Estimating the Prevalence and Risk Factors of Obstetric Fistula in Ethiopia: Results from Demographic and Health Survey.

INTRODUCTION: Obstetric fistula is the most common obstetric problem in low- and middle-income countries where maternal care is inaccessible. Obstetric fistula has serious social and economic consequences resulting in devastating health problems for women. There is a lack of national studies that show the burden of obstetric fistula and risk factors; as a result, this study aimed to estimate the prevalence of obstetric fistula, its symptoms, and risk factors in Ethiopia.
METHODS: A population-level cross-sectional study was conducted with a total of 7590 women who gave birth in the last 5 years, using data from the 2016 Ethiopian Demographic and Health Survey. Complex sample analysis and normalized weighting were used to compensate for the disproportionate sampling in the survey. A multivariable logistic regression model was fitted to find a significant association between obstetric fistula and covariates. Both odds ratios (crude and adjusted) with their corresponding 95% confidence intervals (CI) were reported.
RESULTS: Among the 7590 women having given birth in the last 5 years, 32 (0.42%) women with obstetric fistula were identified. Of these, 64% developed obstetric fistula after live birth and 23.1% developed obstetric fistula after stillbirth. More than 72.8% were associated with prolonged and very difficult labor. No history of contraceptive use (AOR = 3.43; 95% CI: 1.05-11.21), having a big problem of distance from the health facility (AOR = 3.7; 95% CI: 1.05-11.21), early marriage (AOR = 1.52; 95% CI: 1.12-3.5), and being a rural resident (AOR = 1.5; 95% CI:1.2-5.05) were risk factors associated with obstetric fistula.
CONCLUSION: This study finding revealed that obstetric fistula is the most common devastating obstetric problem in Ethiopia. Early marriage, early initiation of sexual intercourse, distance from the health facility, no history of contraceptive use, and rural residence were the predisposing factors to develop an obstetric fistula. Thus, interventions should focus on creating community awareness regarding early marriage and its consequences, early seeking of health facility visiting, and avoiding unintended pregnancy to minimize the subsequent complications.

Introduction

Obstetric fistula is an abnormal connection between a woman’s genital tract and the urinary tract (vesicovaginal fistula) or between the genital tract and the rectum (rectovaginal fistula), predominantly resulting from obstructed labor. Globally, the prevalence of obstetric fistula is nearly 2 million with an estimated incidence of 50,000–100,000 new cases registered each year.1,2 In sub-Saharan Africa 30,000–130,000 new fistula cases were recognized and registered per year. Women who experience obstetric fistula suffer constant incontinence, shame, social segregation, and health problems. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa.25

Obstetric fistula is a complication of childbirth existing nearly solely in low- and middle-income countries and results from prolonged and obstructed labor. It causes substantial grief for the affected women, the continual leakage leads to co-morbidities, and women become ostracized and shunned by their community due to incontinence of urine and/or stool. Women with obstetric fistula encounter health, psychological, and social consequences that are not completely resolved by repairing the fistula.3,4

In low and middle-income countries, limited obstetric care due to shortage of resources, and poor childhood nutrition in development, are associated with obstructed and prolonged labor resulting in downward pressure of the baby’s head on the mother’s pelvis. This leads to damage of tissue in the birth canal which can cause necrotizing of the tissue, thus creating an abnormal communication between organs i.e. obstetric fistula. Whereas, in high-income countries, the cause of obstetric fistula is likely due to iatrogenic causes, such as radiation therapy and any pelvic surgical interventions.5,6

Even though the number of new cases registered every year is more than 3000, around 1447 fistula cases were repaired in all treatment centers of Ethiopia.7

Various studies have reported that being a rural resident, not having attended formal education, not attending antenatal care, no skilled birth attendants, poor health-seeking behavior, poor referral systems, and transportation network, inadequate facilities providing comprehensive obstetric care services, poverty, malnutrition, lack of education, early marriage and childbirth, maternal age, number of births, harmful traditional practices, sexual violence, and lack of good quality or accessible maternal and health care were the contributing factors of obstetric fistula.8–10

Estimation of the burden of obstetric fistula in low-income countries is still a challenge. Urgent action should be made to develop appropriate methods for measuring the national burden of obstetric fistula in order to understand the need for and to provide effective maternal health care. Moreover, the main aim of this study was to estimate the prevalence of obstetric fistula, its symptoms, and risk factors from a further population-level cross-sectional study using the 2016 Ethiopian Demographic and Health Survey. Furthermore, investigating the magnitude of obstetric fistula among reproductive-age women helps in planning to increase community awareness via delivering preventive strategies and opportunities against obstetric fistula at the health institution and community level.

Methods and Materials

Study Area and Design

This study was conducted in Ethiopia using the 2016 Ethiopian Demographic and Health Survey data, which were collected by the Central Statistical Agency (CSA), Ethiopia, and the DHS Program, ICF.

Data and Sampling Procedures

Data for this study were retrieved from the 2016 EDHS, which used a weighted multistage, stratified cluster sampling approach. The 2016 EDHS data employed a two-stage stratified cluster sampling procedure. These are stratification into urban and rural areas and secondly, a fixed number of households were selected systematically from the selected clusters. Then, all women aged 15–49 years in the selected households were included. Women who had a live birth in the last 5 years before the interview were included in this survey. A total of 15,683 women aged 15–49 years were interviewed in the 2016 EDHS, of which 7590 women had at least one live birth in the last 5 years before the survey; 8093 women were excluded from the study due to not having given birth in the 5-year period prior to the survey. Overall, the included sample size for this study was 7590 women who had at least one birth in the last 5 years before the survey, and women with known obstetric fistula in the last 5 years before the survey were excluded.

Objectives

Primary Objective

Estimating the prevalence of obstetric fistula.

Secondary Objective

Risk factors associated with obstetric fistula.

Outcome

Obstetric fistula among women who had at least one birth in the 5-year period prior to the survey.

Experience of Obstetric Fistula: Having a Constant Leakage of Urine or Stool from the Vagina

Obstetric fistula among women who had at least one birth in the 5-year period prior to the survey was the primary outcome of the study which coded as Not experienced obstetric fistula “0” and Experienced obstetric fistula “1”.

Independent Factors

Socio-Demographic and Economic Factors

Region, age at first marriage, age at first birth, age at first delivery, marital status, residence, educational status, employment status, and wealth index.

Maternal, New-Born and Related Indicators

Parity, place of delivery, the status of pregnancy, antenatal care, body mass index, sex of the neonate, the distance of health facility, and birth weight.

Operational Definitions

Household Wealth Quintile

The wealth index classifications were in quintiles: poorest; poor; middle; rich; richest. These were computed using principal component analyses (PCA).

Perceived Distance to Health Facility

The responses for this variable were neither quantitative nor specific to services for delivery. The survey question asked women if the distance was a problem for them to get any medical help from health institutions, not limited to delivery care. The responses were coded as: “yes, big problem”: or, “not a big problem”. We used the same codes for the current study.

Place of Residence

This variable in the EDHS can explain the characteristics of the clusters directly. The two categories were: urban; rural.

Data Processing and Analysis

SPSS version 24 statistical software was used for analysis. A complex sample survey (stratified/clustered) sampling design was used to correctly calculate unequal probabilities of selection with weighted data. Rao-Scott chi-square has been employed to investigate the relationship between different predictors and experience of obstetric fistula through adjusting complex survey sampling. Multivariable binary logistic regression model was fitted to identify the association between explanatory variables and obstetric fistula.

Bivariable logistic regression has been employed to examine the association between obstetric fistula and its risk factors. Both descriptive and inferential statistics were used to present the findings of the study. Multicollinearity was checked to examine the correlation among independent variables. Model fitness was checked with Hosmer Lemeshow test. Finally, adjusted odds ratio (AOR) and crude odds ratio (COR) with its corresponding 95% confidence intervals (CI) with a p-value < 0.05 in multivariable logistic regression were used to declare the statistical association between obstetric fistula and risk factors.

Results

Socio-Demographic and Economic Characteristics

More than three-fourths of the study participants resided in rural parts of Ethiopia. Amongst the total study participants, 93.7% were in union/married. Regarding ethnicity, 41.2% of the women were Oromia ethnic group followed by Amhara 21.5% (Table 1).

Table 1

Socio-Demographic and Economic Characteristics of Women Who Gave Birth in the Five Years Preceding the EDHS 2016, Ethiopia

Variables	Frequency (N)	Percent (%)
Educational status of women
No education	4791	63.1
Primary education	2150	28.3
Secondary education	429	5.5
Higher education	230	3
Residence
Urban	969	12.77
Rural	6621	87.23
Marital status
Married	7109	93.7
Single	56	0.7
Widowed	95	1.3
Divorced	233	3.1
Separated	97	1.3
Religion
Orthodox	2882	38
Muslim	2824	37.2
Other (Protestant, Catholic, Traditional)	1884	24.8
Age at first birth
Below 15 years	1101	15.4
15–19 years	3698	51.6
20–24 years	2216	30.9
25 years and above	156	2.2
Employment status
Currently working	2172	28.6
Not currently working	5418	71.4
Wealth index
Poorest	1651	21.8
Poorer	1654	21.8
Middle	1588	20.9
Richer	1427	18.8
Richest	1269	16.7
Age at first marriage
Below 18 years	5470	72.6
18 years and above	2064	27.4
Region
Amhara	1632	21.5
Oromia	3129	41.2
SNNPR	1601	21.1
Tigray	537	7.1
Harari	17	0.2
Benishangul Gumuz	81	1.1
Gambela	21	0.3
Afar	71	0.9
Addis Ababa	198	2.6
Dire Dawa	33	0.4
Somali	269	3.5
Age at first sexual intercourse
Before 18 years	5925	78. 1
18 years and above	1665	11.9

Obstetrics and Related Characteristics

From the overall study participants, 62.7% of the women had antenatal care follow-up. Regarding body mass index, 71.4% of the women had normal body mass index (Table 2).

Table 2

Obstetrics and Related Characteristics of Women Who Gave Birth in the Five Years Preceding the EDHS 2016, Ethiopia

Variables	Frequency (N)	Percent (%)
Antenatal care
Yes	4757	62.7
No	2833	37.3
Distance of health facility
Big problem	4407	58.1
Not big problem	3183	41.9
Place of delivery
Health institution	861	6.5
Others (Home, on ambulance)	6729	93.5
Body mass index
Underweight	1458	19.2
Normal	5423	71.4
Overweight	411	5.4
Obesity	298	3.9
Sex of neonate
Male	3941	51.9
Female	3649	48.1
Status of pregnancy
Planned	2016	26.6
Unplanned	5574	73.4
Contraceptive use
Yes	2699	35.6
No	4891	64.4

Characteristics of Patients with Obstetric Fistula

From the total 7 patients who underwent an operation to fix their fistula, 4 of them were completely healed and the leakage was completely stopped. Out of 32 women having obstetric fistula, 21 of them suffered from obstetric fistula resulted during delivery of a baby and 20 of them were developed fistula due to obstructed and prolonged labor (Table 3).

Table 3

Characteristics of Women Who Gave Birth in the Five Years Preceding the EDHS 2016, Ethiopia

Variables	Frequency (N)	Percent (%)
At what time the problem happened
During delivery of a live baby	21	65.6
During delivery of a stillbirth	7	21.9
Neither delivering live/stillbirth	4	12.5
Condition of labor
Normal labor/delivery	8	28.57
Prolonged/very difficult labor	20	71.42
Sought treatment for fistula
Yes	17	53.1
No	15	46.9
Where the person sought fistula treatment
Health facility	11	64.7
Others* (religion & tradition)	6	35.3
Operation to fix fistula
Yes	7	41.2
No	10	58.8
Has the leakage stopped completely after fixation
Yes, completely stopped	4	57.14
No, not completely stopped but reduced	3	42.86

Risk Factors Associated with Obstetric Fistula

In multivariable logistic regression, distance from the health facility, history of contraceptive utilization, age at first marriage, and residence were found to be significantly associated with obstetric fistula. The odds of experiencing obstetric fistula among women who had no contraceptive use were 3.43 times (95% CI: 1.05–11.21) higher compared with women who had contraceptive use. Women who had a big problem of distance from the health facility had 3.7 times (95% CI: 1.05–11.21) higher odds of experiencing obstetric fistula compared with their counterparts. Women who had early marriage were 1.52 times (95% CI: 1.12–3.5) more likely to develop obstetric fistula compared with their counterparts. The odds of experiencing obstetric fistula among women who resided in rural areas were 1.5 times (95% CI:1.2–5.05) higher compared with women who resided in urban areas (Table 4).

Table 4

Bivariable and Multivariable Logistic Regression of Women Who Gave Birth in the Five Years Preceding the EDHS 2016, Ethiopia

Variable	Experienced of Obstetric Fistula		COR	AOR	Pseudo R Squared measures
	Yes	No			Cox and Snell	Nagelkerke	McFadden
Distance from health facility					0.001	0.023	0.022
Big problem	26	4380	3.14(1.26–9.8)	3.7(1.4–10.2)
Not big problem	6	3178	1	1
Contraceptive use					0.001	0.019	0.018
Yes	5	2694	1	1
No	27	4864	2.99(1.1–10.4)	3.43(1.05–11.21)
Age at first sexual intercourse					0.011	0.011	0.011
Before 18 years	29	5896	2.7(1.05–10.17)	1.4(0.89–9.87)
18 years and above	3	1662	1
Age at first marriage					0.000	0.001	0.001
Early marriage	24	5445	1.13(1.03–3.8)	1.52(1.12–3.5)
Late marriage	8	2057	1	1
Antenatal care					0.000	0.001	0.001
Yes	22	4735	1	1
No	10	2823	0.76(0.26–2.36)	0.6(0.2–1.9)
Residence
Rural	29	6592	1.4(1.2–5.75)	1.5(1.2–5.05)	0.000	0.002	0.002
Urban	3	966	1	1
Place of delivery					0.000	0.005	0.005
Health facility	7	855	1	1
Others (Home, on ambulance)	25	6704	0.45(0.2–1.65)	0.3(0.08–1.13)
Status of pregnancy					0.000	0.005	0.005
Planned	20	5554	1	1
Unplanned	12	2004	1.66(0.6–4.3)	1.52(0.75–5.03)

Discussion

This is the first nationwide demographic and health survey analysis on the prevalence and associated factors of obstetric fistula in Ethiopia. This study revealed that the prevalence of obstetric fistula is 0.42%. History of contraceptive use, distance from the health facility, age at first sexual intercourse, early marriage, and rural residence were the risk factors associated with obstetric fistula. The finding of this study is lower than in India (23.7%), and Nigeria (3.2%). The discrepancy might be due to the inclusion criteria or the study participants, sample size, socioeconomic status, and the availability of the maternal health-care system of the country.11,14

A worldwide systematic review and meta-analysis result showed that the prevalence of obstetric fistula in South Asia (1.2%), sub-Saharan Africa and South Asia (1.60), Malawi (0.26%), Nigeria (1.1%), Kenya (0.44%), and sub-Saharan Africa (1.57) was in line with these study findings.12,15–17 As the WHO has suggested that over 2 million women, mostly from sub-Saharan African and Asian countries, have a fistula, this would suggest that 3 per 1000 women of reproductive age have a fistula, which is considerably lower than our estimate for the Ethiopian demographic and health survey study.13

The Uganda Demographic and Health Surveys (DHS) showed that 1–2% of Ugandan women have symptoms of OF, of whom only 62% have sought treatment, which is in line with this study finding; of the 32 obstetric fistula patients, 17 (51.8%) have sought treatment. This might be due to the quality of health-care services and accessibility being quite similar. The odds of having obstetric fistula among women who resided in rural areas was 1.5 times higher than that of women who resided in urban areas (AOR = 1.5; 95% CI: 1.2–5.05).

Various works of literature show that rural place of residence is the major risk factor for obstetric fistula, as evidenced by studies conducted in Ethiopia,19 Zambia,20 and West Africa.21 The risk of having obstetric fistula was 1.52 times higher among women having early marriage (marriage <18 years old) than having marriage after 18 years old (AOR = 1.52 (95% CI; 1.12–3.5). Issues of maternal health everywhere are critical since gender-based violence, harmful practices such as female genital mutilation, and early marriages are all contributing factors to the fistula problem across the world.

Women who were not using contraceptives were 3.43 times more likely to have experience of obstetric fistula than women using any contraceptive after controlling for other variables in the model (OR = 3.43; 95% CI: 1.05–11.21). Literatures show that family planning programs can reduce the number of pregnancies in a given population and thus reduce the number of women at risk for pregnancy complications, moreover, obstetric fistula can be prevented through contraception via prevention of unplanned pregnancy.

Women having a big problem in reaching a health facility were 3.7 times more likely to experience obstetric fistula than women with a health facility in close reach(AOR = 3.7; 95% CI:1.4–10.2). This study finding is consistent with one conducted in Kenya which showed that taking more than 2 hours to reach a health facility was a predisposing factor for obstetric fistula.23 In addition, according to the delay model, there are three delays that contribute to obstetrics fistula development: delay in making the decision to seek care; delay in arrival at a health facility; and delay in the provision of adequate care resulting in obstetric fistula.24 Distance from health-care facilities was a determinant factor as playing a role in the delay in seeking of treatment during childbirth. This study advocates nationally representative data, as an advanced sample size can be used to show the burden of the problem. However, this study has a shared cross-sectional study design, which may not show a cause and effect relationship. Besides, the effects of the health system, women’s knowledge and perceptions towards obstetric fistula, and health-worker factors were no assessed.

Conclusion

In sub-Saharan Africa and Asian countries, it is conservatively estimated that more than 2 million young women live with untreated obstetric fistula. This study finding revealed that obstetric fistula is directly linked to one of the major causes of maternal mortality due to obstructed labor. Early marriage, distance from the health facility, no history of contraceptive use, and rural residence were the predisposing factors to develop an obstetric fistula. Thus, interventions should focus on creating community awareness regarding early marriage and its consequences, early seeking of health facility visiting, and avoiding unintended pregnancy to minimize the subsequent complications.