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Obstetric fistula [message #1728] Wed, 02 April 2014 10:03
Messages: 2
Registered: April 2014
Location: New York
1. Obstetric fistula is one of the most serious maternal morbidities, and there continues to be insufficient information on incidence and prevalence for countries to appropriately plan and allocate health system resources for repair and prevention. Much information about the burden of fistula comes from studies analyzing convenience samples at facilities offering repair services, A recent attempt to estimate global prevalence relied on small studies that were for the most part, not designed to provide nationally representative numbers [1].

2. We recommend that three questions from the existing DHS fistula module be incorporated into the core women's questionnaire. Such inclusion would enable collection of data on this maternal morbidity in a routine and consistent manner. It would also enable the assessment of trends over time, currently a lost opportunity when the fistula module is included in some rounds but not others. We suggest that questions F1-F3 from the current fistula module be added to the core questionnaire. These questions read:

• F1: Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery. Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night? (Yes/No, skip to F3 if Yes)
• F2: Have you ever heard of this problem? (Yes/No)
• F3: Did this problem start after you delivered a baby or had a stillbirth? (After delivered baby/After had stillbirth/Neither)

It may be useful to add an additional response category to F3: "After a very early newborn death (first day)."

3. While population-based fistula-specific prevalence studies are generally cost-prohibitive, household survey information can be valuable in helping identify target areas for follow-up research and services. Additionally, while it may not be possible in every survey, special studies conducting clinical screening via pelvic exam on a subset of those reporting incontinence symptoms could be a useful complementary mechanism for generating information about prevalence and areas of highest risk. The data should be tabulated, presented, and used to estimate indicators in the same way that the current fistula model questions are analyzed and reported.

4. Fistula is currently not addressed in the core women's questionnaire. This topic is only addressed in the fistula module, which is not applied by all countries believed to have a significant fistula burden.

5. If only one question could be included, the priority would be F1. If only two questions could be included, the priorities would be F1 and F3. However, these three questions together provide meaningful information to guide program planning, including community outreach to identify women in need of repair. While survey-based assessment of incontinence may lead to over-estimation of fistula, including a question about stillbirth or very early neonatal death is informative, as studies estimate that a very high proportion of fistulas occur after a labor in which there is an intrapartum stillbirth or very early neonatal death [2-5].

6. These questions should be added to surveys in sub-Saharan Africa and South Asia.

Thank you,

Joseph Ruminjo, Fistula Care Plus, EngenderHealth
Ӧzge Tunçalp, Department of Reproductive Health and Research, World Health Organization
Vandana Tripathi, Fistula Care Plus, EngenderHealth

1. Adler AJ, Ronsmans C, Calvert C, Filippi V. Estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013 Dec 30;13:246.
2. Ibrahim T, Sadiq AU, Daniel SO. Characteristics of VVF patients as seen at the specialist hospital Sokoto, Nigeria. West Afr J Med. 2000 Jan-Mar;19(1):59-63.
3. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009 Oct;107 Suppl 1:S5-18, S19.
4. Siddle K, Vieren L, Fiander A. Characterising women with obstetric fistula and urogenital tract injuries in Tanzania. Int Urogynecol J. 2014 Feb;25(2):249-55.
5. Wall LL, Karshima JA, Kirschner C, Arrowsmith SD. The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol. 2004 Apr;190(4):1011-9.

Vandana Tripathi
Fistula Care Plus | EngenderHealth
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