This paper presents findings on women’s treatment seeking for RTIs, which to our knowledge is only the fourth published analysis of large-scale survey data on this issue in India in the past thirty years [21,22,23]. Our analysis of women’s utilisation of services, across states and over time, suggests that utilisation of services for gynaecological morbidity remains a challenge in most parts of India. Less than 40% of women in India who reported symptoms of RTIs reported seeking care— no improvement since the NFHS-3 ten years earlier. Neighbouring countries such as Nepal and Bangladesh report higher proportions of women who sought treatment for similar symptoms: 48 and 60%, respectively [24, 25]. Our analysis, similar to previous NFHS and DLHS rounds, indicated wide variation in treatment utilisation across Indian states, ranging from 64% in Punjab to 8% in Nagaland. Given that health is a state subject in India, differences in state-level health systems likely contribute to this variation. We could not identify any regional patterns or variation consistent with national rankings of state health system performance . The use of public services increased slightly in the past ten years, with declines in utilisation of private facilities in some states. In Punjab, Rajasthan, Uttar Pradesh and Kerala, utilisation increased in both sectors.
Barriers to treatment
Our analysis indicates that equitable access to services is of concern: women who are younger, have no education, lower economic status and reside in rural areas reported lower levels of seeking care, similar to findings from a range of community-based studies [17, 18, 27]. In addition, a comparative analysis of NFHS-II, NFHS-III and DLHS RCH-I and II found higher treatment-seeking amongst women with a higher standard of living, education level and age . Similarly, an analysis of NFHS-2 (1998–99) indicated that seeking care varied according to location and by socioeconomic and demographic group: wealthier, older, educated women were more likely to seek treatment .
Qualitative research has indicated that individual perceptions—such as a well-established notion of a “culture of silence” around gynaecological ailments—and limited-decision making power prevent treatment-seeking [29,30,31]. Women’s normalisation of symptoms, or fear/ embarrassment as barriers to treatment, point to deeper-rooted sociocultural ideas around gynaecological morbidity [11, 13, 32]. Women may believe that reproductive health problems, such as vaginal discharge or pain, are simply “women’s fate” and therefore not a condition for which they should seek medical help [15, 33]. For example, a comparison of treatment-seeking for gynaecological, obstetric and contraceptive morbidity in an urban Delhi community noted that a high proportion (92.9%) of women sought care for obstetric morbidity, while only 50.8% of women with gynaecological morbidity sought care .
Health system factors
Community-based research has largely focused on individual or societal barriers to treatment, with relatively less analysis of the availability, acceptability, accessibility, and quality of services in facilities [1, 35]. Available research indicates that women’s perceptions of health system barriers include financial constraints [15, 36, 37], poor perceived quality of care, and limited access to appropriate treatment [14,15,16]. Studies from Gujarat, West Bengal and Tamil Nadu have highlighted the association between cost of care and treatment seeking for gynaecological morbidity [14,15,16]. Further, vulnerable populations such as migrants/women with migrant husbands and women in the informal economy may face particular challenges in seeking care [38, 39].
Providers’ knowledge and attitudes towards women’s bodies may also influence women’s utilisation of services. For example, a study amongst private providers revealed that most did not perform internal examinations for women with gynaecological ailments . Male healthcare providers in a rural setting indicated that they were unwilling to examine women’s “private parts” and instead spoke to escorts, rather than women themselves . Lastly, it is possible that the lack of accessible, acceptable treatment may drive over/mis-use of over-the counter medication without adequate care .
Although NFHS-4 did not collect data on use of informal providers, earlier rounds of NFHS suggest they were an important source of care. For example, analyses of NFHS-2 indicated that 14% of all consultations for gynaecological symptoms were with informal private providers, with higher use in states such as Bihar (28%), Orissa (25%), West Bengal (39%) and Nagaland (35%). Reported use of informal providers was higher among poorer, lower-caste and uneducated women . More recent community-based studies of women’s preferences also indicate women in rural settings prefer traditional healers, informal providers and home remedies for symptoms of RTIs [14, 41].
Finally, it is noteworthy the NFHS survey rounds straddle the introduction of the National Health Mission, a horizontal health systems reforms largely focused on public sector service delivery related to maternal and child health. Although the program has not appeared to have achieved overall gains in treatment-seeking for RTIs, improvements in states such as Karnataka, Kerala and Himachal Pradesh suggest that the public sector may have become a more viable option for utilisation of gynaecological health services in some states.
Strengths and limitations
The primary strength of this study is the use of nationally representative data that allows comparison of RTI treatment over time and across states. Building on a strong base of existing community-based literature, we examined a range of potential predictors of women’s treatment-seeking in a nationally representative dataset. However, our analysis was limited by focussing on national estimates. Predictive factors may be context-specific, which may explain wide variation between states or lack of associations between women’s empowerment indicators and treatment-seeking, for example. The NFHS collects data on women’s self-reported symptoms, which could result in underestimates, both due to under-reporting and asymptomatic infections [10, 12]. Lastly, our analysis is limited by using a large national survey that examines a range of health issues, which necessarily has a limited number of questions that can incorporate women’s perceptions or attitudes that influence treatment-seeking decisions [11, 42, 43].
We identified several areas which can be improved in the module on RTIs within the NFHS. The NFHS collects data on symptoms from women who report a history of sexual activity. This criterion excludes women who are not, or choose not to report, being sexually active; morbidity estimates thus do not include reproductive tract infections amongst women who are not sexually active. The long (12-month) recall period for symptoms may limit the reliability of estimates, with potential variation in the population by severity of symptoms as well as socioeconomic status . Our understanding of factors that influenced treatment behaviour could be improved by data on awareness and availability of services, as well as information on the use of informal providers and the reported cure rate.