Challenges in measuring obstetric fistula

Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
International Journal of Gynecology & Obstetrics (Impact Factor: 1.54). 12/2007; 99 Suppl 1(Suppl. 1):S4-9. DOI: 10.1016/j.ijgo.2007.06.010
Source: PubMed


Obstetric fistula is gaining visibility within national and international public health agencies. With increased attention to this dire condition comes the demand for better epidemiologic data. This article assesses the current state of knowledge regarding population-based estimates of the incidence and prevalence of obstetric fistulas; proposes a method for better estimating these rates; and discusses the feasibility of this method. We show that there are no solid population-based estimates of the numbers of obstetric fistulas anywhere (the estimate from the most rigorous study being based on only 2 reported fistula cases); and for advocacy purposes, we recommend using the estimates from the 1990 Global Burden of Disease report. To estimate the incidence and prevalence of obstetric fistula, we propose an adaptation of the sibling-based method for direct estimation of maternal mortality. A series of questions are proposed for this use and sample size calculations are provided. The questions may require refinement, however, and we invite research groups to consider testing them.

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    • "Women who survive obstructed labor may suffer severe and longterm morbidity, and genital fistula being one of the most devastating associated conditions. There are no reliable data on the global burden of fistula [3], but a recent systemic review and meta-analysis estimated that there are more than 1 million cases [4]. Fistula repair carries some risk—as does all major surgery—including that of death. "
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    ABSTRACT: Objective To describe the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors. Methods In a descriptive study, confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries between January 2005 and March 2013. Data collection included interviews with key personnel involved in the clinical management of the deceased, and a review of hospital records and patient files following an audit protocol. Results Overall, 26 060 fistula repairs were performed at 44 sites located in 13 countries; 30 deaths were reported in this period. Twenty-one deaths were attributable to surgery, yielding a case fatality of 0.08 per 100 procedures. The cause of death in nearly half of the cases was various manifestations of sepsis and inflammation. Conclusion The case fatality rate for fistula repair surgery in resource-poor countries was in the same range as that for comparable gynecologic operations in high-resource settings. Clinical and systemic issues to be addressed to reduce the case fatality rate include improvement of perioperative care and follow-up, assuring prudent referral or deferral of difficult cases, and maintaining better records.
    Full-text · Article · Aug 2014 · International Journal of Gynecology & Obstetrics
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    • "In Nigeria, according to the 2008 Demographic and Health Survey (DHS), estimated prevalence of fistula symptoms in the southern zones ranges between 0.2% and 0.5% of reproductive aged women, and in the northern zones ranges between 0.3% and 0.8% [9]. The true prevalence and incidence of obstetric fistula remain difficult to determine for several reasons: lack of large-scale, prospective, population-based studies examining pregnancy outcomes (in order to measure incidence); few large, retrospective population-based studies of fistula prevalence; and, where smaller scale studies of fistula incidence and prevalence have been conducted, inaccurate measurement, due to problems regarding questionnaire design (inappropriate contingency questions or lack of specificity in the definition of fistula), or underreporting of fistula symptoms by women (due to the stigma associated with the condition) [10-12]. "
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    ABSTRACT: Obstetric fistula continues to have devastating effects on the physical, social, and economic lives of thousands of women in many low-resource settings. Governments require credible estimates of the backlog of existing cases requiring care to effectively plan for the treatment of fistula cases. Our study aims to quantify the backlog of obstetric fistula cases within two states via community-based screenings and to assess the questions in the Demographic Health Survey (DHS) fistula module. The screening sites, all lower level health facilities, were selected based on their geographic coverage, prior relationships with the communities and availability of fistula surgery facilities in the state. This cross-sectional study included women who presented for fistula screenings at study facilities based on their perceived fistula-like symptoms. Research assistants administered the pre-screening questionnaire. Nurse-midwives then conducted a medical exam. Univariate and bivariate analyses are presented. A total of 268 women attended the screenings. Based on the pre-screening interview, the backlog of fistula cases reported was 75 (28% of women screened). The backlog identified after the medical exam was 26 fistula cases (29.5% of women screened) in Kebbi State sites and 12 cases in Cross River State sites (6.7%). Verification assessment showed that the DHS questionnaire had 92% sensitivity, 83% specificity with 47% positive predictive value and 98% negative predictive value for identifying women afflicted by fistula among women who came for the screenings. This methodology, involving effective, locally appropriate messaging and community outreach followed up with medical examination by nurse-midwives at lower level facilities, is challenging, but represents a promising approach to identify the backlog of women needing surgery and to link them with surgical facilities.
    Full-text · Article · Jan 2014 · BMC Pregnancy and Childbirth
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    • "Morbidity studies not reporting or mentioning fistulae but including a robust design, a thorough physical exam of the genital area that reported cases of uterine prolapse were assumed to have zero cases of fistula, as it was assumed that if fistula had been found it would have been reported. Studies relying on women’s self-reports were excluded because self-reports of reproductive morbidity have been shown to be unreliable [13,15,16]. We excluded studies that were conducted before 1990 or published before 1991. "
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    ABSTRACT: Obstetric fistula is a severe condition which has devastating consequences for a woman's life. The estimation of the burden of fistula at the population level has been impaired by the rarity of diagnosis and the lack of rigorous studies. This study was conducted to determine the prevalence and incidence of fistula in low and middle income countries. Six databases were searched, involving two separate searches: one on fistula specifically and one on broader maternal and reproductive morbidities. Studies including estimates of incidence and prevalence of fistula at the population level were included. We conducted meta-analyses of prevalence of fistula among women of reproductive age and the incidence of fistula among recently pregnant women. Nineteen studies were included in this review. The pooled prevalence in population-based studies was 0.29 (95% CI 0.00, 1.07) fistula per 1000 women of reproductive age in all regions. Separated by region we found 1.57 (95% CI 1.16, 2.06) in sub Saharan Africa and South Asia, 1.60 (95% CI 1.16, 2.10) per 1000 women of reproductive age in sub Saharan Africa and 1.20 (95% CI 0.10, 3.54) per 1000 in South Asia. The pooled incidence was 0.09 (95% CI 0.01, 0.25) per 1000 recently pregnant women. Our study is the most comprehensive study of the burden of fistula to date. Our findings suggest that the prevalence of fistula is lower than previously reported. The low burden of fistula should not detract from their public health importance, however, given the preventability of the condition, and the devastating consequences of fistula.
    Full-text · Article · Dec 2013 · BMC Pregnancy and Childbirth
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