Risk factors for vaginal fistula symptoms in Sub-Saharan Africa: a pooled analysis of national household survey data

Evaluating the current methodological practices and issues in existing literature in pooling complex surveys: a systematic review

BACKGROUND

Pooling data from complex survey designs is increasingly used in the health and medical sciences. However, current methodological practices are not well documented in the literature while performing the pooling strategy. We aimed to review related pooling studies and evaluate the quality of pooling within the framework of specific methodological guidelines, particularly when combining complex surveys such as Demographic & Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS).

METHODS

We performed a systematic literature search focusing on studies utilizing the pooling method with DHS and MICS survey data. These studies were selected from those published between 2010 and 2021 and were retrieved from electronic databases (PubMed and Scopus) in accordance with pre-defined inclusion criteria. Then, we extracted 355 studies for the final review and evaluated the reporting quality of the pooling strategy while considering some methodological issues.

RESULTS

The majority of studies (81.4%) reported using a pooled (one-stage) approach, while 11.8% used a separate (two-stage) approach, and 6.8% used both approaches. Approximately 63.3% of studies did not clearly describe their pooling strategy. Only 3.4% of the studies mentioned the variable harmonization process, while 66.9% addressed dealing with heterogeneity between surveys. All studies that used the separate (two-stage) approach conducted a meta-analytic procedure, while 38.1% of studies using the pooled approach employed a multilevel model. More than half of the studies (55.6%) mentioned the use of clustered standard errors. The Delta method, Bootstrap, and Taylor linearization were each applied in 11.1% of the studies for variance estimation. Survey weights, primary sampling unit (PSU) or cluster, and strata were used together in 30.5% of the studies. Survey weights were employed by 69.8%, PSU or cluster by 43.8%, and the strata variable by 31.7%. Sensitivity analysis was conducted in 16% of the studies.

CONCLUSIONS

Our study revealed that fundamental methodological issues associated with pooling complex survey databases, such as the selection of pooling procedures, data harmonization, accounting for cycle effects, quality control checks, addressing heterogeneity, selecting model effects, utilizing survey design variables, and dealing with missing values, etc., were inadequately reported in the included studies. We recommend authors, readers, reviewers, and editors examine pooling studies more attentively and utilize the customized checklist developed by our study to assess the quality of future pooling studies.

Midterm complications after primary obstetrical anal sphincter injury repair in France

BACKGROUND

Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence.

METHODS

We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs.

RESULTS

Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs.

CONCLUSIONS

Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress.

Urinary incontinence following successful closure of obstetric vesicovaginal fistula repair in Southern Ethiopia

BACKGROUND

Urinary incontinence (UI) after successful closure of obstetric vesicovaginal fistula (VVF) repair is a widely recognized public health problem. However, there is insufficient research evaluating the factors associated with UI after successful obstetric VVF repair in Ethiopia.

OBJECTIVES

The main aim of this study was to assess the magnitude and associated factors of UI following the successful closure of obstetric VVF repair at the Yirgalem Hamlin Fistula Center in the Sidama region of southern Ethiopia.

METHODS

A retrospective cross-sectional analytical study was performed on patients who underwent obstetric VVF repair at the Yirgalem Hamlin Fistula Center between 2016 and 2020. The data were collected from September to October 2021. EPI Data Version 3.1 and SPSS Version 25.0 were used for data entry and analysis. A multivariable binary logistic regression model was used for all variables significant in the bivariate binary logistic analysis to determine the association between the independent variables and outcome variables. The data are presented in tables and figures. Variables with a p-value < 0.05 were considered to be statistically associated with the study outcome.

RESULTS

In total, 499 study subjects were included. The magnitude of UI after successful closure of obstetric VVF repair was 23.25%. A Goh type 4 fistula (AOR = 4.289; 95% CI 1.431, 12.852), a fistula size > 3 cm (AOR = 8.855; 95% CI 4.786, 16.382), a partially damaged urethra (AOR = 2.810; 95% CI 1.441, 5.479), and a completely destroyed urethra (AOR = 5.829; 95% CI 2.094, 16.228) were found to be significantly associated factors with the outcome variable.

CONCLUSIONS

Nearly one in four patients who had successful closure of obstetric VVF repair at the Yirgalem Hamlin fistula center had UI, which is above the WHO recommendations. The presence of a Goh type 4 fistula, large fistula size, and damaged urethral status significantly affect the presence of UI. Therefore, interventions are necessary to prevent and manage UI among patients who underwent obstetric VVF repair and had a closed fistula.

Reconsidering the developmental origins of adult disease paradigm: The 'metabolic coordination of childbirth' hypothesis

In uncomplicated pregnancies, birthweight is inversely associated with adult non-communicable disease (NCD) risk. One proposed mechanism is maternal malnutrition during pregnancy. Another explanation is that shared genes link birthweight with NCDs. Both hypotheses are supported, but evolutionary perspectives address only the environmental pathway. We propose that genetic and environmental associations of birthweight with NCD risk reflect coordinated regulatory systems between mother and foetus, that evolved to reduce risks of obstructed labour. First, the foetus must tailor its growth to maternal metabolic signals, as it cannot predict the size of the birth canal from its own genome. Second, we predict that maternal alleles that promote placental nutrient supply have been selected to constrain foetal growth and gestation length when fetally expressed. Conversely, maternal alleles that increase birth canal size have been selected to promote foetal growth and gestation when fetally expressed. Evidence supports these hypotheses. These regulatory mechanisms may have undergone powerful selection as hominin neonates evolved larger size and encephalisation, since every mother is at risk of gestating a baby excessively for her pelvis. Our perspective can explain the inverse association of birthweight with NCD risk across most of the birthweight range: any constraint of birthweight, through plastic or genetic mechanisms, may reduce the capacity for homeostasis and increase NCD susceptibility. However, maternal obesity and diabetes can overwhelm this coordination system, challenging vaginal delivery while increasing offspring NCD risk. We argue that selection on viable vaginal delivery played an over-arching role in shaping the association of birthweight with NCD risk.

Factors associated with obstetric fistula among reproductive age women in Ethiopia: a community based case control study

BACKGROUND

Obstetric fistula is a major public health concerns in Ethiopia. It is the most devastating cause of all maternal morbidities.

METHOD

Data from the 2016 Ethiopian Demographic Health Survey (EDHS) was analyzed. A community-based unmatched case control study was conducted. Seventy cases and 210 non cases were selected using random number table. Data were analyzed by using STATA statistical software version 14. Multivariable logistic regression model was applied to determine the factors associated with fistula.

RESULTS

The majority of fistula cases were from rural residences. The multivariable statistical model showed that rural residence (Adjusted OR (AOR) = 5, 95% CI 4.26, 7.52), age at first marriage (AOR = 3.3, 95% CI 2.83, 4.60), poorest wealth index (AOR = 3.3, 95% CI 2.24, 5.01) and decision making for contraceptive use by husband alone (AOR = 1.3, 95% CI 1.124, 1.67) were factors significantly associated with obstetric fistula.

CONCLUSION

Age at first marriage, rural residence, poorest wealth index and decision making for contraceptive use by husband alone were significantly associated factors for obstetric fistula. Intervening on these factors will reduce the magnitude of obstetrics fistula. In this context there is in-need to improve on avoiding early marriage through awareness creation to the community and developing legal framework by the policymakers. Furthermore, information about the joint decision making to use contraceptives should be disseminated though mass-media and interpersonal channels.

Feasibility and acceptability of mobile phone data collection for longitudinal follow-up among patients treated for obstetric fistula in Uganda

Rapid dissemination of mobile technology provides substantial opportunity for overcoming challenges reaching rural and marginalized populations. We assessed feasibility and acceptability of longitudinal mobile data capture among women undergoing fistula surgery in Uganda (n = 60) in 2014-2015. Participants were followed for 12 months following surgery, with data captured quarterly, followed by interviews at 12 months. Participant retention was high (97%). Most respondents reported no difficulty with mobile data capture (range 93%-100%), and preferred mobile interview (88%-100%). Mobile data capture saved 1000 person-hours of transit and organizational time. Phone-based mobile data collection provided social support. Our results support this method for longitudinal studies among geographically and socially marginalized populations.

Developing a sexual and reproductive health educational intervention for adolescent Syrian refugee girls: Challenges and lessons learned

In Lebanon, a country with the highest per capita refugee population in the world, roughly one in four persons is forcibly displaced. Early marriage is highly prevalent among Syrian refugees in Lebanon and qualitative studies suggest an unmet need for sexual and reproductive health (SRH) information and services in this community. Adolescent Syrian refugee girls in Lebanon are a vulnerable population at risk of negative SRH outcomes related to early sexual debut, which occurs primarily in the context of early marriage. Despite this need, cultural norms and gender roles generally restrict adolescent girls' access to SRH resources. To address this need for comprehensive sexuality education, our team developed a novel, rights-based, peer-led, adolescent SRH educational curriculum that is specific to the context of Syrian displacement in Lebanon. This curriculum was developed to be administered as part of Project Amenah, a community-based, multi-component intervention that aims to reduce early marriage and improve SRH among adolescent Syrian refugee girls displaced in Lebanon. The curriculum, which features eight discreet age-appropriate units, is based on extensive formative work conducted in this community, as well as adaptations of early marriage programs implemented in low-resource settings elsewhere. Topics covered include, but are not limited to, gender and human rights, communication, negotiation and decision-making, reproductive anatomy, puberty and menstruation, sexually transmitted infections, family planning and modern contraception, and adolescent pregnancy. We encountered several challenges when developing this curriculum, including those related to community acceptability, varying levels of literacy levels among participants, and limited engagement with married adolescents, who may experience mobility restrictions that preclude their participation. We recommend that investigators developing adolescent SRH interventions in similar settings utilize a behavior-determinant-intervention logic model to guide their study design, elucidate community priorities and capacity by conducting preliminary qualitative work and assembling a community advisory board, and follow a peer-led model, which has shown to be effective for adolescent SRH interventions.

Economic burden of female genital mutilation in 27 high-prevalence countries

BACKGROUND

Female genital mutilation (FGM) is a traditional harmful practice affecting 200 million women and girls globally. Health complications of FGM occur immediately and over time, and are associated with healthcare costs that are poorly understood. Quantifying the global FGM-related burden is essential for supporting programmes and policies for prevention and mitigation.

METHODS

Health complications of FGM are derived from a meta-analysis and stratified by acute, uro-gynaecological, obstetric and psychological/sexual. Treatment costs are calculated from national cohort models of 27 high-burden countries over 30 years. Savings associated with full/partial abandonment are compared with a current incidence reference scenario, assuming no changes in FGM practices.

RESULTS

Our model projects an increasing burden of FGM due to population growth. As a reference scenario assuming no change in practices, prevalent cases in 27 countries will rise from 119.4 million (2018) to 205.8 million (2047). Full abandonment could reduce this to 80.0 million (2047), while partial abandonment is insufficient to reduce cases. Current incidence economic burden is US$1.4 billion/year, rising to US$2.1 billion/year in 2047. Full abandonment would reduce the future burden to US$0.8 billion/year by 2047.

CONCLUSION

FGM is a human rights violation, a public health issue and a substantial economic burden that can be avoided through effective prevention strategies. While decreasing trends are observed in some countries, these trends are variable and not consistently observed across settings. Additional resources are needed to prevent FGM to avoid human suffering and growing costs. The findings of this study warrant increased political commitment and investment in the abandonment of FGM.

Childbirth-Associated Fistula and Perineal Tears Repaired on Outreach Campaigns in Remote Democratic Republic of Congo

Purpose

To describe the demographics and evaluate the repair of childbirth-associated injuries leading to incontinence in patients in remote Democratic Republic of Congo (DRC).

Patients and Methods

Four surgical outreach campaigns were organised between March 2018 and October 2019. These campaigns specifically targeted women with incontinence secondary to childbirth-associated injuries. Patients were recruited on a voluntary basis, and locations included Katako-kombe (Sankuru province), Wamba (Haut Uelé province), Karawa (North Ubangi province) and Kipaka (Maniema province). Necessary care was provided along with informal teaching with local healthcare professionals.

Results

A total of 481 patients,14–71 years old with a mean of 32 years of age, were included in this study. The average duration of incontinence associated with a childbirth injury was 6.8 years. Vesicovaginal fistulas (277/481; 57.6%) and perineal tears (148/481; 30.8%) were predominant, while the combination of vesicovaginal and rectovaginal fistulas were seen in only 5 (1.0%) patients. Vaginal delivery (259/481; 53.9%), caesarean section (120/481; 25.0%) and laparotomy (hysterectomy) (102/481; 21.2%) were identified as the causes of the fistulas treated during the surgical campaign. Vesicovaginal fistulas were more likely to require complex repairs, as compared to rectovaginal fistulas and perineal tears (P-value <0.0001). As well, vesicovaginal fistulas were less likely to result in successful resolution of the incontinence when compared to rectovaginal fistulas and perineal tears (P-value < 0.0001).

Conclusion

Vesicovaginal fistulas are predominant among childbirth injuries encountered in remote DRC with poorly managed vaginal deliveries being the leading cause. Cure rate of fistulas and perineal tears is high during outreach campaigns; however, long-term follow-up is limited. There remains a need to train and mentor rural medical professionals in the DRC on adequate management of obstetric emergencies.

Measuring barriers to fistula care: investigating composite measures for targeted fistula programming in Nigeria and Uganda

BACKGROUND

Accessing surgical repair poses challenges to women living with female genital fistula who experience intersectional vulnerabilities including poverty, gender, stigma and geography. Barriers to fistula care have been described qualitatively in several low- and middle-income countries, but limited effort has been made to quantify these factors. This study aimed to develop and validate composite measures to assess barriers to accessing fistula repair in Nigeria and Uganda.

METHODS

This quantitative study built on qualitative findings to content validate composite measures and investigates post-repair client surveys conducted at tertiary hospitals in Northern and Southern Nigeria and Central Uganda asking women about the degree to which a range of barriers affected their access. An iterative scale development approach included exploratory and confirmatory factor analyses of two samples (n = 315 and n = 142, respectively) using STATA 13 software. Reliability, goodness-of-fit, and convergent and predictive validity were assessed.

RESULTS

A preliminary 43-item list demonstrated face and content validity, triangulated with qualitative data collected prior to and concurrently with survey data. The iterative item reduction approach resulted in the validation of a set of composite measures, including two indices and three sub-scales. These include a Financial/Transport Inaccessibility Index (6 items) and a multidimensional Barriers to Fistula Care Index of 17 items comprised of three latent sub-scales: Limited awareness (4 items), Social abandonment (6 items), and Internalized stigma (7 items). Factor analyses resulted in favorable psychometric properties and good reliability across measures (ordinal thetas: 0.70-0.91). Higher levels of barriers to fistula care are associated with a woman living with fistula for longer periods of time, with age and geographic settings as potential confounders.

CONCLUSIONS

This set of composite measures that quantitatively captures barriers to fistula care can be used separately or together in research and programming in low- and middle-income countries.

Nigeria, a high burden state of obstetric fistula: a contextual analysis of key drivers

Obstetric fistula (OF) remain a source of public health concern and one of the most devastating maternal morbidities afflicting about two million women, mostly in developing countries. It is still prevalent in Nigeria due to the existence of socio-cultural beliefs/practices, socio-economic state and poor health facilities. The country's estimated annual 40,000 pregnancy-related deaths account for about 14% of the global maternal mortality, placing it among the top 10 most dangerous countries in the world for a woman to give birth. However, maternal morbidities including OF account for 20 to 30 times the number of maternal mortalities. This review substantiates why OF is yet to be eliminated in Nigeria as one of the countries with the largest burden of obstetric fistula. There is need for coordinated response to prevent and eliminate this morbidity via political commitment, implementation of evidence-based policy and execution of prevention programs.

Obstetric fistulas in Uganda: scoping review using a determinant of health approach to provide a framework for health policy improvement

Background

The uneven global and national distribution of obstetric fistulas suggests a complex network of determinants contributing to fistula development. This study aims to create an understanding of the determinants of obstetric fistula in Uganda and to give a framework for health policy improvement.

Methods

A scoping review of existing literature was performed, searching the PubMed/MEDLINE database, Ugandan Demographic and Health Surveys, and official sources of Ugandan statistics. Data was analysed using the model for the determinants of health by Dahlgren and Whitehead.

Results

Obstetric fistulas are associated with different personal lifestyle factors, certain social and community networks, as well as poor working and living conditions. Malnutrition, early childbearing, limited female empowerment, lack of awareness of childbearing risks, low socioeconomic status, and long distances to emergency obstetric care play a part. Certain regions of Uganda are in particular associated with obstetric fistula, where an accumulation of determinants is notable.

Conclusion

Analysis using the model of Dahlgren and Whitehead shows that obstetric fistulas are associated with determinants at different levels of society. Poverty and low education link these in a web that is disproportionately hard to escape from for the poorest women. This inequity asks for co-operation between ministries to dismantle the environment for obstetric fistula.

Knowledge of obstetric fistula among prenatal clinic attendees and midwives in Mfantsiman municipality, Ghana

Objective

To determine obstetric fistula knowledge among prenatal attendees and midwives in Mfantsiman municipality, Ghana.

Methods

An analytical cross‐sectional study was conducted among prenatal clinic attendees and midwives in Mfantsiman municipality from March to April, 2016. Women were selected by systematic sampling and consenting midwives were recruited. Respondents were interviewed using a pretested structured questionnaire. Data were analyzed using the χ² test and Poisson regression with a robust error variance to generate relative risks (RRs) with 95% confidence intervals (CIs). P<0.05 was considered statistically significant.

Results

Altogether, 393 prenatal attendees and 45 midwives were studied. Mean age of attendees was 28.1 ± 7.1 years. About 29% of prenatal attendees knew of, 37.2% had poor knowledge of, and 56.6% had some misconceptions about obstetric fistula. Women who had attained some level of education (P trend=0.001), were employed (adjusted RR 4.92; 95% CI, 1.98–12.21), or had given birth before (P trend=0.01) were more likely to have heard of obstetric fistula. All midwives knew of obstetric fistula and its preventive measures; however, up to 73.3% had some misconceptions about it.

Conclusion

Educating prenatal attendees and organizing regular refresher courses on obstetric fistula for midwives should be a priority in the municipality.

Educating prenatal attendees and organizing regular refresher courses on obstetric fistula for midwives should be a priority in Mfantsiman municipality.

Measuring the spatial heterogeneity on the reduction of vaginal fistula burden in Ethiopia between 2005 and 2016

Vaginal fistula is a shattering maternal complication characterized by an anomalous opening between the bladder and/or rectum and vagina resulting in continuous leakage of urine or stool. Although prevalent in Ethiopia, its magnitude and distribution is not well studied. We used statistical mapping models using 2005 and 2016 Ethiopia Demographic Health Surveys data combined with a suite of potential risk factors to estimate the burden of vaginal fistula among women of childbearing age. The estimated number of women of childbearing age with lifetime and untreated vaginal fistula in 2016 were 72,533 (95% CI 38,235-124,103) and 31,961 (95% CI 11,596-70,309) respectively. These figures show reduction from the 2005 estimates: 98,098 (95% CI 49,819-170,737) lifetime and 59,114 (95% CI 26,580-118,158) untreated cases of vaginal fistula. The number of districts having more than 200 untreated cases declined drastically from 54 in 2005 to 6 in 2016. Our results show a significant subnational variation in the burden of vaginal fistula. Overall, between 2005 and 2016 there was substantial reduction in the prevalence of vaginal fistula in Ethiopia. Our results help guide local level tracking, planning, spatial targeting of resources and implementation of interventions against vaginal fistula.

Prognostic factors and long-term outcomes of obstetric fistula care using the Tanguiéta model

OBJECTIVES

To identify factors influencing the long-term prognosis after surgical repair of obstetric fistula, establish a prognosis-based classification system, and examine changes in quality of life after surgery.

METHODS

A retrospective study of 308 women who underwent obstetric fistula repair at Saint Jean de Dieu Hospital, Tanguiéta, Benin, between 2008 and 2016, and were supported by a multidisciplinary management model. All participants were from rural areas of Burkina Faso. The women completed interviews before, immediately after, and 2, 4-6, and 12 months after surgery to assess their clinical state and socioeconomic and psychologic status.

RESULTS

Overall, the fistulae of 230/274 (83.9%) women were considered to be repaired after 12 months. Factors associated with poor repair outcome included the presence of sclerotic tissue (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.11-0.53) and intraoperative complications (OR, 0.16; 95% CI, 0.07-0.39). Women with successful surgery had a better quality of life as compared with women with an unrepaired fistula (Ditrovie score, 1.1 vs 3.9; P<0.001).

CONCLUSION

The multidisciplinary Tanguiéta model for management of obstetric fistula allowed successful fistula closure, thereby facilitating the women's long-term social reintegration, and improved quality of life.

Social and cultural factors perpetuating early marriage in rural Gambia: an exploratory mixed methods study

Background: Over the last two decades, early marriage in the Gambia declined significantly (from 58% to 30%). Yet evidence indicates that nearly 8.6% of marriages in the Gambia involved girls younger than 15, and 46.5% of marriages are with girls aged 18 or below. The reasons for the decline but continuing practice of early marriage, despite existing legislation prohibiting child marriage, are not very well understood. Very few studies have been conducted to find out what and how local factors influence decisions about early marriage in the Gambia. More information is therefore needed on underlying reasons for the persistence of early marriage in the Gambia so that program managers can use this information to design strategies towards accelerating the decline of early marriages.  Methods: The study was conducted in 24 rural settlements in Lower Baddibu District in the North Bank Region of the Gambia. It was based on a mixed-methods design including a cross-sectional household survey with a sample of 181 female adolescents and focus group discussions with 16 male and female parents. Focus group discussions were digitally-recorded, transcribed verbatim and analyzed using thematic content analysis, while survey data were analyzed using Stata. Results: Using multiple regression analysis, this study found that ethnicity more than other factors, exerts an independent effect on early marriage. Themes identified during focus group discussions also revealed that fear of premarital sex and loss of virginity outside marriage were major reasons for the perpetuation of early marriage. Conclusions: These findings suggest that the practice of early marriage in rural Gambia is associated with ethnicity and practices related to social and cultural norms. The findings also suggest that in order to decrease early marriages, future efforts should focus on allaying the fears around premarital sex and loss of virginity related to delay in marriage.

Treatment-seeking for vaginal fistula in sub-Saharan Africa

BACKGROUND

There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high.

METHODS

The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI).

RESULTS

Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved.

CONCLUSION

Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Female Genital Mutilation in Sudan

BACKGROUND:

Female genital mutilation or female circumcision (FGM) is a serious health problem in Sudan. This procedure is harmful to women and causes many complications during pregnancy and childbirth.

OBJECTIVE:

This study aims to determine the female genital mutilation (FGM) and its associated factors in Sudan.

SUBJECTS AND METHODS:

Data from Sudan Multiple Indicator Cluster Survey (MICS - UNICEF) was used in this research. The survey was carried out in 2014 and included women aged between 14 – 49 years. A logistic regression model was used to find an association between dependent and independent variables.

RESULT:

Total numbers of 21947 women were included in the survey and out of the 6249 (28.5 %) from urban and 15698 (71.5%) from rural areas. The prevalence of female circumcision was 89%. Women who had circumcised daughters were 32.1 %. The highest prevalence of FGM was reported from South Kordofan state with 7.8%, and lowest was in Red Sea state (7.6%). A significant association was observed between circumcised women and their marital status, daughter circumcision, and the level of education.

CONCLUSION:

The practice of female genital mutilation is spread all over the country. Poor women with low level of education are at high risk for this phenomenon. More efforts have to be provided to end this dangerous practice.

The association between female genital fistula symptoms and gender-based violence: A multicountry secondary analysis of household survey data

OBJECTIVE

The Demographic and Health Surveys (DHS), which include standardised questions on female genital fistula symptoms, provide a unique opportunity to evaluate the epidemiology of fistula. This study sought to examine associations between self-reported fistula symptoms and experience of gender-based violence (GBV) among women interviewed in DHS surveys.

METHODS

This study used data from thirteen DHS surveys with standardised fistula and domestic violence modules. Data from the most recent survey in each country were pooled, weighting each survey equally. Multivariable logistic regressions controlled for maternal and demographic factors.

RESULTS

Prevalence of fistula symptoms in this sample of 95 625 women ranges from 0.3% to 1.8% by country. The majority of women reporting fistula symptoms (56%) have ever experienced physical violence, and more than one-quarter have ever experienced sexual violence (27%), compared with 38% and 13% among women with no symptoms, respectively. Similarly, 16% of women with fistula symptoms report recently experiencing sexual violence-twice the percentage among women not reporting symptoms (8%). Women whose first experience of sexual violence was from a non-partner have almost four times the odds of reporting fistula symptoms compared with women who never experienced sexual violence. These associations indicate a need to investigate temporal and causal relationships between violence and fistula.

CONCLUSIONS

The increased risk of physical and sexual violence among women with fistula symptoms suggests that fistula programmes should incorporate GBV into provider training and services.

Characterisation of the rural indigent population in Burkina Faso: a screening tool for setting priority healthcare services in sub-Saharan Africa

BACKGROUND

In Africa, health research on indigent people has focused on how to target them for services, but little research has been conducted to identify the social groups that compose indigence. Our aim was to identify what makes someone indigent beyond being recognised by the community as needing a card for free healthcare.

METHODS

We used data from a survey conducted to evaluate a state-led intervention for performance-based financing of health services in two districts of Burkina Faso. In 2015, we analysed data of 1783 non-indigents and 829 people defined as indigents by their community in 21 villages following community-based targeting processes. Using a classification tree, we built a model to select socioeconomic and health characteristics that were likely to distinguish between non-indigents and indigents. We described the screening performance of the tree using data from specific nodes.

RESULTS

Widow(er)s under 45 years of age, unmarried people aged 45 years and over, and married women aged 60 years and over were more likely to be identified as indigents by their community. Simple rules based on age, marital status and gender detected indigents with sensitivity of 75.6% and specificity of 55% among those 45 years and over; among those under 45, sensitivity was 85.5% and specificity 92.2%. For both tests combined, sensitivity was 78% and specificity 81%.

CONCLUSION

In moving towards universal health coverage, Burkina Faso should extend free access to priority healthcare services to widow(er)s under 45, unmarried people aged 45 years and over, and married women aged 60 years and over, and services should be adapted to their health needs.

ETHICS CONSIDERATIONS

The collection, storage and release of data for research purposes were authorised by a government ethics committee in Burkina Faso (Decision No. 2013-7-066). Respondent consent was obtained verbally.

Socio-demographic and reproductive health profile of women who experienced signs of obstetric fistula: Results from Pakistan Demographic and Health Survey (PDHS) 2006-2007

OBJECTIVE

to examine the socio-demographic profile of women experiencing signs of obstetric fistula and factors contributing to the development of this condition in Pakistan.

METHODS

secondary data analysis of Pakistan Demographic and Health Survey 2006-07, which for the first time measured signs of obstetric fistula, using a questionnaire at a population level. For the present study, questions directly related to obstetric fistula signs were used to construct a dependent variable. Data were analysed by descriptive and logistic regression analysis, to examine factors associated with development of fistula.

FINDINGS

among women of reproductive age (n = 9134, aged 15-49 years), some 277 (3.0%, 30 per 1000 women who ever gave birth) experienced obstetric fistula signs, whereas 103 (1.1% of all women) were still experiencing the condition at the time of survey. In a logistic regression model, women from the Punjab region (OR = 5.67, 95%CI = 2.10-15.31), women who delivered by caesarean section (OR = 1.91, 95% CI = 1.06-3.42) and reported having complications during pregnancy were more likely to develop obstetric fistula (OR = 1.96, 95%CI = 1.19-3.16).

CONCLUSIONS

Obstetric fistula is one of the neglected public and reproductive health concerns in Pakistan. To eliminate this preventable tragedy, there is a need for better emergency obstetric care facilities and the availability of a fistula repair service throughout the country.

Genital tract fistula: a case series from a tertiary centre in South Africa

INTRODUCTION AND HYPOTHESIS

We describe the demographic profile, aetiology, management and surgical outcomes in women with genital tract fistula presenting to a tertiary urogynaecology unit.

METHODS

This retrospective audit included 87 patients managed in our unit between 2008 and 2015. Frequencies and means with standard deviations are presented for categorical and continuous data. Continuous dependent variables are categorized as above or below the median for bivariate analyses performed using the chi-squared test (α = 0.05).

RESULTS

The mean age of the women was 34.7 years, 64.4% were Black African, 70.2% were multiparous, 49.4% were married, 82.8% were employed, and 21.8% were HIV-infected, with 47.4% on antiretroviral treatment. Vesicovaginal (47.1%) and rectovaginal (41.4%) fistula were the most frequent injuries. The majority of the injuries (67.8%) were obstetric, with 26.4% occurring during caesarean delivery. Repair had been attempted previously in 43.7% of patients. In 63.2% of the repairs the approach was vaginal and in 35.6% abdominal. Interposition grafts were used in 23% of repairs. In 85.1% of patients the initial repair at our centre was successful. Patients with multiple repairs were more likely to have complications (p = 0.03). HIV infection was not significantly associated with complications.

CONCLUSIONS

A high rate of successful repair was found, with previous unsuccessful repairs associated with poorer outcomes, highlighting the need for centralized management.