What We Know and Don’t Know
about Obstetric Fistula: A review
of Current Knowledge
Saifuddin Ahmed
Sara Holtz
Bloomberg School of Public Health, Johns Hopkins University
• Found in the mummy of 2050 BC
• First reference to fistula dated 1550 BC
• Linked obstructed labor to incontinence by
Avicenna (Ibn Sina) – 1030 AD
• Preventable and treatable
•
•
•
•
•
Devastates lives of sufferers
Divorced by husbands
Expelled from home
Ostracized by society
Beg for livelihood
1
Dead Women
Walking
&
Living with Fistula
(Photograph: © 2004 Shaleece Haas. This is an open-access image distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)
“We should start by admitting
that we do not know the extent
or incidence of fistula…”
(Nafis Sadik, 2001)
“Current data on the prevalence
of fistula are virtually nonexistent”
(Browning and Patel, 2004)
2
• No comprehensive world survey
• No question in Demographic and Health
Surveys
• No population level survey where
incidence and prevalence is high
• No ethical answer for treatment options
needed to be offered if a survey finds the
case
Guillain-Barre syndrome
• Incidence: Extremely rare - 1 per 100,000
• Acute inflammatory demyelinating polyneuropathy
• Prognosis: Almost all cases survive and the
majority recover completely.
3
Methods
• Literature search:
– Pubmed
– Popline
• 41 empirical study
– 4 case-control
– All clinic study, except 1 (population based study)
• Sample size: 25 – 1716
– Median N: 123
4
Incidence and Prevalence
• The cited statistics are almost 15 years old
• Prevalence – 2 million
• 1 million in Nigeria !
• Bangladesh – 1.6 per 1000 ever married women
– higher than expected
Meta-analysis:
Obstructed labor
92.6% (95% CI: 90.5 – 94.8)
Ampofo, 1990(Nigeria
Amr, 1998(Jordan)
Danso, 1996(Ghana)
Dekou, 2002(Cote d'I
Gessessew, 2003(Ethi
Gueye,1992 (Senegal)
Hilton, 1998(Nigeria
Ibrahim, 2000(Nigeri
Ijaiya, 2004(Nigeria
Islam, 1992(Banglade
Kelly, 1995(Ethiopia
Lawson, 1989(Nigeria
Majinge, 1995 (Tanza
Muleta, 1997 (Ethiop
Rafiq, 2002(Pakistan
Rahman, 2003(Saudi A
Wall, 2004(Nigeria)
Combined
.7
.8
.9
1
Obstructed labor
5
Does traditional
practice of Gishiri
cutting have a causal
association?
Gishri cut:
7.3% (95% CI: 1.9 28.5)
6
Direct and Indirect Causes
• Direct: Obstructed labor
• Is there other risk factors? Indirect causes
• Why fistula is higher in Sub-Saharan Africa?
• Is there any evidence that the incidence of
obstructed labor is higher in Africa?
Maternal health care and mortality rates
D octor
(% )
Su b-Saharan A frica
Benin 1996
5.8
Burk ina
1.7
Faso 1998/99
C had 1996/97
2.0
C ote
4.1
d'Ivoire 1994
G uinea 1999
17.7
Kenya 1998
27.8
M adagascar 1997
19.0
M alawi 2000
8.2
M ali 2001
2.7
T ogo 1998
3.5
Zam bia 2001/02
2.3
Zim babwe 1999
13.2
N o rth A frica/W est
M orocco 1992
21.3
So uth an d So uth east A sia
Indonesia 1997
10.6
N epal 1996
12.7
Philippines 1998
38.5
Latin A m erica
Bolivia 1994
49.5
H aiti 2000
46.9
Peru 1996
31.7
Antenatal C are
O ther
T otal
H ealth
(% )
P rofessional
(% )
D elivery
C are
(% )
M aternal
M o rtality
R ate (1000
person years)
M atern al
M ortality
R atio
(100,000
live births)
74.5
59.0
80.3
60.7
63.9
32.1
1.06
1.02
498
484
30.0
79.1
32.0
83.2
11.2
44.8
1.84
1.18
827
597
53.0
64.1
57.8
84.3
54.1
78.5
91
79.9
70.7
91.9
76.8
92.5
56.8
82.0
93.3
93.1
29.0
42.1
34.2
55.3
37.8
49.1
43.6
72.2
1.03
0.99
0.99
2.40
1.34
0.68
1.44
0.94
528
590
488
1120
582
389
729
695
10.9
32.2
28.3
0.14
332
78.8
24.9
47.2
89.4
37.6
85.7
20.7
7.6
34.2
0.34
0.88
0.19
352
539
149
3.0
33.4
35.6
52.5
80.3
67.3
42.2
16.8
49.6
0.50
0.77
0.26
305
523
216
7
• Does nutritional status play a role?
– Effect of chronic malnutrition
• Can Vitamin A deficiency play a role?
• Does vaginal infection status initiate the
development of VVF and prevent healing?
• Are there other social and cultural etiologic
factors?
Is early childbearing
associated with
increased risk of
obstructed labor?
8
Meta-analysis:
Proportion Age <15 years
29.9% (95% CI: 12.0 – 47.9)
Ampofo, 1990(Nigeria
Gessessew, 2003(Ethi
Ibrahim, 2000(Nigeri
Majinge, 1995 (Tanza
Rafiq, 2002(Pakistan
Combined
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
Proportion Age <15
Meta-analysis:
Proportion Age <20 years
52.3% (95% CI: 50.9 – 53.7)
Ampofo, 1990(Nigeria
Dekou, 2002(Cote d'I
Gessessew, 2003(Ethi
Harouna, 2001(Niger)
Ijaiya, 2004(Nigeria
Majinge, 1995 (Tanza
Muleta, 1997 (Ethiop
Tehzib, 1983(Nigeria
Waaldijk, 2004(Niger
Combined
.2
.3
.4
.5
.6
.7
.8
Proportion Age <20 years
.9
1
9
Meta-analysis:
Proportion Primigravida
50.8% (95% CI: 38.6 – 63.0)
Amr, 1998(Jordan)
Danso, 1996(Ghana)
Dekou, 2002(Cote d'I
Gessessew, 2003(Ethi
Gharoro, 1999(Nigeri
Gueye,1992 (Senegal)
Harouna, 2001(Niger)
Hilton, 1998(Nigeria
Ibrahim, 2000(Nigeri
Ijaiya, 2004(Nigeria
Kelly, 1995(Ethiopia
Murray, 2002(Ethiopi
Tehzib, 1983(Nigeria
Zoung-Kanyi, 1990(Ca
Combined
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
Proportion Primigravida
Meta-analysis:
Fetal death
84.4% (95% CI: 80.2 – 88.6)
Ampofo, 1990(Nigeria
Dekou, 2002(Cote d'I
Gessessew, 2003(Ethi
Hilton, 1998(Nigeria
Ibrahim, 2000(Nigeri
Mabeya, 2004(Kenya)
Muleta, 1997 (Ethiop
Wall, 2004(Nigeria)
Combined
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
Proportion experienced fetal deaths
10
Divorce:
34.5 % (95% CI: 22.9-52.0)
Meta-analysis:
Proportion Successfully Repaired
86.0% (95% CI: 82.7 – 89.3)
Amr, 1998(Jordan)
Bouffioux, 1987(Guin
Elkins, 1988(Ghana)
Gessessew, 2003(Ethi
Gharoro, 1999(Nigeri
Gueye,1992 (Senegal)
Hilton, 1998(Nigeria
Ibrahim, 2000(Nigeri
Kelly, 1995(Ethiopia
Lawson, 1989(Nigeria
Mabeya, 2004(Kenya)
Majinge, 1995 (Tanza
Muleta, 1997 (Ethiop
Murray, 2002(Ethiopi
Rafiq, 2002(Pakistan
Rahman, 2003(Saudi A
Waaldijk, 2004(Niger
Wall, 2004(Nigeria)
Zoung-Kanyi, 1990(Ca
Combined
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
Surgical Success Rate
11
“At the world’s current
capacity to repair fistula, it
would take at least 400
years to clear the backlog
of patients, provided that
there are no more new
cases”
Browning and Patel, 2004
12