour
 population
 number of female population
 women of reproductive age
 nationality
 age structure of the population
 average age for marriage of women
 birth intervals
 Social parameters having an impact on the reproductive health of women
 social status
 education
 assessment of living conditions
 size of the family
 number of desired children
 Health self-assessment
 do you consider yourself as a healthy person
 if no, what’s your illness 3
 Awareness and use of different contraceptive methods
 awareness of different contraceptive methods
 source of information on contraceptive methods
 what contraceptive method is preferable
 women’s approach to organizations giving reproductive health/family planning services
 responsibility for prevention of pregnancy
 Abortion and its consequences
 number of abortions
 post abortion complications
 post abortion contraceptive use
 Responsibility in case of unwanted pregnancy
 reasons for the termination of pregnancy (desire of spouse, personal desire, having enough children)
 women’s right to abortion
 Sexual behaviour
 at what age did you first have sex
 satisfaction with sexual life
 number of sex partners
 you are informed about your sex partner’s relations with his/her other sex partners
 Awareness of sexually transmitted diseases and approach to the prophylaxis of STD
 awareness of sexually transmitted diseases
 do you consider sexually transmitted diseases as dangerous
 source of information regarding prevention of sexually transmitted diseases
 your approach to the methods of sexually transmitted diseases prevention
 your partner’s approach to the methods of STD prevention.
 Screening on the basis of sexually transmitted diseases
 genital disorders in the last year
 had your partner sexually transmitted disease treatment
 are you suspicious of having sexually transmitted disease yourself
 had you more than one partner in the last two months Analysis of the interview and recommendations The analysis of the data were carried out on the basis of grouping by themes and were compared with the existing statistics of health care of the Ministry of Health. But some of the indicators can not be compared because of the lack of official statistical data. Data assessment methodology was based on the WHO materials. Screening for identification of extra-genital and genital pathology and sexually transmitted diseases In order to study the structure of the extra-genital and genital pathology, sexually transmitted diseases screening was carried and was focused on: 4
 population-demographic parameters
 medical-social aspects
 harmful habits of the respondent
 information about husband, children
 past medical history in childhood, in puberty, in the later stages of life
 disorder of the mammary glands, uterus and uterine neck
 menstrual functions
 reproductive history
 complaints
 Data of clinical investigation
 height, weight
 hirsutism
 gynaecological examination
 mammary gland condition
 Data of additional methods of investigation
 smear
 diagnosis of chlamydia
 ultrasound investigation
 syphilis test
 hepatitis B, C
 HIV/AIDS
 diagnosis Methods of investigation History taking, general clinical and gynaecological investigation was conducted by standard methods. Index of the body mass (IBM) was detected on the basis of G. Brey formula (1978). IBM was determined as to the weight in kilograms against the height in square metres. body mass, kg IBM= ----------------------- (body height, m)2 The standard of IBM for the reproductive age of women is equal to 20–26, (IBM equal to 26–30 indicates to the smallest possibility of having metabolic disorder, above 30-0 average risk of its development, above 40-0 high level of risk of metabolic disorder development of IBM in comparison with obesity assessment of B.G. Baranova’s figure (1979), it may be considered that index significance from 30 to 40 corresponds to the III obesity level (excess of the body mass is 50%) and index significance above 40 is the IV obesity level (excess of the body mass is 100%). Assessment of hirsutism was conducted according to the diagram worked out by P. Ferriman, J. Calney in 1961. Hirsutism was examined on each seventh zone of the anterior aspect and two additional zones of the posterior aspect (zones 8–9 cover both anterior and posterior). Hirsutism intensity was assessed according to the 4-score system. Due to the total score, which is equal to 36, the hormone status indicator was estimated. Such assessment made possible to have the quantitative assessment of the pilosis. 5Mammary gland investigation was carried out in the position of lying down and standing with palpation of internal and external quadrants of glands, regional lymph nodes. All patients’ papilla was investigated to detect the absence and presence of lac, colostrum, its colour, consistence and character. As it is known, mammary glands are part of the reproductive system, hormone-depending organ. According to the national and international scientists research findings about 40% of gynaecological patients have different types of fibrocystic mastopathy. Once the pathology was detected, women were directed to an outpatient department for further investigation. Ultrasound investigation was carried out with ALOKA equipment. Investigation was carried out by abdominal apparatus. By ultrasound investigation the major size of uterus (length, width, size of anterior and posterior), ovary (length, width, size of anterior and posterior), moderate uterine echo was determined. Echoscopy was considered as a screening method to detect genital pathology. Smear flora investigation. Taking and staining a smear was conducted in accordance with the established method. The result was assessed in accordance with M. Heurlin method. Four degrees of the cleanness of the vaginal smear were determined. I degree – Doederlyan bacillus and epithelial cells. II degree – vaginal bacillus is less than separate leucocytes 5–6, Gram-positive diplococcus coma variable. III degree – few vaginal bacillus, leucocytes 20 and more, profuse of cocci, coma variable, microorganisms. IV degree – lack of vaginal bacillus, only leucocytes, different microflora, streptococcus, staphylococcus, intestine bacillus, Trichomonas, etc. For the laboratory diagnostics of chlamydia the individual biochemical analyses like SINTRON, BIORESEARCH, INC, USA, Chlamygen F was used. (Express diagnosticum of chlamys is an enzymatic system to detect chlamydia trachomatis immediately on the samples taken from patients. Diagnosticum Chlamygen F is an enzymatic system of identification that is based on using synthetic substratum, which in the presence of the specific enzyme of chlamydia trachomatis bacterium goes through chemical changes. In the presence of chromogen this chemical reaction brings to the purple stain the end of the applicator. Time for analyses is 10 minutes and 30 seconds.) Curettage of the cervical canal was taken after removing mucous plugs from the 1.5 centimetre depth of the canal with the help of single use sterile probe. The probe was carefully brought into the cervical canal not touching the wall of vagina and with the slightest curettage movement (but without blood) the material was taken. Curettage requirements: diagnostic material must contain a great number of epithelial cells because chlamydia is intracellular parasite (if mucous membrane is damaged) and minimum mucus, exudation and blood admixture. Results were read from result interpretation card: positive weak, moderate and strong reaction. Diagnostic of hepatitis virus was conducted in accordance with immunoenzymatic analyses, methods to identify surface antigen of hepatitis B (HbsAg) virus, immunoenzymatic analyses for identification of antibody to hepatitis C were used. Test system worked out by scientific- production enterprise “Akvanast” of St Petersburg was used. Immunoenzymatic analyses was conducted on the basis of generally accepted method. 6In order to detect pathogene of syphilis a special test system designed in scientific-production enterprise “Akvanast” of St Petersburg was used. Immunoenzymatic analyses was conducted on the basis of generally accepted method. Immunoenzymatic analyses will allow to identify the presence of antibody to the pathogen of syphilis (Tr. Pallidum) in the blood serum of a man because of the interaction with specific synthetic peptide absorbed on the surface of small cavity of polistirol plane-Figure. In order to detect antibody to the human virus of immunodeficiency a system of Vironostiha HIV Uni-Form 11 plus 0 was used in accordance with the generally accepted method. Computer IBM was used for statistical analyses processing maps and questionnaire which made possible to receive all statistical information including information on different groups, to have quantity and percentage of parameters regarding each group. Review of the reproductive health Tajikistan is situated in the centre of the central Asia, 93% of its territory is occupied by mountains, population is about 6 million, with high rate of population growth 16.1% per 1000 population (1998), urban population is 26.9%, rural population is 73.1 (1998). As the structure of population shows there are 50.2% women and out of it 22.5% women of fertile age. According to the official statistical data, in 1995 the number of women marriages during a year at the age under 20 (16–19 years old) was 29.1%. Traditionally, there is a high birth rate and large families, the number of the members of the family is 6.1, in rural areas 7.1. More than 25% families have five and more children. The number of permanent citizens in oblasts are: 1. Khatlon – 2 117 700 2. Leninaba – 1 834 800 3. Gorno-Badakhshan – 194 100 4. RRS – 1 339 600. Demographic policy improvement in regional conditions of the Republic of Tajikistan must be based on the identification of the priorities by taking into account the historic development of the republic, its national composition, specifics of living conditions and its culture and traditions. Major demographic policy objectives must be directed to the improvement of the quality of life and reproductive health of the population. Major objectives of the reproductive health is set up in the National Program on family planning with focus on further strengthening the health care and longer life, children health, strengthening the family and marriage relations, creating favourable conditions for bringing up children. In spite of the fact that there is a high birth rate in Tajikistan, there is a tendency of decrease of birth rate in the republic, in oblasts and in Dushanbe for the last years. Thus in RRS the birth rate went down from 40.3% (per 1000) in 1990 to 25.7% in 1997; in Khatlon oblast from 45.5% in 1990 to 25.9% in 1997; in Leninabad oblast from 35.4% to 27.3% correspondingly; in Gorno- Badakhshan from 35.1% to 25.2% and in Dushanbe from 22.7% to 12.3%. 7Fig. 1. Dynamics of regional birth rate of the Republic 22.7 40.3 35.4 45.5 35.1 38.4 12.3 25.7 27.3 25.9 25.2 25 0 5 10 15 20 25 30 35 40 45 50 55 Dushanbe RRS Leninabad oblast Khatlon Oblast Gorno-Badakhshan Republic 1990 1997 As Fig. 1 shows, the decrease of the birth rate in the Republic started from 38.4% (1990) to 25.0% (1997). There is a tendency of decrease of mortality in Tajikistan from 6.2% (per 1000) in 1990 to 5.3% in 1997. Unfavourable demographic situation in the republic had an impact on the reproductive indicators, natural population growth and brought to migration losses. Fig. 2 shows the changes in natural population growth in 1997 in comparison with 1990. Fig. 2. Natural population growth indicator (per 1000) 16 34.7 29.2 39.2 28.5 32.2 5.1 20.4 21.5 19.5 20.7 19.2 0 5 10 15 20 25 30 35 40 45 D us ha nb e R R S Le ni na ba d ob la st K ha tlo n O bl as t G or no - B ad ak hs ha n R ep ub lic 1990 1997 Fig. 2 shows sharp changes in the natural population growth indicators all over the country. The average life expectancy is 68.3 (1995) including: men – 65.5; women – 71.2. 8Infant mortality Infant mortality is decreasing in the Republic although it is still considered very high. Fig. 3. Infant mortality indicator (per 1000 live born) 31.7 43.3 40.1 43.5 36.4 40.9 58 38.8 54.5 46.8 31.9 47 38.2 18.8 35.9 24.6 24.9 27.6 0 5 10 15 20 25 30 35 40 45 50 55 60 65 D us ha nb e R R S Le ni na ba d ob la st K ha tlo n O bl as t G or no - B ad ak hs ha n R ep ub lic 1990 1993 1997 The big variation of infant mortality in 1990, 1993, 1997 is impressive, for example: 40.5–54.5–35.9 in Leninabad oblast 43.3–38.8–18.8 in RRS. The incomplete registration issues should be taken into account. Findings of the checking of infant mortality registration conducted by the Ministry of Health and the State Statistics Committee of the Republic of Tajikistan was 20% of cases were not registered. Biological factors affecting on the infant mortality such as the age of mother, parity, interval between childbirth, body mass at the time of birth, the health state of the mother worsened. According to the Tajik Scientific Research Institute of the Obstetrics, Gynaecology and Paediatrics for the last three years every second mother in childbirth had body mass deficit, every third child had slow intrauterine development. Perinatal mortality shows similar trends. 9Fig. 4. Perinatal mortality indicator (per 1000 births) 38.4 20.6 18.9 22.6 15.9 22.4 13.7 19.4 18.5 25 15.8 22.1 0 5 10 15 20 25 30 35 40 45 D us ha nb e R R S Le ni na ba d ob la st K ha tlo n O bl as t G or no - B ad ak hs ha n R ep ub lic 1990 1997 Maternal mortality One of the major health care problems is maternal mortality. Scientific researches in this field indicates to the following major factors having an impact on the maternal mortality rate: 1. Social: bad living conditions, lack of sanitary culture of women, hard labour conditions and problems of health care. 2. Medical-biological: large number of childbirth and multipara, low health index, high rate of extra-genital diseases. Dynamics of maternal mortality indicator in the Republic (per 100 000 live births) is: in 1992 – 69.6 in 1995 – 58.2 in 1997 – 64.6. Table 1 shows dynamics of maternal mortality in Kathlon oblast from 1990 to 1998 and in 1998 MMR is 43.7 per 100 000 live births which is lower than the national figure in that particular year. Table 1. Maternal mortality, per 100 000 live births, in Kathlon oblast Rate 1990 1992 1993 1994 1995 1996 1997 1998 Kathlon oblast 51.3 55.6 80.1 62.1 93.8 110.2 61.4 43.7 10 Fig. 5. Structure of maternal mortality (%) 37.5 26.7 12.2 12.2 11.4 haemorrhage gestosis extra-genital diseases abortion and its complications septic diseases According to Fig. 5 major cause of the maternal mortality is haemorrhage – 37.5%, the second cause is toxaemia of pregnancy and its complications (eclampcia, eclamptic coma) – 26.7%, then comes abortion and its complications, extra-genital diseases – 12.2%, accordingly, septic diseases – 11.4%. The regional pathology of Tajikistan is anaemia – 63.0% during pregnancy period. Universal risk factor for the republic is multipara, childbirth at the age under 20 and above 35, childbirth with short intergenetic period. Khatlon is one of the biggest oblasts in Tajikistan, with 2 117 700 population. The rural population of the oblast is 81.5%, urban population is 18.5%. Population is mainly engaged in agriculture, men are employed in the industry, construction, transport. Women are 50.3%, men are 49.7%, women of fertile age are 23.2%. Some 45.2% of families with 6 to 10 members share one house, 13 859 have five and more children. The main reason for having children perhaps they could help parents in agriculture works as well as in domestic works. Maternal and infant mortality indicators are higher than in other oblasts. Hospitals are poorly staffed with obstetricians-gynaecologists in Khatlon oblast only 59.2%, compared to 94.6% in Leninabad oblast and 92.3% in Gorno-Badakhshan. Results of the survey The team made eight trips to Khatlon oblast rayons (Bokhtar, Vose, Kulob) and also to cities Kurgan-Tube and Kulob. For the survey on reproductive health a questionnaire and a map of investigation of gynaecological patient was designed. General state of health, objective, gynaecological, ultrasound investigations were carried out, smear was taken for flora, a test was conducted in order to identify chlamydia, RW, AIDS, hepatitis B and C. In this survey, 400 women were examined, 3000 women were interviewed. Survey was conducted in different women age groups:
 7.7% teenagers 15–16 years old
 18.5 young women up to 20 years old
 39.3% from 21 to 29 years old
 24.6% from 31 to 45 years old
 9.9% above 46 years old. 11 Fig. 6. Age composition of the surveyed women (%) As Fig. 6 indicates 65.5% of young women were interviewed. The ethnicity of the respondents are:
 Tajiks – 72.06%
 Uzbeks – 22.3%
 Russians – 4.7%
 respondents of other nationalities – 0.94%. Fig. 7. National composition of the respondents (%) As Fig. 7 shows 72.06% of respondents are Tajiks. The majority of respondents 76.5% were married, including civil and Moslem marriages, 9.68% were not married, 13.8% respondents were divorced. Respondents belonged to the following categories:
 workers – 23.5%
 housewives – 23.5% 72.06 22.3 4.7 0.94 0 10 20 30 40 50 60 70 80 Tajiks Uzbeks Russians Other nationalities 7,7 18,5 39,3 24,6 9,9 0 5 10 15 20 25 30 35 40 45 50 the age of 15- 16 up to the age of 20 the age of 21- 29 the age of 31- 45 above the age of 45 12
 employees – 35.8%
 farmers – 10.3%
 students – 6.9%. Fig. 8. Social status (%) As Fig. 8 shows the main respondents are employees, workers and housewives. There were no illiterate respondents. Respondents had the following education level:
 35.0% with secondary education
 21.4% with special secondary education
 15.1% with incomplete secondary education
 19.4% with incomplete higher education
 9.11% with higher education. As the data shows all respondents have education and only comparatively low number of respondents have higher education – 9.11%. Fig. 9. Indicator of education level (%) 23.5 23.5 35.8 10.3 6.9 workers housewives employees farmers students 35 21,4 15,1 19,4 9,11 0 5 10 15 20 25 30 35 40 45 se co nd ar y ed uc at io n sp ec ia l se co nd ar y ed uc at io n no n- co m pl et ed se co nd ar y ed uc at io n no n- co m pl et ed hi gh er ed uc at io n hi gh er ed uc at io n 13 Thus different level of women were covered by survey: different age, social status and education and besides that the majority of respondents were natives of the Khatlon oblast. Survey of reproductive functions Menstrual function Menstrual cycle started: at the age of 11–13 – 75.6% at the age of 14–16 – 23.2% above 17 – 1.2%. Thus, the main percentage of the respondents having the menstrual function at the age of 11–13 indicates to the early age of puberty of girls. Menstrual function became stable: immediately – 93.7% after 1–6 months – 3.77% more than after 6 months – 0.63% regular menstrual cycles – 93.71% irregular menstrual cycles – 6.29% pains prior menstruation –25.8% heavy periods – 12.58% scanty periods – 9.43%. Sexual function Fig. 10. First sexual intercourse (%) The majority of women have started the sexual life at the age of 19 and above. It should be noted that 10.8% of respondents had first intercourse at the age of 13–15. The survey data indicates the early sexual experience of women from big families. 10.75 57.8 31.38 13-15 age 16-18 age above the age of 19 14 Respondents had:
 multipara – 37.5%
 2–3 children – 35.4%
 1 child –27.1% Living conditions:
 67.7% have unsatisfied living conditions
 61.7% have had insufficient food in the family
 56.5% children have insufficient food
 36.6 have really unsatisfactory housing conditions
 25.0% do not have enough resources to buy medicine. Fig. 11. Living conditions (%) As the analysis shows (Fig. 12):
 many families with 6 to 10 members share one house – 45.2%
 with 4–5 members – 23.41%
 with 2–3 members – 21.5%
 with one member – 9.9%. Fig. 12. Family size (members per household) 61.3 67.74 61.29 56.47 38.7 32.36 38.71 43.53 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Socio-living conditions Material Famile nutrition Children's nutrition unsatisfied satisfied 45.2 23.4 21.5 9.9 0 10 20 30 40 50 6-10 4-5 2-3 1 15 In Khatlon oblast 69.7% live in bad sanitary-epidemiological conditions. Birth interval is:
 up to 1 year – 0.9%
 up to 1–1.5 year – 28.4%
 up to 2–2.5 years – 45.9%
 more than 3 years – 19.6%. Thus, the majority of women have very short birth interval. According to the respondents the birth interval became longer: 2–2.5 years or 45.9%, the percentage of more than 3 years has increased to 19.6%. Though the interval between childbirth is 1–1.5 year is 28.4%. Traditionally Tajikistan has large families. The response to the question “How many children would you like to have?” was the following:
 55.9% want to have 3–4 children
 18.8% want to have 1–2 children
 25.2% want to have 5–6 children. The high rate of multipara was the reason to study the awareness of the population on the contraceptive methods regulating childbirth. Some 21.9% of respondents were not able to name at least one birth regulating method which indicates to the low awareness. Fig. 13. Respondents approach to regulating birth (in %) Our respondents prefer the following methods of contraceptives: intrauterine spiral – 57.5%, surgical sterilization – 4.4%, hormonal pills – 8.1%, injections –12.7%, condom – 15.0% spermicide – 2.3%. It should be noted that 10.8% of women do not use contraceptive method on religious purposes and the number of women who consider contraceptives as not necessary is very high that also indicates to the low level of awareness of women on the affect of the multipara and often pregnancy on their health. 25.5 10.8 56.5 7.2 Do not need Do not use because of religious reasons Consider as necessary Never thought of it 16 Sources of information on contraceptives: 89.6% respondents received information on the methods of birth regulation from medical staff. The awareness of respondents regarding different contraceptive methods (see Fig. 14). The following data was obtained:
 interrupted sexual intercourse –18.2%
 intrauterine device – 33.27%
 hormonal pills – 18.2%
 condom – 15.6%
 hormonal injections – 14.4%
 calendar method – 6.3%
 surgical sterilization – 0.8%
 lactation amenorrhoea method – 11.2%. Fig. 14. Contraceptive use Various population strata has various information sources. Students receive less information on contraceptive methods from medical personnel but employees, housewives – 62.9% receive information mainly from medical personnel. It is necessary to pay attention to the right, correct advice and post-natal contraceptives during the first 48 hours after childbirth. Law of the Republic of Tajikistan allows surgical sterilization in accordance with the indicators and voluntary consent of spouses. Above 80 cases of surgical sterilization was carried out in clinics of the Tajik Scientific Research Institute of Obstetrics, Gynecology and Pediatrics in 1997–1998. It is a sensitive issue for Khatlon oblast, only 0.77% respondents prefer this method of contraceptives. As the findings of the survey shows interviewed women use the following contraceptive methods:
 57.5% – intrauterine device
 8.1% – hormonal pills
 12.7% – injections (Depo-Provera) 7.8 18.2 32.2 11.2 7.7 0.77 15.6 6.4 interruption of sexual intercourse hormonal pills intrauterine spiral did not use contraceptives hormonal injections surgical sterilization condom calendar method 17
 15.0% – condom
 2.3% – spermicides
 3.7% – interruption of sexual intercourse
 0.7% – injectable contraceptives. In spite of the measures taken to improve access to family planning services and provided services in the health centre that was supported by various international organizations the above- mentioned data reflects the need to expand access to various contraceptive methods. It is necessary to improve the information on family planning benefits by widely using mass media and teachers of secondary schools. Especially the investigation of Khatlon oblast women showed that their reproductive health needs to be improved. Investigation of women showed that every second woman had Trichomonas or chlamydia or gonorrhoea, there were syphilis cases (data is in the next chapter). In this context the information on safe sex should be undertaken in Khatlon oblast. Health status of respondents The response to the question “How you consider the state of your health?” was that 53% of respondents consider their health as satisfactory. At the same time we found out that these women had the following diseases in their childhood:
 influenza and angina – 26.2%
 measles – 22.58%
 gastrointestinal tract disorder –20.1%
 kidney diseases – 9.07%
 scarlet fever – 3.23%
 Hepatitis A – 3.23%
 other diseases – 18.8%. Analysis of diseases in the period of puberty indicated to the increase ratio of Botkin’s disease up to 6.45%, lung disorder – 6.72%, malaria – 2.63%. Analysis of diseases in the later stage of life shows the sharp increase of gynaecological diseases – 45.16%, kidney disorder – 15%, endocrinopathy – 5.6%, cardiovascular diseases – 4.8%. The investigation findings are: anaemia –76.7% which can be considered as a regional pathology.
 23.4% – body mass deficiency
 5.4% – cardiovascular diseases
 34.4 % – kidney disorder
 6.7% – respiratory track disorder
 23.4% – gastrointestinal tract disorder
 30.1% – genitals. The gynaecological investigation of women indicates to the presence of the following diseases:
 uterine myoma – 3.5%
 ovarian cyst –1.8%
 ovarian cystic disorder – 4.02%
 ovarian cystoma – 1.1%
 chronic inflammation of reproductive tract – 49.3% 18
 commissura diseases1 – 9.2%
 anomaly uterine development – 3.2%
 sterility – 7.18%
 uterine hypoplasia – 4.5%
 pathology of uterine cervix – 4.8%
 hirsutism including trichosis – 8.2%.
 Mastopathy was detected in 8.0% cases. Fig. 15. Structure of detected gynaecological diseases (%) It is necessary to note that only one woman indicated the presence of cancer in her history – she was operated for uterine cancer. There was only one case of mammary gland cancer detected. Additional investigation – ultrasound investigation confirmed the presence of pyelonephritis urolithic disease, development anomaly and kidney position. Taking into consideration the fact that toxaemia is the second widest spread disease in the structure of maternal mortality in Tajikistan, with the combination of toxaemia forms the diseases of kidney and anaemia develops. We found out that there is an interconnection between extra-genital diseases and birth interval. All women with extra-genital diseases were directed to the district doctor and registered in the district outpatient department. Identification and treatment of extra-genital diseases like anaemia, kidney and liver disorder requires close attention and successful treatment of patients with such diseases in combination with reasonable contraceptive use will promote the decrease of maternal mortality in Khatlon oblast. One of the serious concerns are genital diseases in Khatlon women. As Fig. 15 shows the inflammation of genitals is 49.3% and large percentage of colpitis – 25.17%. Thus many gynaecological diseases were identified by our specialists and confirmed by ultrasound investigation for the first time. High rate of maternal, perinatal mortality and diseases, high percentage of extra-genital diseases, bad living conditions, low culture and awareness on 1 Those which occur after inflammatory diseases. As a complication after pelvic inflammatory diseases-like skar, commissure which lead to pain and infertility. 49.3 4.5 7.2 4.5 3.5 3.5 1.8 1.1 7.2 9.2 0 10 20 30 40 50 inflammatory diseases NOMC sterility uterine hypoplasia adhesive diseases uterine myoma ovarian histosis anextumor other adhesive process 19 regulating childbirth of the population and insufficient contraceptive coverage makes it necessary to improve access to family planning and providing contraceptive services. Conclusions and recommendations 1. It should be noted that a large number of women respondents had sexual intercourse at an early age – teenagers (10.8%). Thus, there is a necessity to develop educational programme and measures for population and teenagers on reproductive health issues. 2. High rate of women with short birth interval urges to take measures on providing all women with qualified advice and provide them with the contraceptive methods they prefer including the post-natal and post abortion period. 3. It is necessary to expand provided contraceptive services, including surgical sterilization in the procedure as set up by the law of the country. 4. It is necessary to focus on access and quality of the educational programs and measures for the population. 5. High rate of extra-genital and genital diseases, low index of woman’s health especially in rural areas requires to design measures for improving teenagers’ health and health of women of reproductive age. 6. Issues of improving living conditions of women and children should be also taken into consideration. Survey on abortion prevalence and its consequences According to WHO data (A. Mark Belsey, 1987) between 40 to 60 million abortions were performed per year in the world. It is difficult to obtain assessment of the legal abortions and it is unreal to obtain back-street abortions. The assumption of the scope of artificial abortion in the world is from 24 to 32 per 100 pregnancy. According to WHO/EURO data from 1995, about nine million abortions are performed in the Region, most of these in NIS. Abortion in Tajikistan is the prevailing method of birth regulation in spite of the decreasing tendency. In conformity with the law women have a right of choice in family planning issues including abortion in case of medical indicators or social indicators. Though the total number of induced abortions has decreased for the previous years: from 32 582 in 1995 to 27 339 in 1997. At the same time number of mini-abortions have increased as Fig. 1. shows. Table 2. Number of abortions in the Republic of Tajikistan 1990–1998 (absolute number) 1990 1991 1992 1993 1994 1995 1996 1997 1998 Number of abortions 52658 52072 47040 40078 35709 32582 28505 27339 24514 Including mini abortions 2147 13353 14360 15315 13721 12819 10644 10325 9147 20 Abortion indicator per 1000 newborns is lower in comparison with Kazakhstan and Turkmenistan and higher than in Uzbekistan. But for the last years the number of artificial abortions have decreased from 150.6 in 1995 to 191.1 in 1997 and to 164.4 in 1998 per 1000 newborns. Table 3. Abortion indicator per 1000 newborns Country 1990 1991 1992 1993 1994 1995 1996 1997 Tajikistan 195.0 243.0 261.0 214.0 220.0 223.0 215.0 191.1 Uzbekistan 277.3 260.3 238.2 217.3 178.7 154.4 156.3 160.3 Kazakhstan 719.0 767.0 1038.0 923.0 853.0 269.0 459.0 439.0 Turkmenistan 284.0 280.0 282.0 251.0 258.0 272.0 256.0 266.0 Kyrgyzstan 277.0 260.3 238.2 217.3 178.7 154.4 231.0 220.0 Out of total number of abortions the specific weight of abortion in adolescent girls up to 19 years is about 1.43% and there is no decreasing tendency. In the structure of maternal mortality abortion occupies third place and there is no decreasing tendency. Fig. 16. Regional abortion frequency of the Republic of Tajikistan (1997) Fifth part of the total abortions per year is performed in Khatlon oblast (23.0%). 3723 abortions were performed in Khatlon oblast in 1996 and 3852 in 1997 or 91.2% and 86.1% per 1000 live births correspondingly. As the above-mentioned data shows abortion is the major method of birth regulation in Tajikistan. Many causes of this problem are not studied well so far. The above-mentioned facts reflect the abortion situation in the country, defines and justifies scientific-research work on this issue. The objective of this survey is to reveal the social aspect of the prevalence of abortion in the republic. 38% 23% 23% 11%5% Leninabad oblast Dushanbe Khatlon oblast RRS Gorno- Badkhshan oblast 21 Major tasks of the survey were: 1. to study medical-socio causes of the artificial abortion; 2. to identify major factors or risk group of reproductive health of women who have received abortion and their dependence on the contraceptive services quality for the population; 3. to identify needs of women for contraceptive services who have received abortion. The result of the survey will help to work out a comprehensive strategy to decrease the need for artificial abortion and prevent unsafe abortion through free access to the contraceptive services. Characteristics of investigated women With the help of specially designed questionnaire 1000 Tajik women that received abortion as a mean of birth regulation were interviewed. The survey was conducted in Khatlon oblast that reflects very low health index in the republic. The questionnaire consisted of 26 questions regarding age, social status, education, nationality, health state, desired number of children, first sex, causes for abortion, contraceptive awareness and approach to abortion. Respondents took active part in the survey and readily answered to all questions, they realized the importance of survey and their own contribution in the design of reproductive health strategy in Tajikistan. Social aspects of reproductive behaviour of women All strata of population from 15 to 49 years old were covered by the survey, 59.76% were of active reproductive age, 6.33% – younger than 20. Respondents were mainly married women (72%). 1.53% that received abortion was unmarried women. Fig. 17. Age of respondents that received abortion (%) It should be pointed out that the highest rate of abortion is among age group of 35–39. Thus as the survey findings show this age group is the “risk group” on abortion. 0,32 1,11 3,18 14,33 17 19,96 26,32 17,78 0 5 10 15 20 25 30 at the age of 15-16 at the age of 17-18 at the age of 19-20 at the age of 21-25 at the age of 26-29 at the age of 30-34 at the age of 35-39 at the age of 40-49 22 The majority of respondents were:
 Tajiks – 69.25%
 Uzbeks – 22.25%
 Russians – 8.5% Socio-demographic composition of women that received therapeutic abortion shows that the majority were employed in the industrial sector – 65.67%: employees – 35.3%, workers – 12.87%, farmers – 17.56%, housewives – 30.3% and students – 1.31%, disabled – 2.61%. There were no illiterate among respondents. As the survey shows 1/3 respondents (32.6%) had bad living conditions and very low income of the members of the family. Almost half of the participants (46.35%) with 6 to 10 members and only 8.29% families with up to five members shared one house. The survey shows that only half of the women (53%) who had abortion assess their health state as good but others suffer from extra-genital and gynaecological diseases. Fig. 18. Sickness rate of women that received abortion (%) The investigation of health shows the highest percentage of patients in those age groups that belong to risk group during pregnancy and delivery. 40% of young respondents at the age of 15– 16 have cardiovascular diseases. 50% respondents at the age of 19–20 have renal disorder, 43.08% at the age of 26–29, 36.02% at the age of 40–49. 20% of respondents suffer from gynaecological diseases at the age of 15–16, 50% at the age of 17–18 and also every fourth respondent at the age of 19–20, every fifth at the age of 26–29. 53 47 healthy sick 1 50 100 23 Fig. 19. Morbidity of women that received abortion (%) One third of women that wanted the interruption of unwanted pregnancy got married at the age of 17–18 (37.9%) and at the age of 19–20 (33.37%). As Fig. 20 shows, 4.31% got married at the age of 15–16. However, nearly 34% got married between the age of 19 to 20. Fig. 20. Marriage age (%) The questionnaire was designed to review the approach of women that had abortion to the number of children in the family. The survey revealed that for the last years the average number of children and also the approach to the big families in the family has changed in the rural areas. 7.26 10.89 6.2 15.73 17.55 23.29 22.12 24.82 cardiovascular system liver disorder gastrointest inal disorder sexually transmitted diseases gynecological disorder 30-34 35-39 40-49 4.31 20.61 33.37 22.25 3.16 16.3 0 5 10 15 20 25 30 35 40 at the age of 15-16 at the age of 17-18 at the age of 19-20 at the age of 21-26 at the age of 27-32 no family 24 Fig. 21. Number of children in the family The following approach to the number of children in the family was among multipara women:
 52.8% wanted to have not more than 3–4 children (35.97%);
 46.1% wanted to have not more than 2 children;
 only 1.1% wanted to have more than 6 children. Those women that had abortion in their past medical history had very short intergenetic period (less than 2 years) – 35.4% and the majority of them (64.65%) had more than 2.5 years of intergenetic period between childbirth. It is the evidence of using abortion as the only birth regulation method by many rural women. Thus, the major factors having impact on the reproductive behaviour of women that received abortion are low socioeconomic level of population, early marriage and large families. Approach to abortion The focus of our survey was to study the approach of rural women to abortion that receive abortion as a method of birth regulation and have still no access to contraceptive services. The answer to the question whether woman has the right to interrupt pregnancy (to receive abortion) was:
 76.9% – positive
 10.0% – consider abortion a sin
 6.2% – has no right
 6.8% – did not answer. 30.3 44.71 10.53 2.39 1.2 17.67 55.5 26.82 5.89 4.91 0 10 20 30 40 50 60 1-2 children 3-4 children 5-6 children more than 6 children no children actually wanted 25 Fig. 22. Survey of woman’s right regarding abortion As the survey findings show not all women were willing to go to the medical facilities to get advice regarding such services. Fig. 23. Number of abortions history (%) As the findings of the survey show 68.4% respondents of active reproductive age had abortion, 19% – had one abortion, 22% – had two abortions, 28% – had three abortions, 31% – had four to five abortions. 89,31 0,65 7,63 1,2 1,2 0 20 40 60 80 100 yes no tradition did not think no no answer 6.8% 6.2% 10% 77% no answer have no right a sin yes 26 Fig. 24. Percentage of women with one or more abortions among all women who reported abortions As the data confirms the majority of young women at the age of 25 to 30 (41.6%) received abortion. More than four abortions were in the history of:
 55.6% – farmers
 27.1% – workers
 36.42% – employees
 37.41% – housewives. The marital status of women had an effect on the frequency and quantity of abortion: for married women the interruption of pregnancy through abortion 1.5 times higher than the childbirth. The survey shows the causes for pregnancy interruption. Summary of data on the causes of abortion as means of birth regulation given in the Figure below: Abortion causes were united into three groups: I group – depends on woman; II group – does not depend on woman; III group – depends on socioeconomic problems. Table 4. Causes for receiving abortion A group of reasons depending on woman: a) the desired number of children 34.3% b) negative approach to contraceptives 1.2% A group of reasons not depending on woman: a) no access to contraceptives 3.1% b) no contraceptive information 5.2% A group of reasons depending on socioeconomic issues a) difficult socioeconomic conditions 56.2% Thus the major reasons for pregnancy interruption were:
 the desired number of children (34.3%)
 difficult financial and living conditions (56.2%). 30.86 42.46 9.716.98 1 2 3 4 and more 27 The following issues depended on the woman: desire of a woman to limit number of children, husband’s absence, difficulties in combining study and work and upbringing of children, desire to make a career, bad relationship in the family. Socioeconomic conditions related to bad housing conditions, low salary, and shortage of free of charge children facilities. Analysis of the termination of pregnancy shows that many women received abortion in accordance with their own will (71.97%) and only 10.58% in accordance with the will of husband. As the survey indicates half of the respondents – housewives desired to terminate pregnancy (49.6%) and only in 17.88% it was the desire of husband. Husband’s will was prevailing among workers (57.21%) and farmers (55.49%). The obtained data indicate to involvement of men in reproductive health and also the level of women employment in the society. As the results of the questionnaire show, women are free to make decision regarding maternity – 23.9% decided to stop giving birth to a child but did not know how to prevent unwanted pregnancy. It should be noted that the same reasons brought to the interruption of pregnancy – 100% disabled women and 62.5% students. Thus, it is the targeted group of the population, which needs the access to the contraceptive services. As the figure shows 5.2% women of reproductive age still use abortion as a mean of birth regulation because of the lack of information on modern contraceptive methods and negative approach to contraceptives. Thus, it is impossible to refer only to one major cause of abortion because many women indicated two-three reasons. Reasons for abortion are very serious and need drastic and urgent measures in order to prevent unwanted pregnancy not only of sick but also of healthy women. In accordance with the results of the survey to the risk group of unwanted pregnancy belong students, unemployed and single women. Abortion complications In Tajikistan therapeutic abortion (planned and emergency) is performed in gynaecological department and mini-abortions in rooms and centres of reproductive health. As the survey indicates more than half respondents received therapeutic abortion in:
 hospitals – 52.3%
 ambulatory – 44.8%
 unsafe conditions – 2.9%. Among respondents who received abortion – 25.31% of women had post abortion complications in their history. 26.1% women had post abortion complications. According to the figure the most frequent cases are the presidual ovum – 10.51% and also the perforation of uterine indicates to low quality of abortion. Accurate statistical data on sterility are not available in Tajikistan. Survey result indicates to the abortion complications that caused sterility in 3.7% cases. There are no statistical data on sterility in Tajikistan. The major causes of woman’s sterility as was mentioned by respondents are: oviducal, hormonal disorder, endometriosis, etc. 28 Fig. 25. Post-abortion complications (%) Awareness of contraceptive methods As far as abortion is becoming a common practice the issue of awareness of women on avoiding unwanted pregnancy becomes crucial and we focus our research on this issue. According to the sociological survey only 75.4% women have heard about this or that contraceptive method. The Figure below shows the awareness of contraceptive methods of those respondents that received abortion (several answers were expected). The question was not answered by single and unmarried women. Fig. 26. Respondents’ awareness of contraceptive methods (%) Lack of information was observed among those who had sexual intercourse and were not married (18%). The obtained information reflects the low level of awareness of women on comprehensive contraceptive methods in rural areas that received abortion: the majority of them are aware of intrauterine spiral, more than 1/3 women of interrupted sexual intercourse and very small group of other methods of contraception of pregnancy. Thus the following women are informed on: 11.15 10.51 9.55 3.66 0.77 74.69 0 2 4 6 8 10 12 14 infection presidual ovum recuretagge sterility operative interference was not 4.59 15.96 18.75 14.76 30.12 8.720.7 6.4 interrupted sexual intercourse condom hormonal pills hormonal injections intrauterine spiral calendar method surgical sterilization no information 29
 intrauterine spiral – 30.1%
 condom – 16.0%
 oral contraceptives – 18.8%
 injections – 15.0%
 calendar method – 8.7%
 interrupted sexual intercourse – 4.6%
 surgical sterilization – 0.7%
 several methods – 6.1%. Fig. 27. Source of information on contraceptive methods (%) 49.9 28.1 16.9 3.3 1.8 0 5 10 15 20 25 30 35 40 45 50 from medical staff from acquaintances from books from partner from relatives Data on the source of information on contraceptive issues is of interest. Marital status and place of residence of respondents did not affect the source of information. As the figure shows 49.9% respondents receive information on contraceptive methods from medical staff and only 16.9% from mass media. According to our materials there is a significant difference in awareness of contraceptive use. Fig. 28. Use of contraceptive methods (%) 7.130.088.474.95 9.65 8.89 6.9 53.93 do not use irrigation injections calendar method condom oral contraceptives intrauterine spiral interrupted sexual intercourse In spite of the fact that the majority of respondents were aware of the intrau terine device only 56% used it but interrupted sexual intercourse prevailed over other methods – 69%. 30 From 43.08% of women who received abortions and mini abortions used post abortion contraceptives and only 26% was provided with this service right after abortion. Every third woman (30.86%) decided to avoid pregnancy. Analysis of the causes of the refusal to use contraceptive right after abortion gave the following picture: Fig. 29. Cause for absence of contraceptive immediately after abortion (%) 75.35 12.98 8.51 3.16 0 10 20 30 40 50 60 70 80 did not offer expensive negative approach did not respond Material analysis shows the lack of basic knowledge of the population on family planning and avoidance of unwanted pregnancy, lack of qualified doctor’s advice on the individual choice of contraceptives that caused negative approach of women to the modern effective methods of contraceptives and to the prevalence of conservative method of the interruption of the unwanted pregnancy. Lack of information dissemination on contraceptive methods and vesting the problems of abortion prophylaxis with women caused the passiveness of men in this issue (contraceptive issue is discussed only in 3.27% cases). Nevertheless, the research reflects the changing approach and abortion is replaced by contraceptives. The obtained data indicate that further contraceptive coverage will promote the reduction of abortion, especially among women belonging to the category with unsatisfied needs in family planning. Besides, access to the different contraceptive methods will promote the reduction of women with unsatisfied needs in family planning and “contraceptive failures”. Fig. 30. Usage tendency of contraceptives and abortion of reproductive age women in Khatlon oblast 33.319.615.711.39.2 214 220 223 215 191.1 0 50 100 150 200 250 19971996199519941993 Use of Contraceptives Use of Abortion 31 The survey will result in the design of comprehensive strategy for the reduction of needs in artificial abortion and preventing unsafe abortion through providing contraceptive services. Replacement of abortion by contraceptives must be a real factor for women of Tajikistan. Decrease of abortions will result in the decrease of maternal mortality indicators in Tajikistan. Methods used in the survey:
 sociological
 general laboratory analyses
 special. Conclusion 1. As the survey findings show the large number of abortions were made on women at the age of 35–39. 2. One of the major reasons for pregnancy interruption were that the family had already the desired number of children and bad financial and living conditions. 3. The obtained information reflects the low level of awareness of women on comprehensive contraceptive methods. It should be noted that there is totally low awareness on surgical sterility. 4. Post abortion complications like presidual ovum indicates to low quality of medical personnel providing such services. 5. Lack of providing post abortion contraceptive services should be taken into consideration. 6. The approach of rural women to the number of children in the family has changed. 52.8% respondents want to have not more than 3–4 children. Recommendations The post abortion period gives a unique opportunity to the medical staff to help women to solve the problem of unwanted pregnancy and abortion. A fertility return rapidly after abortion and it is very important to make right choice of contraceptive method to avoid pregnancy. To avoid another pregnancy and possibly another abortion, all women who receive abortion care should also be given counselling and information so that they understand:
 the consequences and complications of unsafe abortion for health;
 the risk of becoming pregnant again;
 what are the safe methods to prevent or delay pregnancy;
 where and how they can obtain family planning services. Tasks
 provide the majority of women with access to appropriate treatment of post abortion complications;
 to provide the majority of women with access to the information services on avoiding unwanted pregnancy; 32
 to provide the majority of women with access to measures of avoiding unsafe abortion;
 to provide the majority of women with access to the information services on post abortion contraceptives that receive post abortion complication treatment;
 to increase awareness of male population on birth regulation methods. Sexually transmitted diseases The Republic of Tajikistan is in transition to the market economy that worsened the reproductive health problems. Socioeconomic crisis caused the increase of sexually transmitted diseases. On the other side there is a lack of reagents, diagnostic and laboratory equipment and trained staff for the qualified diagnostics of STD. There are cases of self-treatment and treatment by unqualified specialists sometimes without medical education that provides recurrence of the disease and danger of infecting others. Major goal of the research was to study medical-social factors of sexually transmitted diseases and to develop further strategy of their prevention. There were the following tasks: (i) identify population awareness of sexually transmitted diseases; (ii) identify “high risk” groups; (iii) identify frequency and the most wide-spread clinical forms of sexually transmitted diseases; (iv) identify population approach to individual protection means against sexually transmitted diseases; (v) develop prophylaxis strategy of sexually transmitted diseases and their complications. Current situation of sexually transmitted diseases in central Asian republics. Fig. 31. Syphilis morbidity (per 100 000 population) in central Asian republics 1990–1996 0 50 100 150 200 250 1996 1995 1994 1993 1992 1991 1990 Uzbekistan Turmenistan Tajikistan Kirgizistan Kazakhstan 33 Country 1990 1991 1992 1993 1994 1995 1996 Kazakhstan 1.45 2.1 3.49 8.14 32.6 122.9 231.2 Kyrgyzstan 1.97 2.04 2.76 4.36 22.4 73.1 152.3 Tajikistan 1.66 1.64 2.9 5.85 8.34 19.16 19.0 Turkmenistan 4.62 5.2 6.2 8.3 15 32.3 38.0 Uzbekistan 1.78 1.9 2.3 4.4 11.4 25.4 39.5 Actually in all central Asian republics there is a morbidity growth of gonococci infection. As Fig. 32 shows morbidity growth of gonococci infection is rather high in Kazakhstan and low in Tajikistan and the assumption is that not all cases were registered and reported. Fig. 32. Gonococci infection morbidity (per 100 000 population) in central Asian republics 1990–1995 0 20 40 60 80 100 120 140 1990 1991 1992 1993 1994 1995 Uzbekistan Turmenistan Tajikistan Kirgizistan Kazakhstan Country 1990 1991 1992 1993 1994 1995 Kazakhstan 105.21 113.5 126.59 137.85 110.53 125.9 Kyrgyzstan 54.03 55.56 70.98 50.27 57.8 56.3 Tajikistan 20.3 19.58 20.7 25.56 22.45 19.48 Turkmenistan 30.65 31.3 23.5 27.3 30.5 29.2 Uzbekistan 21.39 19.2 17.7 20.9 22.4 26.4 For the last 10 years, Dushanbe Dermatovenereologic Dispensary registered 195 children and teenagers and out of them 34 had gonorrhoea, children up to 14 years old (17.4%) that makes 1.4% out of the total number of gonorrhoea patients. The general concern is the growing morbidity of newborn. The number of children and teenagers are increasing and they were infected with gonorrhoea economica. There is a decreasing tendency of hepatitis B in all central Asian republics though morbidity hepatitis B is higher in Uzbekistan (Fig. 33). 34 Fig. 33. Morbidity hepatitis B (per 100 000 population) in central Asian republics 1990–1995 0 25 50 75 100 125 150 1990 1991 1992 1993 1994 1995 Kazakhstan Kirgizistan Tajikistan Turmenistan Uzbekistan Country 1990 1991 1992 1993 1994 1995 Kazakhstan 31.7 31.3 25.1 23.6 26.8 28.8 Kyrgyzstan 40.5 36.7 32.8 32.3 31.2 28.9 Tajikistan 68.7 75.5 20.7 33.0 20.8 17.1 Turkmenistan 30.65 31.3 39.7 35.5 24.2 22.0 Uzbekistan 21.39 147.8 133.2 109.3 83.8 94.0 Situation in the republic of Tajikistan There is an increasing tendency of sexually transmitted diseases in the Republic of Tajikistan. Statistical analysis in regions shows that morbidity of sexually transmitted diseases is rather high in Dushanbe, Leninabad and Khatlon oblasts (Table 5). Table 5. Sexually transmitted disease morbidity indicator (per 100 000 population 1995–1996) Region Gonorrhoea Trichomonas Syphilis 1995 1996 1997 1995 1996 1997 1995 1996 1997 Dushanbe 54.7 31.9 30.4 33.2 5.6 6.0 87.2 72.9 71.2 Leninabad oblast 25.5 19.9 19.2 17.3 13.7 17.5 17.8 21.6 26.0 Khatlon oblast 11.3 6.3 5.7 14.6 7.1 9.0 9.3 10.5 12.8 RRS 7.4 7.5 6.4 26.3 20.6 22.7 10.0 9.5 12.1 Gorno-Badakhshan 2.0 2.0 5.1 – – – 4.0 7.3 6.3 Republic 19.1 9.8 12.1 28.4 12.0 12.0 19.6 19.0 22.6 *Data of State Statistics Agency of the Republic of Tajikistan. Statistical data shows that there is an increasing tendency of sexually transmitted diseases thus syphilis indicator in 1997 increased for 13 times compared to 1990 and made 22.6 per 100 000 population. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates 25 people 35 are infected with AIDS though Ministry of Health estimates 4 people are infected with HIV. In 1991, Republican Centre for Prophylaxis and Combat AIDS was established. The mentioned figures do not reflect the actual morbidity rate of the sexually transmitted diseases: there is incomplete diagnostics and registration of all sexually transmitted diseases in the Republic at the same time it is known that this group of diseases include more than 20 diseases including hepatitis B and HIV/AIDS. It should be noted that 60–80% women gonorrhoea patients and 65% women – chlamydia patients do not have symptoms of disease because the diagnostics is not available. No investigation is carried out for a number of diseases of sexually transmitted diseases (chlamydia, herpes, bacterial vaginitis and others) in the Republic. A serious sexually transmitted diseases outbreak has a grave effect on the sexual and reproductive health of population in general, particularly for teenagers and youth. With the aim to identify prevalence of sexually transmitted diseases we used questionnaire in Khatlon oblast: Kurgan-Tube, Kulob, Vose, Bokhtar rayon. Sexual behaviour and relations Questionnaire findings indicate early sexual life. The overall respondents – 72% had first sexual intercourse at the age of up to 20, including ages 13–15 1.25% (Fig. 34). Fig. 34. Beginning of sexual life (%) 1.25 3.37 30.09 36.08 21.22 7.74 0.25 0 5 10 15 20 25 30 35 40 13-14 15-16 17-18 19-20 21-24 25-29 30 and above Some 3% of respondents had sexual intercourse before marriage. Taking into consideration the national culture and tradition and in spite of the fact that questionnaire was confidential some respondents concealed such fact. In accordance with the Tajik Scientific and Research Institute of Obstetrics, Gynaecology and Paediatrics data, the number of precocious pregnancy is increasing and the age of the unigravidas is 15–16 that makes 4.4% (1997). Awareness of sexually transmitted diseases In accordance with the survey findings the awareness of the probability of being infected with sexually transmitted diseases and preventive measures of the risk group and population are not sufficient. There is significant lack of awareness of sexually transmitted diseases. For example, the response to the question “Do you have any idea regarding sexually transmitted diseases?” was 36 negative – 71% and positive – 28% and it appeared that housewives and farmers were less aware that reflects the lack of access to family planning services of this category of women (Fig. 35). Fig. 35. Are you aware of sexually transmitted diseases? (%) 43.79 29.17 35.67 12.99 47.34 50 53.8 59.86 8.88 20.83 10.53 27.15 0 10 20 30 40 50 60 Em ployees Farm ers Students H ousew ives have no idea heard but do not know exactly fully aware It is the evidence of the lack of awareness of all population strata on the probability of being infected with sexually transmitted diseases and the preventive measures. Fig. 36. Awareness of different age groups of sexually transmitted diseases 0 10 20 30 40 50 60 70 80 17-18 19-20 21-25 26-29 30-34 35-39 40-49 have no idea heard but do not know exactly fully aware Age structure analysis indicates that respondents at the age of 17–18 are less aware. Only 6.2% at the age of 17–18 are completely aware of sexually transmitted diseases and others 68.7% heard but do not have enough information regarding sexually transmitted diseases or do not have reliable information. The same situation with the age group of 19–20, i.e. mainly sexually active group of population – teenagers, youth that belong to the “high risk” group. 37 In accordance with the interview results women at the age of 26–29 and out of them 37.4% are fully aware of STD (Fig. 36). This means that only 1/3 of interviewed women at the age of 21–29 of Khatlon oblast are aware of sexually transmitted diseases. Awareness of contraceptive methods Respondents are aware of contraceptive methods like the intrauterine device – 26.6%, hormonal methods – 16.87% and condom – 12.2%. 3.1% women are not aware of contraceptive methods (Fig. 37). Fig. 37. What contraceptive methods do you know? 5.34 13.51 16.8715.74 26.61 6.48 12.26 3.18 interrupted sexual intercourse condom hormonal pills hormonal injections intrauterine spiral calendar method abortion do not know Preference of various contraceptive methods More than 50% of respondents prefer the intrauterine device as a contraceptive method – 50.7; 16.8% – hormonal method; 10.4% – condom (Fig. 38). Fig. 38. What contraceptive methods do you prefer? 4.6 10.417.69 9.29 50.75 2.53 10.88 3.85 interrupted sexual intercourse condom hormonal pills hormonal injections intrauterine spiral calendar method abortion do not know 38 Low preference to condom and the high rate of morbidity of STD in Khatlon oblast is the result of low awareness of population on STD and preventive methods. Knowing the probability of being infected with sexually transmitted diseases the response to the question “What is your approach to preventive methods against sexually transmitted diseases?” was: 25.4% students – negative, 28.8% farmers and 20.1% housewives – do you not know any preventive methods against STD (Fig. 39). Fig. 39. What is your approach to preventive methods against sexually transmitted diseases? (%) 78.5 65.49 72.13 62.63 8.1 5.63 25.41 17.27 13.4 28.87 2.46 20.1 0 10 20 30 40 50 60 70 80 Em ployees Farm ers Students H ousew ives do not know negative positive It is the evidence of low awareness of all categories of respondents covered by the survey regarding preventive methods against sexually transmitted diseases. A major work on awareness of population should be done through involvement of mahalla (district) and women councils, activists, and mass media: radio, TV, booklets, newspapers, etc. Family couples should be more involved in this process as far as the national tradition envisages that women are responsible for contraceptives. 38.0% respondents do not know about their sexual partners’ approach to the preventive measures against sexually transmitted diseases and 6.7% assess their sexual partners approach to the preventive measures against sexually transmitted diseases as negative, and as positive 55.1%, at the same time 63.0% respondents consider a permanent sexual partner as means of preventive measures against sexually transmitted diseases and only 26.0% want to use condom. Screening for sexually transmitted diseases The conducted screening for sexually transmitted diseases consisted of several questions including “Had you any sexual disorders for the last year?” 30.0% – every third in the age group of 17–20 had skin diseases of genitals; from 85.7% to 90.5% respondents had genital discharge (Fig. 40). 39 Fig. 40. Clinical symptoms of STD (%) 3.85 5.88 3.03 3.53 4.94 14.81 14.29 5.77 10.1 7.58 5.88 4.94 7.41 1.75 90.38 82.35 89.39 90.59 90.12 77.78 85.71 0 10 20 30 40 50 60 70 80 90 100 40-49 35-39 30-34 26-29 21-25 19-20 17-18 skin diseases of genitals ulcer genital discharge Overall result of screening shows the lack of awareness of respondents regarding sexually transmitted diseases. Even with the clear symptoms of the disease: genital discharge – 86.5% women, skin diseases of genitals, ulcer – 6.7%, 74.3% – women gave a negative respond to the question “Are you suspicious of having sexually transmitted diseases?”, difficult to answer – 16.8% and positive only –8.9%. Housewives were more suspicious – 51.1% and students – 39.4% (Fig. 41). Fig. 41. Screening of sexually transmitted diseases (%) 7.9 10.6 14.7 8.9 23.1 13.6 16.8 68.9 89.3 55.3 74.3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Has your partner ever been treated for genital disorders? Did you have more than one partner for the last 2 months? Does your sexual partner have other sexual partners? Are you suspicious of having sexually transmitted disease? yes do not know not 40 Investigation of sexually transmitted disease patients Analysis conducted on the basis of gynaecological cards of patients revealed the prevalence of sexually transmitted diseases in Khatlon oblast. 146 (36.5%) women out of 400 investigated women, i.e. every third investigated woman was infected with sexually transmitted disease. The structure of STDs is shown in Fig. 42. Fig. 42. Structure of sexually transmitted diseases (%) 14.9 25.3 5.2 17.9 5.6 6.2 8.5 16.4 chlamys trichomanis gonococci candida syphilis hepatitis B hepatitis C not detected There is a following morbidity structure of STD:
 trichomoniasis – 25.3%
 candida –17.3%
 chlamydia – 14. 9%
 gonorrhoea – 5.2%
 hepatitis B – 6.2%
 hepatitis C – 8.5%
 syphilis – 5.6%
 other – 16.4. The above-mentioned findings reflect the prevalence of sexually transmitted diseases among population of the oblast that had seriously suffered from the civil war and now experiencing the hard socioeconomic crisis. At the same time it indicates to low level of reproductive health and reproductive culture of the population especially regarding awareness of sexually transmitted diseases. Clinical forms of STD The situation is also bad with the clinic forms of sexually transmitted diseases. Every second woman (41.0%) had colpitis, every sixth woman (15.0%) had endometritis, every sixth woman (14. 9%) had cervical erosion, every 20th woman (5.24%) had endocervicitis and every 14th woman (7.2%) had infection spread beyond the vaginal orifice. 41 There are 11.3% cases of mixed infection including:
 4.1% of mixed chlamys- trichomonas infection
 0.5% of combined infection of chlamys-trichomonas – syphilis
 5.1% of combination of trichomoniasis+candidiasis
 1.5% of the combination of trichomoniasis+syphilis. Two hundred people were investigated for HIV/AIDS. Four cases of HIV infection were registered in the republic (two cases in 1991, one in 1997 and another in 1998) but the lack of awareness and avoiding visits to doctors can not reflect the actual situation. Approximately estimation is 50 cases of HIV (data of Republican Centre of Combat against AIDS). Official statistical data do not reflect real situation in the country, though the worsening socioeconomic situation, growth of migration process, development of prostitution and drug addiction promotes the development of HIV infection thus creating a group of high risk: youth from unregulated families, prisoners, drug addicts, beggars etc that can easily be infected with sexually transmitted diseases including HIV/AIDS. The age structure of respondents shows that diseases develop in reproductive age but more often at the age of 21–39 when reproductive activity is high (Fig. 43). Fig. 43. Age structure of patients with sexually transmitted diseases (%) 0.63 4.4 15.09 12.58 24.53 25.79 16.98 at the age of 17-18 at the age of 19-20 at the age of 21-25 at the age of 26-29 at the age of 30-34 at the age of 35-39 at the age of 40-49 77.3% of patients have secondary education. Sexually transmitted diseases morbidity is low among those with higher education – 1.89%, 16.35% – with special secondary education and 4.4% with incomplete secondary education. More than 51.57% patients with sexually transmitted diseases are workers. 31.45% housewives and 13.21% employees, 3.14% farmers suffer from sexually transmitted diseases (Fig. 44). 42 Fig. 44. Social status of patients with sexually transmitted diseases (%) 51.57 3.14 13.21 31.45 workers farmers employees housewives The highest rate of patients infected with sexually transmitted diseases – 89.9% are married, i.e. there is high risk of the probability of infecting not only sexual partner but also the members of the family. 10.06% patients are not married. Findings of the surveyed couples are the following: 48.43% husbands smoke, 19.55% drink much alcohol, 1.89% husbands are drug addicts (in this case we do not know a real picture because drug addiction is highly developed in the Republic). Some 64.15% patients have bad living conditions, 68.5% of patients have insufficient financial condition and 53.4% have insufficient food (Fig. 45). Fig. 45. Living and financial conditions of patients with sexually transmitted diseases (%) 64.15 68.55 53.46 50.14 35.85 31.45 46.54 49.86 0% 20% 40% 60% 80% 100% living conditions financial family food children nutrition unsatisfied satisfied Low health index was identified in oblast. 76.7% patients with sexually transmitted diseases had anaemia. 35.0% of patients with sexually transmitted diseases had other extragenital pathology. Menstrual functions: 76.7% of menarche was identified at the age of 11–13, 93.7% menstrual cycle became regular, 3.77% menstrual cycle became regular after 1–6 months, 93.7% regular 43 menstrual cycle, 6.3% irregular. Duration of menstrual period up to 3 days –36.48%, up to 5 days – 43.4% and more than 5 days – 20.13%. 42.0% of patients had early sexual life including 20.7% at the age of 13–15, 21.3% at the age of 16–18. 23.9% patients have 1–2 children, 27.6% 3–5 children, 15.0% from 6 to 10 children that promotes the prevalence of some forms of STD infected through contacts. Analysis of contraceptive methods that were preferred by the majority of patients with sexually transmitted diseases indicates that 62% patients did not use any contraceptive method, 32.0% prefer intrauterine spiral. It is the evidence of the lack of awareness of the population and the need to conduct qualified consultations, advice while providing contraceptive services and the urgent need to provide double preventive measures – from unwanted pregnancy and being infected with sexually transmitted diseases. Fig. 46. Contraceptive methods preferred by patients with STD 0% 32% 5% 62% 1% 0%0% interrupted sexual intercourse hormonal pills intrauterine spiral condom calendar method injections do not use contraceptives 15.7% patients with sexually transmitted disease had no symptoms of STD. The most frequent complaints were pains 27.6%, genital discharge – 26.4%. There is a high rate of sterility – 23.2%. Analysis of flora smear identified 17.24% – I degree of the vaginal sterility, 22.07% – II degree of the vaginal sterility. The high rate of trichomonas –25.3%, Candida fungus – 17.93%, chlamydia – 14.9%, gonorrhoea – 5.2% is the major concern (Fig. 47). 60.8% – had III–IV degree of the vaginal sterility. 44 Fig. 47. Microflora characteristics of patients with STD (%) 18 14.9 25.3 5.2 17.9 bacterium chlamys trichomonas gonococci Candida. Identified clinical forms of genital diseases of patients with sexually transmitted disease. Patients with sexually transmitted disease had more often colpitis – 41.0%, metroendometritis – 15.0%, cervical erosion – 14.9%, adnexitis – 7.2%, endocervicitis – 5.24%. Serologic study of blood of 200 patients identified hepatitis B – 6.2%, hepatitis C – 8.5%, syphilis – 5.2%, HIV/AIDS – 0.00%. Survey findings indicate to the prevalence of sexually transmitted diseases in Khatlon oblast. In the Republic of Tajikistan, in comparison to 1990, the syphilis morbidity increased more than 13 times; the most frequent are trichomonas, syphilis, chlamys. The causes are the sharp socioeconomic changes and their impact on the sexual behaviour, access and efficiency of medical help especially in rural areas as 70% of population live in rural areas. The inopportune and inadequate treatment causes the chronic diseases and results in contact bleeding, sterility, pelvic pain, extrauterine pregnancy, tumour diseases of the uterine cervix and adnexa and as the result of it even young women become disabled. The major findings of the survey are the lack of awareness of the population on the sexually transmitted disease prevention. The natural component of the reproductive health program is justification and organization of activities on measures of the sexually transmitted diseases prophylaxis, practical hygiene education of the population, correct diagnosis and treatment of these diseases. Taking into consideration the conditions in our country, the reproductive health programme is one of the important sources of control over sexually transmitted diseases as women can not visit dermatovenereologic dispensary because of the tradition, but they do usually visit the obstetrician of the maternity house or district obstetrician gynaecologist. Prevention and control of sexually transmitted diseases are the major factor for improving reproductive health of the population. 45 Summary 1. The findings of the survey revealed the prevalence of STD in Women of Khatlon oblast. 2. Low awareness of STD should be noted – 72.0% respondents have no idea of STD. 15–19 years old respondents had low awareness of STD but at the same time according to our data the number of early marriages in this group is high – 70.9%. 3. 28.8% respondents do not use preventive measures and means against STD. 4. High rate of morbidity is in the age group of 21–39 – active reproductive age. 5. The large number of patients are with primary and secondary education – 77.3%. Recommendations 1. To recognize STD as the general public health problem that affects the entire population and requires comprehensive support. 2. To recognize the necessity of intersectoral approach to the combat STDs. 3. To design and implement standardized methods of diagnostics and treatment of STD. 4. To establish WHO syndromic approaches in the medical facilities without having to resort to hospital services for STDS. 5. To take measures on the reduction of men and women migration by improving living standard. 6. To take measures on decreasing the rate of sexually transmitted diseases morbidity by providing services improve and strengthen the awareness of population on sexually transmitted diseases and propaganda of safe sex behaviour. Measures should include services for the risk groups, awareness of population and information on safe sex. 7. To develop the necessary opportunities, skills and knowledge. It requires technical assistance on local or international level.