Professor Karen Ballard, Dr Fekade Ayanachew, Professor Jeremy Wright and Habtamu Atnafu
The incidence of obstetric fistula remains high in countries where there is limited access or poor uptake of facility-based care during childbirth. Ethiopian women have traditionally delivered their babies at home and despite considerable increases in the availability of community based maternal services, the 2014 mini demographic health survey (undertaken in Ethiopia) revealed that just 15% of women delivered at a health facility.
The prevalence of both obstetric fistula and pelvic organ prolapse has been difficult to determine as women are often reluctant to disclose their symptoms, and the cost of performing large community-based prevalence studies makes them prohibitively expensive particularly as there is a need to identify the cause of urinary incontinence through clinical examination.
Studies have therefore tended to be small and often based on hospital inpatient populations or use data collected for different purposes where the diagnosis has not been confirmed by clinical examination.
This article summarises the excellent work of Professor Karen Ballard, Dr Fekade Ayanachew (Medical Director Addis Ababa Fistula Hospital), Professor Jeremy Wright and Habtamu Atnafu which was published in the International Urogynecology Journal – January 2016.
One of the many strengths of this research is that it attempted to survey a large number of women of reproductive age in Ethiopia who are based in the rural community.
23,023 women aged 15-49 years were randomly selected from a population living in communities served by 26 health centres based in 3 zones of North and East Ethiopia (East Harraghe, South Gondar and West Gojjam). The majority of people in these zones are living on subsistence farming. 113 health posts (which are based in villages) were selected to give a balance of women who lived close, a medium distance or far away from one of the 26 health centres. This resulted in 28,000 households being surveyed by Health Extension Workers (HEWs) who run the health posts.
The HEWs were all female and worked within the selected villages. They could therefore locate the selected households and because they were reasonably well acquainted with many of the women, they were able to have the intimate discussions required for the questions being asked. Data collection took 6-7 days depending on the terrain that had to be crossed.
Since the majority of women were unable to read or write, the survey was verbally administered and the responses written down for them. All women reporting symptoms of a possible fistula were seen by a clinical member of the research team and examined to confirm the diagnosis.
Ninety two percent of surveys were completed. The average age of women was 29.5 years with a significant 22% reporting that they were unaware of the symptoms of fistula (this varied between 11 and 31% across the three regions). Thirty-five suspected fistulae were reported and 13 of these were confirmed clinically.
All the women reported that the fistula occurred following childbirth, 11 of whom had a vaginal delivery and 2 a caesarean section. Sadly, only 3 of the 13 pregnancies resulted in a live birth.
The prevalence of fistula was therefore reported to be 6 per 10,000 (95% CI 3-8) reproductive age women (0.06%). The prevalence of untreated fistula was 2 per 10,000 (95% CI 0-4) reproductive age women (0.02%). The prevalence of symptomatic pelvic organ prolapse was 1% (95% CI 0.86-1.14) or 100 per 10,000 women.
Whilst the study was limited to three zones in Ethiopia, the finding of a clinically confirmed fistula prevalence of 6 per 10,000 women (0.06%) is significant and important to note that
Only 1/3 of the women with fistula-like symptoms in Karen Ballard’s study turned out to have a confirmed fistula.
A previously reported 1% prevalence1 in Ethiopia in 2005 did not include clinical examination to confirm the diagnosis, making it possible that the prevalence could have been overestimated then and its true level may have been closer to 0.3%. Even if this is true, the 2016 figures point to an important fistula reduction and is likely to reflect a general improvement in the uptake of maternal health services.
Since obstetric fistula largely results from prolonged obstructed labour, efforts to improve access to maternal health services should have a positive impact on the fistula prevalence. Improvements in maternal services have been prioritised in the fourth and final phase of the 20 year Ethiopian Health Sector Development Plan resulting in a sizeable increased provision of maternal care over the last few years. Community based health centres have increased in number along with increases in the number of midwives being trained.
Access to services has been made easier with better roads and the provision of ambulances prioritising women in labour. The apparent reduction in fistula prevalence seen in this study suggests that this integrated approach to maternal care is starting to bear fruit.
Click here to see how the Hamlin College of Midwives is improving access to quality healthcare and reducing fistula prevalence by deploying midwives into remote rural health centres.
There is still work to be done however – 23% of the Ethiopian population are women of reproductive age and if 2 in every 10,000 women have an untreated fistula, at least 5,000 women between the ages of 15-49 years still require fistula surgery. This figure does not include older women past reproductive age who may have lived with fistula for many years.
The HEW (health extension workers), as well as remotely placed midwives, will play a key role in identifying these women and facilitating their access to appropriate care at a hospital such as the Addis Ababa Fistula Hospital, or one of Hamlin Fistula Ethiopia’s other five regional hospitals.
Finally, while the prevalence of fistula appears to be declining, symptomatic pelvic organ prolapse remains a significant problem for women in Ethiopia and is likely to become more so as women live longer. The finding of 1% pelvic prolapse amongst reproductive age women means that at least 200,000 women suffer with the condition and given this is likely to be much higher in older women and the life expectancy of women in Ethiopia is rising, the rate of symptomatic pelvic organ prolapse is likely to increase.
Author: Felicity Gallimore – Obstetrician and Hamlin Fistula Ethiopia (Australia) volunteer.
- Central Statistical Agency (Ethiopia). Ethiopia Demographic & Health Survey 2005 (Addis Ababa, Ethiopia)