From menarche to menopause: A population-based assessment of water, sanitation, and hygiene risk factors for reproductive tract infection symptoms over life stages in rural girls and women in India.

Belen Torondel,Robert Dreibelbis,Ambarish Dutta,Pinaki Panigrahi,Lauren Sager,Krushna Chandra Sahoo,Matthew C Freeman,Padmalaya Das,Clarissa Brocklehurst,Kelly K Baker,Bhabani Das,Bijaya Padhi,Bethany Caruso

doi:10.1371/journal.pone.0188234

Abstract

Women face greater challenges than men in accessing water, sanitation, and hygiene (WASH) resources to address their daily needs, and may respond to these challenges by adopting unsafe practices that increase the risk of reproductive tract infections (RTIs). WASH practices may change as women transition through socially-defined life stage experiences, like marriage and pregnancy. Thus, the relationship between WASH practices and RTIs might vary across female reproductive life stages. This cross-sectional study assessed the relationship between WASH exposures and self-reported RTI symptoms in 3,952 girls and women from two rural districts in India, and tested whether social exposures represented by reproductive life stage was an effect modifier of associations. In fully adjusted models, RTI symptoms were less common in women using a latrine without water for defecation versus open defecation (Odds Ratio (OR) = 0.69; Confidence Interval (CI) = 0.48, 0.98) and those walking shorter distances to a bathing location (OR = 0.79, CI = 0.63, 0.99), but there was no association between using a latrine with a water source and RTIs versus open defecation (OR = 1.09; CI = 0.69, 1.72). Unexpectedly, RTI symptoms were more common for women bathing daily with soap (OR = 6.55, CI = 3.60, 11.94) and for women washing their hands after defecation with soap (OR = 10.27; CI = 5.53, 19.08) or ash/soil/mud (OR = 6.02; CI = 3.07, 11.77) versus water only or no hand washing. WASH practices of girls and women varied across reproductive life stages, but the associations between WASH practices and RTI symptoms were not moderated by or confounded by life stage status. This study provides new evidence that WASH access and practices are associated with self-reported reproductive tract infection symptoms in rural Indian girls and women from different reproductive life stages. However, the counterintuitive directions of effect for soap use highlights that causality and mechanisms of effect cannot be inferred from this study design. Future research is needed to understand whether improvements in water and sanitation access could improve the practice of safe hygiene behaviors and reduce the global burden of RTIs in women.

Highlights

Girls and women experience greater challenges than boys and men in safely accessing water, sanitation, and hygiene (WASH) resources, including social and sexual violence, while seeking locations to address bodily needs.[1,2,3,4,5,6,7] In addition, women have greater needs for consistent access to sanitation and water to maintain personal hygiene, during menstruation
Hygiene practices, including frequency of bathing, douching, using a cloth to clean inside the vagina, type of cleansing material, quality of bathing water, and washing and reusing cloth pads as an absorbent material during menstruation have been implicated as risk factors for self-reported and diagnostically-confirmed vaginitis.[27,28,29,30,31,32,33,34,35]
One case-control study linked to this study found that after accounting for the use of cloth pads and socio-economic factors, water and sanitation access was not associated with reproductive tract infections (RTIs) symptoms or laboratory confirmed vaginosis in women presenting for care at a health care center.[32]

Summary

Introduction

Inadequate water and sanitation access affects women’s health in many ways beyond infectious disease, including increased psychosocial stress, urinary incontinence and constipation, maternal mortality, and preterm birth.[5, 8,9,10,11] Water and sanitation access may be important determinants of hygiene-related diseases, like reproductive tract infections (RTI). Prevention of RTIs is critical because they can increase the risk of other severe reproductive diseases, including pelvic inflammatory disease, infertility, sexually transmitted diseases, ectopic pregnancy, miscarriage, and preterm birth.[5, 8, 16,17,18,19,20,21,22,23,24] RTI symptoms can be caused by sexually transmitted infections, like trichomoniasis, as well as by bacterial vaginosis and vaginal candidiasis, which have been linked to both sexual and vaginal hygiene exposures.[13, 25, 26] Hygiene practices, including frequency of bathing, douching, using a cloth to clean inside the vagina, type of cleansing material, quality of bathing water, and washing and reusing cloth pads as an absorbent material during menstruation have been implicated as risk factors for self-reported and diagnostically-confirmed vaginitis.[27,28,29,30,31,32,33,34,35]

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Results

Conclusion