Prevalence Of Pelvic Inflammatory Disease Among Women Of Child Bearing Age In Magajin Gari Birnin-gwari Local Government Kaduna State

INTRODUCTION

1.1 Background of the Study

Pelvic inflammatory disease is one of the common causes of morbidity in women of child bearing age group. The incidence is more in adolescent and young females because of sexually active lifestyle, risk taking behavior, biologic vulnerability and their behavioral and cognitive risk factors. Acute PID usually present with abdominal pain, backache and vaginal discharges. Early diagnosis and proper antibiotics treatment is essential to prevent complications such as pelvic abscess formation, peritonitis, adhesion formation and infertility. (Chetana, Gopchade, 2018).

Pelvic inflammatory disease (PID) is the inflammation of the adnexa of the uterus, that mainly manifests in a subclinical/chronic context and goes largely underreported. However, it poses a major threat to women’s health, as it is responsible for infertility and ectopic pregnancies, as well as chronic pelvic pain. Previous studies in Jordan have not reported PID, attributed mainly to the social structure of the country which largely represents a sexually conservative population (Al kuran et al., 2021).

 Pelvic inflammatory disease (PID) is an infectious polymicrobial disorder of the upper genital tract that affects around 4-12% of young women worldwide (R. F. Savaris, D. G. Fuhrich, et al., 2017). This clinical entity can be attributed to a variety of bacteria. Chlamydia Trachomatis (C Trachomatis) and Neisseria gonorrhea (N Gonorrhea) are identified in one-half to one-third of cases. Other bacteria such as Mycoplasma genitalium, Urea-plasma species, and fastidious bacterial vaginosis- (BV-) associated bacteria (Sneathia (Leptotrichia) sanguinegens, Sneathiaamnionii, and Atopobiumvaginae) and BV-associated bacteria (BVAB1) are emerging as underdiagnosed etiologic agents (C. L. Haggerty, P. A. Totten, et al., 2016). Due to its microbiological heterogeneity, one of the main concerns regarding PID is providing an effective treatment. Additionally, the growing multidrug resistance of gonococci and the absence of an antibiotic regimen that proves to be optimal in terms of safety and effectiveness are a challenge for almost every healthcare system (Savari, et al, 2017).

In USA, present data suggest that N. gonorrhoeae, C. trachomatis and/or M. genitalium are present in about 30% of PID cases (Kreisel K., 2014) and Bacterial Vaginosis-associated or urogenital pathobiontic bacteria (S. agalactiae, Staphylococcus aureus and Enterobacteriaceae) is in about 70% of cases (Sharma et al., 2014). 

The incidence of PID is correlated strongly with the prevalence of sexually transmitted diseases; a fraction of the infections might be of endogenous origin. The use of intrauterine contraceptive devices and abortions procedures, even legal ones, contribute to the higher occurrence risk. Bethan et al, (2014) in a study in Canada concluded that there is evidence of heterogeneity in the risk of PID after chlamydia in this large population-based cohort. 

Young women and those with repeated infections have the highest risk and may benefit from more intensive health promotion interventions. Furthermore, describing progression to PID as an average rate, as seen in the majority of published mathematical models of chlamydia, may be an inappropriate oversimplification. Sensitivity analyses should be used to explore the impact of individual based risks on the predicted impact of screening strategies. (R. F. Savaris, D. G. Fuhrich, et al., 2017).

Jordan is an Islamic conservative country and sexuality is not encouraged outside wedlock. Therefore, it is not surprising that chlamydial infection is exceptionally low in Jordan, reaching 4.6% among symptomatic patients with urethritis, of both sexes. An even older thesis estimated the C. trachomatis infection to 5.7% in men and 3.3% in women. This is markedly lower than Western more liberal societies, where the chlamydial infection can reach as high as 39.3% in adolescent men and 11.1% in women in USA. A report of the staggering 19.5% prevalence of PID in a cohort of adolescent females presenting to an urban emergency with abdominal or genitourinary complaints, shows the impact on western youth (CDC. Chlamydia—2017 sexually transmitted diseases surveillance. 2017).

The risk factors for PID include multiple sexual partners, sexually transmitted disease in past, Aginal douching, and Gynecologic surgical procedures such as endometrial biopsy, curettage, and hysteroscopy. Barrier methods of contraception are associated with decreased chances of sexually transmitted diseases and consequently associated with decreased incidence of pelvic inflammatory diseases. Oral contraceptive pills (OCPs) are reported to be having a protective effect against pelvic inflammatory diseases but this has been contested by many researchers and till now there is no clear evidence as to whether OCPs actually reduces incidence of PID or just mask the symptoms. The other method of contraception namely intrauterine contraceptive devices (IUCD) is clearly associated with increased risk of pelvic PID and there isten-fold increases in the risk .It is caused by persistent pathogenic infections that permits the microorganisms to ascend from the initial infection point (the vagina and the endocervix) to the endometrium or beyond (Kumar & Singh, 2017). 

It presents a range of clinical manifestations from totally asymptomatic to endometritis, parametritis, tubo-ovarian abscess, salpingitis, oophoritis, pelvic peritonitis, perihepatitis (Fitz–Hugh–Curtis syndrome) and even ovarian carcinogenesis (Ingerslev et al., 2017). PID is the cause of about 30% of infertility cases and 50% of ectopic pregnancies. Therefore it presents a signifcant public health and economic burden, for women in the reproductive age. (Naaz et al., 2016). Despite its obvious importance in women’s health, the prevalence of PID is unclear because it is largely underreported, either because it is asymptomatic or with mild symptom or because of social and ethical constraints. 

Due to financial and technical difculties, PID prevention programs based on pathogen screening are not available or reliable in many countries, thus the actual burden of PID may be even greater than anticipated (Sartelli et al., 2017). A self-reporting USA survey, in 2013–2014, estimated the PID incidence to 4.4% (Kreisel K., 2017) showing slight decline from previous reports (Leichliter et al., 2017). USA currently runs a preventive program against chlamydia and gonorrhoea infection in adolescents, to help prevent PID, but questions are raised on whether youngsters might be willing to participate. The identifcation of the pathogen responsible for PID is hampered by the imprecision in diagnosing PID, the difficulty in sampling the upper genital track, the frequent super-infection and the difficulty of identifying the pathogen (Risser et al, 2017).

Also, early sexual intercourse is commonly associated with a higher number of lifetime sexual partners which further predisposes them to developing PID and multiple sex partners predispose women to the development of PID. The higher the number of sex partners a woman has, the higher the risk of developing PID. A higher number of concurrent partner as well as frequent partner change also siantly increase risk of PID. Adolescents and young adults, who constitute majority of undergraduates, commonly have multiple sex partners which predispose them to developing PID. They also have a higher number of concurrent partners as well as a higher frequency of partner change. Also, women whose partners are not faithful to them are also at increased risk of developing PID, especially if their partners engage in unprotected sex with other women. (Raya et al., 2013).

 It is important therefore that both partners must be faithful to each other as history of multiple sex partners by either the woman or her partner increases her risk of developing PID. (Bamherger et al., 2013). Adolescents and young women from low socioeconomic backgrounds are more likely to have multiple sex partners as they succumb to unprotected sex through coercion, force, violence and transactional reasons. Similarly, those women with previous history of PID/STI are at greater risk of developing PID (Ugboma et al., 2014).

This may be due to poor treatment leading to chronicity of the infection. It could also be due to re-infection after treatment. Inaccurate information regarding PID and STIs among members of the public is also known risk factors for PID (Moses, 2015).

Inconsistent use of barrier contraceptive is also a major risk for the development of PID. (Ugboma et al., 2014). Consistent condom use has been shown to significantly reduce the risk of developing PID as well as prevent unwanted pregnancy. Low socioeconomic status is a significant risk factor for PID, (WHO., 2015). This is because students from poor family background are more likely to engage in risky sexual behaviour that predisposes them to PID. They do this in order to get money to augment whatever they get from their parents. On the other hand, students from high socioeconomic backgrounds whose financial needs are met by their parents may not engage in such activities. The higher incidence of PID in women of lower socioeconomic status may be due in part to a woman's lack of education and awareness of health and disease and her accessibility to medical care (Dehne, 2015). They may also engage more in sex with older men (so called “sugar daddies”) for gifts, pocket money and school fees as majority of such girls are often responsible for their fees and even send money to their poor parents from such proceeds. Those men who make the decisions that affect sexual risk almost universally do not like to use barrier contraceptives, thus sex in this vulnerable group is most likely to be unprotected. 

Lack of access to good health care facilities for patients with STIs from low socioeconomic backgrounds may also facilitate progression to PID in this group. They would rather patronize patent medicine dealers and quacks. They are also at higher risks of unwanted pregnancies from unprotected sex, making them engage in criminal abortion in the hands of quacks and under unsanitary conditions further increasing their susceptibility to PID. The diagnosis of PID is primarily based on a history of abdominal or pelvic pain or cramping of varying intensity, new or abnormal vaginal discharge, fever or chills (which may be high grade), dyspareunia, heavy or prolonged menses or coital bleeding and clinical findings of lower genital tract inflammation associated with pelvic organ tenderness (cervical motion tenderness, uterine tenderness and adnexal tenderness). (WHO 2015). Diagnosis of PID based on above clinical findings has been shown to have a positive predictive value of 65 – 90% (Dehne, 2015).

The diagnostic criteria for PID according to the World Health Organisation (WHO) and the Center for Disease Control and Prevention (CDC) include the presence of one or more of the following major criteria: cervical motion tenderness, uterine tenderness or adnexal tenderness with no other apparent cause (Aladeselu, 2015). The following minor criteria are supportive but not required for the diagnosis: Fever greater than or equal to 38.0Oc, abnormal discharge per cervix or vagina, white blood cells (WBCs) on Gram stain or Saline of cervical swab, Gonorrhoea or Chlamydia testing positive, increased Erythrocyte Sedimentation Rate (ESR) or C – reactive protein, and PID findings on diagnostic study, (Moses, 2015). Most specific findings, though not required and rarely indicated unless refractory to management or unclear diagnosis: Laparoscopy findings consistent with PID which is the Gold Standard for diagnosis, Endometrial Biopsy with histology suggestive of Endometritis, Imaging such as Trans-vaginal Ultrasound or Magnetic Resonance Imaging (MRI) with classic findings thickened, fluid filled tubes, Free pelvic fluid may be present, Tubo-ovarian complex, Tubal hyperaemia on Doppler Ultrasound (Moses, 2015). The differential diagnoses include ectopic pregnancy, appendicitis, cervicitis, urinary tract infection, and adnexal tumors.

1.2 Statement of the problem

Pelvic inflammatory disease is a common disorder of the reproductive tract that is frequently misdiagnosed and inadequately treated. PID is a syndrome that causes substantial morbidity, including chronic pelvic pain, to women globally. (Sharon et al., 2021).

World Health Organization (WHO) estimated that nearly one million people became infected every day with any of four curable sexually transmitted infections (STIs). (Klaussner et al., 2017). The economic burden imposed by STDs/STIs in General as well as PID is considerable as various research studies have revealed over the past four decades. Analysis of data, for example, from 2018 revealed that lifetime direct medical costs of STIs in United States was estimated at $15.9 billion in 2019 (Donald E Graydanus MD, Dr HC (ATHENS) 2021).

Recent studies of women with PID have reported that fewer than half of women receiving a diagnosis of PID have chlamydial infection, while mycoplasma genitalium, and the constellation of bacteria associated with bacterial vaginosis may account for a substantial fraction of PID cases. (Sharon et al., 2021).

The burden of bacterial Vaginosis is highest in Sub-Saharan Africa. Vaginal dysbiosis has been associated with increased susceptibility to and transmission of HIV and other sexually transmitted infections and increased risk of pelvic inflammatory disease (PID) preterm birth, and maternal and neonatal infections. (Janneke et al., 2017).

PID affects millions of women each year, and is witnessing an uptick in Nigeria as well as many other countries, Paul Ogoegbulem, an Abuja based Medical Practitioner says on Business Day online national daily, (October, 2019) that PID is an infection of one or more pelvic organs that includes the uterus, cervix, and fallopian tubes, witnessing a surge because many people leave STDs untreated for a long time.

1.3 Research Questions

• What is the incidence of PID among women of child bearing age in MagajinGari, BirninGwar LGA?

• What is the knowledge of PID among women of child bearing age in  MagajinGari, BirninGwari LGA?

• What are the causes of PID among women of child bearing age in MagajinGari,BirninGwari LGA?

• What are preventive measures of PID among women of child bearing age in MagajinGari, BirninGwari LGA?

1.4 Objectives of the Study

General Objective

To determine the prevalence of pelvic inflammatory disease among women of child bearing age in MagajinGari, BirninGwari Local Government, Kaduna State

Specific Objectives

• To determine the incidence of PID among women of child bearing age in MagajinGari, BirninGwari Local Government Area, Kaduna state.

• To assess the knowledge of women of child bearing age on the complications of Pelvic Inflammatory Diseases in MagajinGari, BirninGwari Local Government Area, Kaduna State.

• To identify possible factors associated with occurrence of PID among women of child bearing age in MagajinGari, BirninGwari Local Government Area, Kaduna State.

• To identify prevention of PID among women of child bearing age in MagajinGari, BirninGwari Local Government, Kaduna State.

1.5 Significant of the Study

This study may enlighten people especially the victims of PID about the complication, it’s prevention and how best to manage themselves on continuous treatment as well as other members of the community who are across the border of being infected with the disease. It may serve as reference purpose for future research.

The study indicates that PID at the general hospital MagajinGari, BirninGwari is a research priority and this coincides with the proposal.

1.6 Delimitation of the Study.

The study is limited to the women of women of child bearing age, in MagajinGari, BirninGwari Local Government of Kaduna State.

1.7 Definition of Terms

Acute infection

This refers to the micro-living inside a host for a limited period of time, typically less than six months.

Adolescent 

The phase of life between childhood and adulthood, usually 10 – 19 years age.

Antibodies 

These are proteins that protect the body when an unwanted substance enters.

Antigen 

Any substance that causes immune system to produce antibodies against it.

Bacterial infection

Is an infection caused by bacterial, can often be treated successfully with antibiotics.

Chlamydia 

Is an STI caused by specific strain of bacteria known as chlamydia trachomatis.

Chronic infection

Is characterized by prolong incubation period followed by progression of disease.

Contraception 

Is any method, medicine or device used to prevent pregnancy.

Disease: Any harmful deviation from the normal structure or functional state of an organism, generally association with signs and symptoms.

Female genitalia

Is a structure of both internal and external female reproductive organs, which includes mumps pubis, labia minora, labia majora, urethra, fallopian tube, uterus etc.

Gonorrhea 

Is a sexual transmitted infection (STI) caused by bacteria called Neisseria Gonorrhoeae or Gonococcus.

Incidence: Refer to the occurrence of new cases of disease in a population over a specified period of time.

Inflammation

This is part of the process by which immune system defends the body from harmful agent such as bacterial and viruses.

Intra-uterine

Simply means inside the uterus; a small, hollow pear shaped organ in a woman’s pelvis in which a fetus  develop.

Intra-Uterine Contraceptive Device(IUCD): A small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy.

Pathogen

Is defined as an organism causing disease to its host, with severity of disease symptoms referred to as virulence.

Pelvic inflammatory disease (PID): is a polymicrobial infection in women characterized by infection of the upper genital tract including endometritis, salpingitis, pelvic peritonitis, occasionally leading to the formation of tubo-ovarian abscess.

Prevalence: Is the proportion of persons in a population who have a particular disease or attribute at a specified point in time or over a specified period of time.

Health: A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

Reproductive age

The chronological age in woman at 15 - 49 years, usually between menarche and menopause.

Reproductive organs

These are organs that are responsible for many functions in the body which is characterized by female and male reproductive organs.

Sexually Transmitted Diseases(STDs): Infections that are passed from one person to another through sexual contact.

Viral infection

These are many illnesses caused by pathogenic viral micro-organism.

Women of Reproductive Age: Also referred to (15 - 49 years) women of childbearing age; ages of active reproduction who desire either to have no [additional] children or to postpone the next child and who are currently using a modern method of contraception.

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