Burden of obstetric fistula: from measurement to action
Authors: Saifuddin Ahmed, Özge Tunçalp
Journal: The Lancet Global Health (2015)

For every maternal death, an additional 20–30 women develop serious pregnancy-related complications. Among all maternal morbidities, obstetric fistula is one of the most devastating. It is caused by injury during childbirth, resulting in an abnormal opening between the vagina and the bladder (vesicovaginal fistula) or rectum (rectovaginal fistula), leading to continuous urinary or fecal incontinence. Obstructed labour is the most common cause of vesicovaginal fistula in low-income countries.1Wall LL Obstetric vesicovaginal fistula as an international public-health problem.Lancet. 2006; 368: 1201-1209Summary Full Text Full Text PDF PubMed Scopus (273) Google Scholar Worldwide, an estimated 2–3 million women have obstetric fistula,1Wall LL Obstetric vesicovaginal fistula as an international public-health problem.Lancet. 2006; 368: 1201-1209Summary Full Text Full Text PDF PubMed Scopus (273) Google Scholar almost exclusively in sub-Saharan Africa and south Asia. However, this is a rough estimate and few data exist about the epidemiology of obstetric fistula. In The Lancet Global Health, Mathieu Maheu-Giroux and colleagues2Maheu-Giroux M Fillipi V Samadoulougou S et al.Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data.Lancet Glob Health. 2015; 3: e271-e278Summary Full Text Full Text PDF Scopus (57) Google Scholar estimate lifetime and point prevalence of vesicovaginal fistula in 19 sub-Saharan African countries. This paper is the first to estimate the prevalence of vaginal fistula (both obstetric and from other causes) based on population-level data from a large number of countries, using nationally representative surveys. The two most common sources of data for obstetric fistula are medical records and self-reported surveys. Medical records grossly underestimate the prevalence and incidence of obstetric fistula, as a result of the population affected by fistula and their limited access to medical care. Conversely, self-reported data from surveys, such as those used by Maheu-Giroux and colleagues, have low diagnostic value for maternal complications. Furthermore, Maheu-Giroux and colleagues2Maheu-Giroux M Fillipi V Samadoulougou S et al.Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data.Lancet Glob Health. 2015; 3: e271-e278Summary Full Text Full Text PDF Scopus (57) Google Scholar limited their sample to women aged 15–49 years who were available for household interviews; institutionalised women at rehabilitation centres, women at facilities undergoing or awaiting surgical treatments, and women older than 49 years with fistula were not accounted for. Finally, there is an additional risk of misclassification because postpartum incontinence is common. Maheu-Giroux and colleagues2Maheu-Giroux M Fillipi V Samadoulougou S et al.Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data.Lancet Glob Health. 2015; 3: e271-e278Summary Full Text Full Text PDF Scopus (57) Google Scholar used Bayesian statistics in an attempt to correct for misclassification bias and improve their estimates. Their results are crucial for quantifying the disease burden and for the development of country-specific policy and planning strategies to prevent and treat obstetric fistula. Take the example of Ethiopia. The figure shows the numbers of women treated between 2010 and 2013, in Ethiopia, Uganda, and Nigeria. Fistula surgery is rarely done at private facilities and outside of the listed centres, and thus underestimating fistula surgery is unlikely. From 2010 to 2013, on average, fewer than 2000 women each year had surgery for obstetric fistula in Ethiopia. Maheu-Giroux and colleagues2Maheu-Giroux M Fillipi V Samadoulougou S et al.Prevalence of vaginal fistula symptoms in 19 sub-Saharan African countries: a meta-analysis of national household survey data.Lancet Glob Health. 2015; 3: e271-e278Summary Full Text Full Text PDF Scopus (57) Google Scholar show that more than 110 000 women in Ethiopia presently have vaginal fistula. These data imply that if no new cases occur, it will take at least 55 years to treat the existing patients in Ethiopia at the current rate. Clearly, Ethiopia has deficiencies in national treatment planning—most women will never receive surgical treatment despite living in a country with one of the world's best treatment facilities for obstetric fistula, including a dedicated fistula treatment and training facility at Addis Ababa Fistula Hospital. The situation in other countries is unlikely to be better. All cases of obstetric fistula can be prevented with timely access to emergency obstetric care, especially caesarean section. Obstetric fistula was virtually eliminated in Europe and the USA between 1935 and 1950, because of universal access to safe delivery care. That it is still a public health problem in some countries shows the enormous gap in maternal health care between high-income and low-income nations and is a result of the egregious failure of health systems in these regions to provide safe maternity care. Poor women without timely access to safe intrapartum care are most vulnerable to obstetric fistula and the physical and psychological consequences affect quality of life.4Ahmed S Holtz SA Social and economic consequences of obstetric fistula: life changed forever?.Int J Gynaecol Obstet. 2007; 99: S10-S15Summary Full Text Full Text PDF PubMed Scopus (128) Google Scholar Affected women are often abandoned by their husbands and families, and ostracised by their communities. In many societies, obstetric fistula is stigmatised. It is not surprising that these women have been considered as "the most dispossessed, outcast, powerless group of women in the world".5Wall LL Obstetric fistulas in Africa and the developing world: new efforts to solve an age-old problem.Womens Health Issues. 1996; 6: 229-234Summary Full Text PDF PubMed Scopus (19) Google Scholar Since the initiation of the "Campaign to End Fistula" by UNFPA and other organisations in 2003, awareness among policy makers has significantly increased. However, the lack of reliable data for prevalence and incidence has hampered efforts to formulate an appropriate and coordinated response to obstetric fistula. The collection of accurate and reliable maternal morbidity data in low-income countries is difficult, especially for obstetric fistula.6Tuncalp O Tripathi V Landry E Stanton CK Ahmed S Measuring the incidence and prevalence of obstetric fistula: approaches, needs and recommendations.Bull World Health Organ. 2015; 93: 60-62Crossref PubMed Scopus (43) Google Scholar, 7Stanton C Holtz SA Ahmed S Challenges in measuring obstetric fistula.Int J Gynaecol Obstet. 2007; 99: S4-S9Summary Full Text Full Text PDF PubMed Scopus (52) Google Scholar Estimation of the burden of obstetric fistula in low-income countries is still a challenge. At a recent meeting,8Fistula Care PlusMaternal Health Task ForceFistula Care Plus: Report of Technical Consultation on Fistula Measurement and Estimation, July 10–11, 2014. EngenderHealth/Fistula Care Plus, New York2014Google Scholar an urgent call was made to develop appropriate methods for measuring national burdens of obstetric fistula so that effective maternal health care can be developed. Obstetric fistula disproportionately affects the poorest women, whose voices are scarcely heard. Every life counts and we hope that the need for better data to inform decision-making and planning at the national level will be recognised in international and national safe motherhood agendas and appropriate resources will be mobilised to collect reliable data about obstetric fistula. We declare no competing interests. Prevalence of symptoms of vaginal fistula in 19 sub-Saharan Africa countries: a meta-analysis of national household survey dataThis study is the first to estimate the burden of vaginal fistula in 19 sub-Saharan Africa countries using nationally representative survey data. Point prevalence was slightly lower than previously estimated but these earlier estimates are within the prevalence's credible intervals. Although vaginal fistula is relatively rare, it is still too common in sub-Saharan Africa. Full-Text PDF Open Access