Global burden of obstructed labour in the year 2000

Abstract

The most frequent cause of obstructed labour is cephalo-pelvic disproportion - a mismatch between the fetal head and the mother's pelvic brim. The fetus may be large in relation to the maternal pelvic brim, such as the fetus of a diabetic woman, or the pelvis may be contracted, which is more common when malnutrition is prevalent. Some other causes of obstructed labour may be malpresentation or malposition of the fetus (shoulder, brow or occipito-posterior positions). In rare cases, locked twins or pelvic tumours can cause obstruction1. Neglected obstructed labour (OL) is a major cause of both maternal and newborn morbidity and mortality. The obstruction can only be alleviated by means of an operative delivery, either caesarean section or other instrumental delivery (forceps, vacuum extraction or simphysiotomy). Maternal complications include intrauterine infections following prolonged rupture of membranes, trauma to the bladder and/or rectum due to pressure from the fetal head or damage during delivery, and ruptured uterus with consequent haemorrhage, shock or even death. Trauma to the bladder during vaginal or instrumental delivery may lead to stress incontinence. By far the most severe and distressing long-term condition following obstructed labour is obstetric fistula - a hole which forms in the vaginal wall communicating into the bladder (vesico- vaginal fistula) or the rectum (recto-vaginal fistula) or both. In developing countries, fistulae are commonly the result of prolonged obstructed labour and follow pressure necrosis caused by impacti on of the presenting part during difficult labour. In the infant, neglected obstructed labour may cause asphyxia leading to stillbirth, brain damage or neonatal death1. Obstructed labour ranked 41st in GBD 1990, representing 0.5% of the burden of all conditions and 22% of all maternal conditions.2 It was estimated to be the most disabling of all maternal conditions. This draft paper summarizes the data and methods used to produce the Version 2 estimates of obstructed labour burden of the year 2000.

Full text

1
Global Burden of Disease 2000
Global burden of obstructed labour
in the year 2000
Carmen Dolea1 and Carla AbouZahr2
Evidence and Information for Policy (EIP),
World Health Organization,
Geneva, July 2003
1. Introduction
Labour is considered obstructed when the presenting part of the fetus cannot progress into
the birth canal, despite strong uterine contractions. It is more common in humans than in
primates, because the birth canal of a woman is not as straight and wide as in primates1.
The most frequent cause of obstructed labour is cephalo-pelvic disproportion - a mismatch
between the fetal head and the mother's pelvic brim. The fetus may be large in relation to
the maternal pelvic brim, such as the fetus of a diabetic woman, or the pelvis may be
contracted, which is more common when malnutrition is prevalent. Some other causes of
obstructed labour may be malpresentation or malposition of the fetus (shoulder, brow or
occipito-posterior positions). In rare cases, locked twins or pelvic tumours can cause
obstruction1.
Neglected obstructed labour (OL) is a major cause of both maternal and newborn morbidity
and mortality. The obstruction can only be alleviated by means of an operative delivery,
either caesarean section or other instrumental delivery (forceps, vacuum extraction or
simphysiotomy). Maternal complications include intrauterine infections following
prolonged rupture of membranes, trauma to the bladder and/or rectum due to pressure from
the fetal head or damage during delivery, and ruptured uterus with consequent haemorrhage,
shock or even death. Trauma to the bladder during vaginal or instrumental delivery may
lead to stress incontinence. By far the most severe and distressing long-term condition
following obstructed labour is obstetric fistula - a hole which forms in the vaginal wall
communicating into the bladder (vesico-vaginal fistula) or the rectum (recto-vaginal fistula)
or both. In developing countries, fistulae are commonly the result of prolonged obstructed
labour and follow pressure necrosis caused by impaction of the presenting part during
difficult labour. In the infant, neglected obstructed labour may cause asphyxia leading to
stillbirth, brain damage or neonatal death1.
Obstructed labour ranked 41st in GBD 1990, representing 0.5% of the burden of all
conditions and 22% of all maternal conditions.2 It was estimated to be the most disabling of
all maternal conditions. This draft paper summarizes the data and methods used to produce
the Version 2 estimates of obstructed labour burden of the year 2000.
1 Epidemiology and Burden of Disease, WHO Geneva (EBD/GPE)
2 Reproductive Health and Research, WHO Geneva (RHR)

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Global Burden of Disease 2000
2. Case and sequelae definitions
There is no clear definition and confusion of terms used by different authors remains3.
The term "dystocia" is most frequently used as an equivalent for obstructed labour, but it
covers a broad range of conditions, from labour lasting more than 12 hours to uterine
rupture, feto-pelvic disproportion or abnormal fetal presentation. Moreover, estimating
the duration of labour may be difficult, especially in settings without appropriate
monitoring technology. It is, however, accepted that if obstruction cannot be overcome
by manipulation or instrumental delivery, caesarean section is needed. The definitions
used by GBD 2000 for obstructed labour and its sequelae are listed in table 2.1.
Table 2.1 GBD 2000 case and sequelae definitions for obstructed labour
Cause category GBD 2000 Code ICD 9 codes ICD 10 codes
Obstructed labour U046 660-665 O62-O66
Sequela Definition
Cases Labour with no advance of the presenting part of the fetus despite strong uterine
contractions, left untreated (neglected)
Caesarean section for
obstructed labour
Cases of obstructed labour for which a caesarean section has been performed
Stress incontinence Cases with frequent leaking of urine during sneezing or coughing as a result of
obstructed labour
Recto and vesico-
vaginal fistula
Cases with communication between the vaginal wall and the bladder or the
rectum resulting from obstructed labour
3. Population prevalence and incidence studies
Appropriate surveys were identified by a MEDLINE and PubMed search, using the
words "obstructed labour", "dystocia", "incidence", and "epidemiology" and by tracking
references from the papers identified in this way; in addition, we examined regional
offices' literature databases and statistics, performed a key word search of major
obstetric and gynaecology journals and consulted with experts for unpublished work.
We included the studies in our analysis if they had a clear definition of cases, if data
were available on incidence, mortality or case fatality rate, natural history and age
distribution, and if sample size was adequate. We gave priority to population-based
studies, but used also the information from hospital-based studies in regions where most
deliveries take place in hospitals.
Self-reported maternal morbidity tends to overestimate incidence and results depend on
the sensitivity and specificity of the instrument. Several attempts have been made to
validate the results of self-reported maternal morbidity by comparing responses from
women interviews shortly after hospital delivery with their hospital case notes. Table
3.1 presents the sensitivity and specificity of prolonged labour as recalled and reported
to interviewers in these studies. Comparisons are difficult, as studies may have used

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Global Burden of Disease 2000
different definitions and study design, and their results may not be generalised to women
who do not deliver in hospital. Thus, self-reported maternal morbidity cannot provide
exact estimates of prevalence and incidence. However, until a more comprehensive data
collection on all deliveries, especially in the developing world, will become available,
self-reports in response to well-designed and well worded interviews may be the only
way to collect information about maternal morbidity4.
Table 3.1. Sensitivity and specificity of prolonged labour as recalled and reported to
interviewers
Philippines 19955 Bolivia 19986 Ghana 19967 Indonesia 19978
Questions “labour lasting more
than 12 hours” “extended pushing”
(for sensitivity
“extended labour”
(for specificity)
“labour lasting more
than 24 hours,
responses in hours”
Sensitivity 0.41 0.21 0.74 0.31
Specificity 0.88 0.99 0.83 0.77
Adapted from ref. 4
3.1 Incidence
As shown in table 3.2, epidemiological studies of obstructed labour demonstrated varying
estimates in the incidence of obstructed labour. This is likely to be due to a number of
factors including variations in case definition and inadequate case ascertainment.
Furthermore, hospital based studies of obstructed labour will not give valid estimates of
incidence as the study population includes only those who access health services.
Studies often use caesarean section or instrumental delivery due to obstructed
labour/dystocia as a proxy measure for obstructed labour. This is problematic, however, as
the rate in developing countries may not represent met need and the rate in developed
countries is likely to be inflated due to other factors. For example, in the United States in
the 1980s there were six times as many indications for a caesarean for cephalo-pelvic
disproportion than in Ireland for groups of women who showed the same characteristics
(nulliparity, known risk factors, age of mother and birth weight of child) and delivered in
comparable hospitals. The difference was therefore not epidemiological but due to a
subjective "cultural" factor when assessing the need for intervention.
Due to these problems in estimating obstructed labour incidence from epidemiological
studies, it has been assumed as in GBD1990 that the incidence of obstructed labour varies
between 3 and 6 per cent (Table 3.3). The lower figure was applied in more developed
regions (Regions A to C) and the lower figured to less developed areas where early
marriage and childhood malnutrition are more prevalent (sub-regions D and E). The
proportion of births within a health facility by sub-region was used as a proxy for timely
access to treatment (caesarean section, instrumental delivery, symphysiotomy) to estimate
the incidence of neglected obstructed labour (Table 3.3). Where health facility births were
greater than 95%, treatment coverage was assumed to be 100%.

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Global Burden of Disease 2000
Table 3.2. Incidence studies for obstructed labour
Region Study
population Type of study Years Sample
size Diagnostic criteria
Incidence
per 100 live
births
(deliveries)
Ref.
AFRO D
Senegal 2 urban areas
(Saint Louis
and Kaolack)
Population-
based study
on a cohort of
pregnant
women
1996 3,476 live
births OL leading to
instrumental delivery,
C-section, uterine
rupture, laceration of
perineum or death)
2.36 9
Niger Niamey (6
maternity
wards)
Hospital
(maternity
wards)-based,
longitudinal
study
1997 3,625
deliveries Obstructed labour:
dystocia, uterine
rupture and vesico-
vaginal fistulae
3.60 10
Burkina
Faso, Mali,
Mauritania
Niger,
Senegal,
Cote
d’Ivoire*
Ouagadougou,
Bamako,
Nouakchott,
Niamey,
Kaolack
region,
Abidjan*
Population-
based,
multicentre
door-to-door
census of all
pregnant
women
Dec
1994-
June
1996
20,326
women;
16318
deliveries
Prolonged labour
lasting more than
12h, uterine rupture,
assisted vaginal
delivery,
compression, feto-
pelvic disproportion
resulting in caesarean
delivery or abnormal
fetal lie requiring
surgical delivery
18.3 (17.7-
18.9)
3
Burkina
Faso, Mali,
Mauritania
Niger,
Senegal,
Cote
d’Ivoire
Ouagadougou,
Bamako,
Nouakchott,
Niamey,
Kaolack
region, Abidjan
Population-
based,
multicentre
door-to-door
census of all
pregnant
women
Dec
1994-
June
1996
20,326
women;
19694 live
births
Obstructed labour
requiring either
instrumental
extraction or C-
section, and uterine
rupture and other
complications such as
laceration of
perineum, pelvic
fistulae or death
2.05 (1.86-
2.26)
11
Nigeria Eastern
Nigeria Population
based 1985-
1989 11,299
deliveries cephalo-pelvic
disproportion 4.70 12
Nigeria University
College
Hospital,
Ibadan
Retrospective
hospital based 1978-
1991 39,456
deliveries labour where further
progress was
impossible without
interference
0.96 13
EURO A
UK St Michel's
Hospital and
Southmed
Hospital,
Bristol,
Prospective
hospital cohort Febr
1999-
Jan
2000
10,106
deliveries singleton cephalic
pregnancies requiring
operative delivery in
theatre at full
dilatation
3.90 14
Ireland The National
Maternity
Hospital,
Dublin
Retrospective
hospital based 1990-
1994 9,018
nulliparous
women
Labour lasting more
than 12 h from the
time of admission to
the delivery ward until
delivery of the infant
1.6 15

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Global Burden of Disease 2000
Table 3.3. Estimates of the incidence of obstructed labour by region
WHO region Estimated incidence of
obstructed labour per 100 live
births
Proportion deliveries in health
facilities (per 100 live births) Estimated incidence of
NEGLECTED obstructed labour
per 100 live births
AFRO D 6.0 33 4.0
AFRO E 6.0 38 3.7
AMRO A 3.0 99 0.0
AMRO B 3.0 79 0.6
AMRO D 6.0 49 3.1
EMRO B 3.0 69 0.9
EMRO D 6.0 39 3.7
EURO A 3.0 98 0.0
EURO B1 3.0 98 0.0
EURO B2 3.0 98 0.0
EURO C 3.0 98 0.0
SEARO B 3.0 33 2.0
SEARO D 6.0 21 4.8
WPRO A 3.0 97 0.0
WPRO B1 3.0 54 1.4
WPRO B2 3.0 52 1.4
WPRO B3 3.0 85 0.5
3.2 Incidence and prevalence of sequelae of obstructed labour
Available data on prevalence of sequelae of obstructed labour are scarce. For stress
incontinence, most studies come from the USA and Europe, with minimal information
on other parts of the world. A literature review by Mason et al. in 1999 showed that the
prevalence of stress incontinence during pregnancy ranges between 23-67% and declines
following delivery. In postpartum women stress incontinence (of varying severity)
ranges from 6 to 29%16. In the same study, the authors interviewed 1008 pregnant
women attending antenatal clinics in the UK, initially at 34-36 weeks of gestation and
then at 8-10 weeks following delivery. Using a questionnaire to elicit symptoms of
stress incontinence and its severity, they found a prevalence of daily stress incontinence
during pregnancy of 11%, and of stress incontinence several times per week of 19%.
The corresponding figures for symptoms following delivery were 2% and 5%
respectively. Viktrup et al in 1992 found that 1% of women had daily stress
incontinence following delivery17.
In another study, including 109 nulliparous women, examined by means of a
questionnaire, clinical examination, perineal sonography, and urethral pressure profiles,
Meyer et al. found a prevalence of stress urinary incontinence after spontaneous and
instrumental delivery of 21% and 34%, respectively18. However, the study did not give
details on the severity of symptoms. Although the length of second stage of labour has
not been associated with stress incontinence, forceps delivery is responsible for a ten-
times increase of the risk of postpartum stress incontinence in a developed country19.
However, some other authors report that there is no difference in the prevalence of
delivery16,20,21. Grand multiparity was shown to be associated with an increased risk of

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Global Burden of Disease 2000
developing persistent stress incontinence during reproductive age, and the delivery of at
least one baby weighing more than 4000g seems to be a predominant factor22.
The GBD 1990 assumed that all cases of OL were followed by stress incontinence. The
current version of the GBD considers assumed that a quarter of cases of obstructed
labour left untreated would develop moderate of severe stress incontinence, with a
disability weight of 0.025 for women between 15-49 and 0.033 for women older than 50
years.
For caesarean section, we assumed that in 90% of cases of treated obstructed labour a
caesarean section is performed, and in the remaining 10% an instrumental delivery.
For rectovaginal and vesico-vaginal fistula, in developing regions the incidence ranges
from 0.01% to 0.08% of births (Table 3.4). These reports are mostly from Africa are
available, and largely from surgical series rather the population-based studies. In a
population-based study from West Africa, where 19,342 women were followed up for
42 days postpartum, 2 cases of vesico-vaginal fistula were diagnosed, resulting in an
incidence of 0.01% of deliveries. Both cases occurred in a rural area, giving a rural
incidence of fistula of 0.12% deliveries. On the basis of this study, the authors estimated
a minimum annual incidence of fistula in rural Sub-Saharan Africa of 33,451 new cases
for the year 199923. Danso et al. retrospectively identified 153 cases of genito-urinary
fistula at a teaching hospital in Kumasi, Ghana between 1977-1992. 150 of these were
of obstetric origin (91.5%) and 121 were due to prolonged obstructed labour (73.8%).
The hospital incidence of obstetric fistula was estimated at 0.1% of deliveries24. Prual et
al., in a longitudinal study in Niamey, Niger of 3,625 deliveries, found 2 cases of vesico-
vaginal fistula, with a hospital incidence of 0.06% of deliveries25. Hilton et al. reported
715 cases of fistula in a hospital in Nigeria between 1990-1994, 92.2% of which were of
obstetric origin, and 80.3% following neglected obstructed labour26. No obstetric fistula
resulting from obstructed labour is seen today in developed countries.
For GBD2000 we expressed the obstetric fistula rate of 0.08% of births as a proportion
of neglected obstructed labour cases for the AFRO E region. The same rate of 0.08% of
births was used in GBD1990. This results in an incidence rate of obstetric fistula of
2.15% of neglected obstructed labour cases. This rate was applied to the regional rates of
neglected obstructed labour to determine the overall incidence of obstetric fistula.
3.3 Determinants and trends in obstructed labour
The likelihood of obstructed labour can be anticipated if the mother is short and/or has
had prior difficult labour27. In the MOMA study3 ssmall stature, previous caesaren
section and nulliparity were associated with an increased risk of dystocia, but none of
these factors have adequate positive predictive value as screening tools. It is thus almost
impossible to predict the occurrence of dystocia before the onset of labour. Labour must
therefore be monitored carefully and systems to manage or refer complications must be
available.
Trends in obstructed labour are difficult to assess because studies may have used
different definitions. However, as some of the potential risk factors have not improved
significantly (nutrition, access to delivery in health facilities etc.) one can assume that
the incidence of OL has remained stable during the last ten years.

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Global Burden of Disease 2000
Table 3.4. Incidence studies for recto-vaginal (RVF) and vesico-vaginal fistula (VVF)
Region Study
population
Type of study Years Sample
size Diagnostic criteria RVF/VVF
incidence per
100 deliveries
Ref.
AFRO D
Niger 6 maternity
wards,
Niamey
Maternity
wards-based,
longitudinal
1997 3,625
deliveries vesico-vaginal
fistulae following
delivery
0.06% 25
Ghana Komfo
Anokye
Teaching
hospital,
Kumasi
Retrospective
hospital
based,
medical
records
Jan
1977-
Dec
1992
157,449
deliveries genito-urinary fistula 0.10% 24
Burkina
Faso, Mali,
Mauritania
Niger,
Senegal,
Cote
d’Ivoire
Ouagadougo
u, Bamako,
Nouakchott,
Niamey,
Kaolack
region,
Abidjan
Population
based
prospective
study
1994-
1996 19,342
pregnant
women
permanent leakage
of urine and/or
faeces through
vagina
0.01%; in rural
area: 0.12% 37
Nigeria Eastern
Nigeria Population
based 1985-
1989 11,299
deliveries 0.65% (14% of
all cases of OL) 12
4. Mortality and case fatality
There is relatively more information on mortality from obstructed labour when
compared with incidence studies. These data, however, must be interpreted with
caution, because a death due to OL may be misclassified under other headings, including
sepsis, ruptured uterus or haemorrhage, all of which could be secondary to obstructed
labour1. Data from community-based studies that assessed the cause-specific maternal
mortality are summarized in Table 4.1.
The GBD 1990 estimated deaths due to obstructed labour starting from the total number
of maternal deaths, and apportioning a percentage to OL, based on reports from different
sources1. A first set of regional estimates of total number of maternal deaths was
produced using the methodology developed for WHO/UNICEF 1995 estimates of
maternal mortality28. Available information on cause of death distributions in each
region, including data from vital registration systems were then used to estimate the
proportion of different causes of maternal mortality. The general methodology used for
mortality estimates of the GBD 2000 is described in Mathers et al.29 Using this
methodology it was estimated that globally obstructed labour is responsible for 8% of all
maternal deaths.

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Global Burden of Disease 2000
Table 4.1. Proportion of maternal deaths due to obstructed labour – community-based
studies
WHO
Region/Country Setting Type of study Period
of
study
Total number of
maternal deaths % due to
obstructed labour
Ref
AFRO D
Gambia A rural area RAMOS Jan
1993-
Dec
1998
18 5.6 30
Guinea-Bissau the 5 northern
regions of
Guinea-Bissau
RAMOS 1989-
1996 144 16.7 31
Ghana Ejisu health
district community based
survey of maternal
mortality
1985-
1990 44 6.8 32
Burkina Faso,
Mali, Mauritania,
Niger, Senegal,
Cote d'Ivoire
5 urban areas
and 1 rural area population based
prospective study 1994-
1996 55 12.7 33
AMRO B
Mexico 3 states in
Mexico Verbal autopsy 1995 145 8 34
SEARO D
Bangladesh Matlab area,
Bangladesh Verbal autopsy in
demographic
surveillance
system
1987-
1993 174 8 35
Figure 5.1. Obstructed labour disease model
.
Years lived with disability (YLDs) were calculated for the boxes shaded in grey
Pregnant
women
Obstructed labour
Deaths
Fistula (recto/vesico-vaginal)
General
Mortality
Caesarean section
Stress incontinence
NEGLECTED
Obstructed labour

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Global Burden of Disease 2000
5. Disease model for obstructed labour
Figure 5.1 shows the disease model for obstructed labour.
Compared to the GBD 1990, the current version of burden estimates is based on the
assumption that a proportion of cases of obstructed labour will have access to timely
treatment (mainly caesarean section). Thus, only those cases for which obstructed
labour is ngelected (untreated) may develop stress incontinence (the proportion of which
is thought to be 25%) or obstetric fistula. Stress incontinence is mainly a consequence
of normal vaginal delivery and its burden is captured under the category of "other
maternal conditions". The assumptions on mortality due to obstructed labour remain
unchanged.
Table 5.1. Comparison between GBD 1990 and GBD 2000 disease models
GBD 1990 GBD 2000
Stages/Sequelae Episodes
Stress incontinence
Recto-vaginal and vesico-vaginal fistula
Episodes
Caesarean section for obstructed labour
Stress incontinence
Recto-vaginal and vesico-vaginal fistula
Incidence rates for
episodes 5.1% globally 6% for sub-regions D and E, 3% for sub-
regions A, B and C.
Incidence rate for
caesarean section N/A In developed regions, 90% of all treated OL
cases.
Incidence rate for
stress incontinence All cases with obstructed labour 25% of neglected obstructed labour cases
develop moderate to severe stress
incontinence
Incidence rate for
obstetric fistula Between 50 and 80 per 100,000 births 2.15% of neglected obstructed labour cases
Remission rate for
sequelae 0 0
Case fatality for
episodes Proportional mortality model
(8% of all maternal deaths globally)
Proportional mortality model
(8% of all maternal deaths globally)
Disability weight for
caesarean section N/A 0.349
Disability weight for
stress incontinence 0.025 (15-59 years)
0.033 (60+ years)
0.025 (15-59 years)
0.033 (60+ years)
Disability weight for
recto-vaginal and
vesico-vaginal fistula
0.430 (treated and untreated) 0.430 (treated and untreated)

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Global Burden of Disease 2000
6. Health state descriptions and disability weights
Complications of obstructed labour/sequelae considered for the burden of disease
estimates 2000 were caesarean section, stress incontinence and recto-vaginal fistula.
Caesarean section
For caesarean section following obstructed labour these version 2 estimates of the
GBD2000 use the interim disability weight elicited by the authors of the Australia and
Victoria burden of disease study. The authors used the EuroQol5+ classification system
from the Netherlands Disability Weights study to describe the health state based on 6
dimensions of health: mobility, self care, usual activities, pain/discomfort,
anxiety/depression, cognition. This disability weight will be revised using health state
valuation data from the WHO World Health Survey in 2003.
Stress urinary incontinence
In general, very few studies examined the physical, emotional and practical effects of
stress incontinence after childbirth. Typically, most studies report on the effects of
incontinence in general, irrespective of type, and on a wide age range or on an elderly
population. A literature view conducted by Mason et al. provides a fairly
comprehensive description of the health state of women affected by urinary incontinence
in general36. It has been suggested that women with stress incontinence have fewer
psychological problems, or perceive their complaint to be less of a problem compared to
women with urge or mixed incontinence. Nevertheless, because in our estimates we
considered the moderate to severe cases of stress incontinence, the description provided
by Mason et al. may be considered as appropriate for our purpose.
Some women described incontinence as a social rather than a medical problem, and it
was also perceived as an inevitable consequence of motherhood. Few women seek help
for this condition, and those who do, usually wait for one year or more after it develops
to discuss it. Incontinence was reported to affect levels of self-esteem and confidence.
Women's mental and physical health suffered as a result of their condition. One quarter
of incontinent women believe that their mental health was affected by their incontinence
to a moderate or severe extent. Other reported psychological effects included
depression, anxiety, irritability, worry, frustration and tension. Incontinence also
affected the desire or ability to take part in recreational or sporting activities. It
restricted the type of activity, such as shopping, travel, or going on holiday, that
involved unfamiliar places where toilet facilities were unknown or unavailable.
Recto-vaginal and vesico-vaginal fistula
Recto-vaginal and vesico-vaginal fistula represent a communication between the vaginal
wall and the rectum and/or the urinary bladder. Usually the conditions appear after
prolonged and neglected obstructed labour in places where delivery is not appropriately
assisted. In developing countries it is usually a feature of young and malnourished
primipara, having an obstructed labour and lacking the means for a rapid referral to a health
facility. In developed regions, fistula usually follows gynaecological surgery, or
radiotherapy for cervical cancer.

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Global Burden of Disease 2000
When labour is obstructed (compacted pelvis, macrosomia, malpresentation, uterus
atony), the fetal head impacts against the soft tissue of the pelvic floor, pinning the
bladder base and the urethra against the pelvic bone. It is the duration of impaction
without relief rather than the magnitude of the pressure, which determines the degree of
tissue necrosis. The fistula site depends greatly on the degree of cervical effacement and
dilatation, and the level at which the presenting part impacts. In the absence of any
intervention, this condition may last for several days, in which time at the place of the
impact the damaged tissue is extending due to lack of vascularisation and eventually a
hole appears from vagina into the bladder, and sometimes the rectum. At the end of this
interval, the fetus dies and is macerated; the mothers are exhausted because of bleeding
and or sepsis and they will deliver a stillborn fetus.
The consequence of fistula is urinary or faecal incontinence, i.e. permanent leaking of
urine or faeces through the vagina, a condition that is almost unendurable for women,
who have to continue living thereafter unclean, outcast, smelling of urine and faeces37.
In addition to their physical injuries, women who have experienced prolonged
obstructed labour often develop serious social problems, including divorce, exclusion
from religious activities, separate from their families, worsening poverty, malnutrition
and almost unendurable suffering.

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Global Burden of Disease 2000
7. Regional incidence, prevalence and mortality estimates
Table 7.1. Obstructed labour: age-specific incidence and mortality rate estimates for WHO
epidemiological subregions, 2000.
Subregion
Incidence neglected
obstructed labour/1000
women 15-59
Stress incontinence
incidence/1000 women
15-59
RVF/VVF
incidence/100,000
women 15-59
Mortality obstructed
labour/100,000 women
15-59
AFRO D 6.1 1.3 13.0 13.1
AFRO E 5.8 1.3 12.3 13.3
AMRO A 0.0 0.0 0.0 0.0
AMRO B 0.4 0.1 0.9 0.0
AMRO D 2.9 0.7 6.2 0.6
EMRO B 0.9 0.2 1.8 0.2
EMRO D 3.8 0.9 8.0 0.4
EURO A 0.0 0.0 0.0 0.0
EURO B1 0.0 0.0 0.0 0.0
EURO B2 0.0 0.0 0.0 0.0
EURO C 0.0 0.0 0.0 0.0
SEARO B 1.4 0.3 2.9 1.4
SEARO D 4.8 1.1 10.3 4.5
WPRO A 0.0 0.0 0.0 0.0
WPRO B1 0.7 0.2 1.5 0.0
WPRO B2 1.1 0.3 2.4 1.1
WPRO B3 0.5 0.1 1.2 1.1
World 2.0 0.5 4.3 2.4
8. Global burden of obstructed labour in 2000
General methods used for the estimation of the global burden of disease are given
elsewhere38. The tables and graphs below summarise the global burden of obstructed
labour estimates for the GBD 2000 and compare them with the obstructed labour
estimates from the GBD 199039.
Table 8.1. Obstructed labour: global Deaths, total YLD, YLL and DALY estimates, 1990
and 2000
GBD1990
GBD2000
Deaths ('000) 34
43
YLD('000)
5,457
1,672
YLL('000)
1,004
1,279
DALY('000)
6,462
2,951

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Global Burden of Disease 2000
Table 8.2. Obstructed labour: YLD, YLL and DALY estimates for WHO epidemiological
subregions, 2000
Subregion YLD/100,000 YLL/100,000 YLD(‘000) YLL(‘000) DALY(‘000)
AFRO D 139.6 208.0 234 349 583
AFRO E 121.4 203.8 206 346 552
AMRO A 1.4 0.0 2 0 2
AMRO B 14.4 0.3 32 1 33
AMRO D 78.7 9.8 28 3 32
EMRO B 24.3 3.4 16 2 19
EMRO D 98.0 6.2 67 4 71
EURO A 1.1 0.0 2 0 2
EURO B1 1.2 0.0 1 0 1
EURO B2 1.9 0.0 0 0 0
EURO C 0.9 0.0 1 0 1
SEARO B 39.8 25.0 78 49 128
SEARO D 127.2 77.6 831 507 1,338
WPRO A 1.1 0.0 1 0 1
WPRO B1 22.2 0.5 147 3 150
WPRO B2 31.8 19.1 23 14 37
WPRO B3 16.8 18.6 1 1 1
World 55.7 42.6 1,672 1,279 2,951
Figure 8.1. Obstructed labour YLD rates, broad regions, 1990 and 2000.
FEMALES - YLD per 1,000
0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
EME - A regions
FSE - Euro B+C
IND - SEARO D
CHI - WPRO B1
OAI - SEARB+WPRB2/3
SSA - AFRO D+E
LAC - AMRO B+D
MEC - EMRO B+D
World
YLD/1000
GBD 2000
GBD 1990

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Global Burden of Disease 2000
Figure 8.2. Obstructed labour YLL rates, broad regions, 1990 and 2000.
FEMALES - YLL per 1,000
0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00
EME - A regions
FSE - Euro B+C
IND - SEARO D
CHI - WPRO B1
OAI - SEARB+WPRB2/3
SSA - AFRO D+E
LAC - AMRO B+D
MEC - EMRO B+D
World
YLL/1000
GBD 2000
GBD 1990
9. Conclusions
One of the main limitations in estimating the global burden of obstructed labour, as well
as the other maternal conditions, is that epidemiological studies are currently using
different definitions of the condition, rendering those studies difficult to compare. More
efforts are needed to develop standard definitions, that researchers can refer to, and that
may allow comparability of their work. These are version 3 estimates for the GBD 2000.
Apart from the uncertainty analysis, updating estimates to reflect revisions of mortality
estimates and any new or revised epidemiological data or evidence, it is not intended to
undertake any major addition revision of these estimates.
We welcome comments and criticisms of these draft estimates, and information on
additional sources of data and evidence. Please contact Colin Mathers (Evidence and
Information for Policy, WHO Geneva) on email mathersc@who.int.
Acknowledgements
We particularly wish to thank Stephen Lim, who carried out final revisions of the estimates and
documentation during the second half of 2003.
We particularly wish to thank colleagues from Reproductive Health Research Department who
provided comments and suggestions on data sources and assumptions, particularly Metin
Gulmezoglu, Jose Villar, Luc De Bernis and Ana Betran. We also thank the many staff of the
Global Programme on Evidence for Health Policy who contributed to the development of life
tables and cause of death analysis. In particular we thank Omar Ahmad, Brodie Ferguson, Mie
Inoue, Alan Lopez, Rafael Lozano Doris Ma Fat, Christopher Murray and Chalapati Rao. We
thank Susan Piccolo for excellent secretarial assistance. This study has been supported by a grant
from the National Institute on Aging, USA.

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Global Burden of Disease 2000
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