Reproductive Tract Disorders among Afghan Refugee Women Attending Health Clinics in Haripur, Pakistan

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INTRODUCTION

Decades of strife have caused millions of Afghans to flee violence, political oppression, and economic instability (1) to become one of the largest groups of refugees in the world (2). Many live in neighbouring countries, such as Pakistan (2). Within Pakistan, an estimated 62% of Afghan refugees live in the Northwest Frontier Province (3).

In 1991, the Pakistan/Afghanistan office of Save the Children-USA joined the Safe Motherhood Initiative to provide healthcare to the refugees living in the Haripur camps in the Northwest Frontier Province. In 1998, as not much was known about the prevalence of morbidities due to RTIs within the Afghan refugee community, a clinical study was initiated to explore the extent of morbidity and possible associated behavioural factors. Much of past research on health of the refugee women has focused on women's delivery-related health, with particular emphasis on maternal mortality ratio (MMR). However, the MMR does not adequately represent other issues that can severely affect women's health, such as reproductive tract infections (RTIs). Untreated or improperly-treated RTIs can have severe, long-term sequelae, such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, low birthweight of offspring, or foetal loss (4-6), and can increase a woman's and her community's risk of acquisition and transmission of HIV (7-9).

Since this study was conducted in 1998, there have been several political changes in the area with dramatic repercussions for Afghan refugees. Significant repatriation efforts are being exerted, resulting in an often-fluctuating refugee population (3). A recent report by the United Nations High Commissioner for Refugees (UNHCR) estimated that, as of end-2008, there were more than 2.8 million Afghan refugees. Approximately 1.8 million of these refugees continue to live in the UNHCR-supported refugee camps in Pakistan, with very little improvements in living conditions (2). Although this study was conducted in 1998, there have been no studies published in the intermediate period addressing morbidity due to RTIs among Afghan refugee women. Therefore, our findings remain highly relevant and urgent.

The objectives of this study were to assess the prevalence of RTIs and other gynaecological disorders among Afghan refugee women attending Basic Health Units (BHUs) in Haripur, Pakistan, and to describe the most commonly-occurring RTIs. Behavioural factors that might be contributing to the development of RTIs were also explored.

MATERIALS AND METHODS

In 1998, there were 115,000 Afghan refugees of diverse ethnic groups, originating from different parts of Afghanistan, living in 18 refugee villages in Haripur. These refugee villages were served by a network of seven BHUs. The catchment area in this study included all the seven BHUs. In 1996, a verification exercise estimated that there were about 22,540 (19.6%) women of reproductive age among the Hairpur refugee population.

Training and pre-study preparations

Each BHU was staffed by a primary healthcare (PHC) team, headed by an Afghan female physician and a rotating male doctor catering to the gender-specific needs of the male population. Fieldwork was conducted from January to mid-March 1999. Before commencing fieldwork, a five-week preparatory phase of the project began in November 1998. During this phase, it was ensured that all the seven BHUs had the necessary equipment and materials required for the study. Medical Officers received training on the syndromic guidelines of the World Health Organization, diagnosis and management of reproductive tract disorders and other clinical issues, such as vaginal ecosystem, normal and abnormal flora, factors affecting vaginal flora, etc. Medical Officers also received training on interviewing techniques, collection of vaginal swab, plating of specimens, and preparation of slides. Field-testing of the questionnaire was conducted in the latter part of December 1998. …