Determination of Origin of Obstetric Fistula in Patients Receiving Care in Ebonyi State, Nigeria
Miller, S.; Janko, M.; Bengston, A.; Kuhn, R.; Adeoye, S. University of Denver, Josef Korbel School of International Studies
Obstetric Fistula Defined: Obstetric fistula (OF) is an abnormal hole caused by the necrosis of the tissue between the birth canal and surrounding areas due to obstructed labor. The tissues between the vagina, rectum, and bladder are the most often affected, resulting in incontinence.
In recent years, obstetric fistula has gained increasing attention as a major international public health concern. Despite greater awareness of this issue, it remains a critical problem about which relatively little is known. Prevalence Estimates: Although it is often cited that there are three million cases of fistula world wide, with approximately 50,000 100,000 new cases each year, these numbers are methodologically suspect and true prevalence and incidence rates are not known (1,2). Importantly, the large presence of fistula in the southeastern, Christian part of Nigeria stands in contrast to prevailing assumptions that fistula is a problem isolated to the northern, Muslim parts of the country. Fistula is believed to be most common in areas of the world reporting high maternal mortality rates, such as sub Saharan Africa and Asia (3). Patients often suffer from various social and clinical sequelae, including: Spousal abandonment (separation or divorce) in 36% of cases. Social rejection in 53% of Nigerian cases; depression in 33% (4). Repair facilities are not widely available, transportation costs and distances are high. The cost of emergency obstetric care is prohibitive. -The cost of a cesarean section in Nigeria is equivalent to 9 months of wages (5). Women often do not know that treatment exists, and 16-32% of women remain incontinent even after surgical repair (6). 80% of women with OF never seek treatment (1).
Discussion Aggregated Analysis
Prevalence of Fistula at the LGA level was positively correlated with poverty ( =.74; P = 0.006), whereas the correlation between treatment of fistula and poverty was not statistically significant ( =-.03; P = 0.92). Interestingly, women are developing fistula at a higher parity than what would otherwise be expected from a review of the relevant literature. Furthermore, women who developed fistula had a higher proportion of deliveries in a hospital than WOCBA in general, though this could be due to a number of reasons, including the possibility that women who were at risk for developing fistula were identified and thus more likely to deliver in a hospital. As expected, women with fistula were of slighter stature than the average for the region, and appear much more likely to be in a polygamous marriage.
This is a preliminary investigation of ongoing work in the region, and is currently being developed into a case control study. Because social rehabilitation is the ultimate goal for fistula patients, and because designing effective programs requires an understanding of patients' needs, this work seeks to provide sound quantitative analysis in support of that goal. Secondarily, it seeks to help make the current, qualitative literature on social rehabilitation of OF patients more robust.
Case data from Ebonyi State was obtained from hospital records and data gathered during the Southeast Regional Fistula Centre¶s community outreach efforts. Those data were then anonymized during a six-week period spanning April and May 2009, when investigator Angie Bengtson was in country. Those records were later matched to Geographic Information System (GIS) data obtained from a private Nigerian firm using ArcGIS 10 and Stata. Total cases and total repairs were mapped at the town level in order to gain an understanding of the spatial distribution of both fistula and treatment within Ebonyi. These data were then aggregated and mapped at the Local Government Area (LGA), and, using population and housing data from the 2006 Nigerian census, the investigators were able to estimate OF prevalence among women of child bearing age. Another map showing the repair rate (repairs/total cases) at the LGA level was constructed for further broad-based comparison. In order to understand the underlying economic conditions in Ebonyi in relation to fistula prevalence, the investigators conducted a factor analysis of several key socioeconomic variables and mapped the results so as to show the overall socioeconomic status within each Local Government Area (LGA). Finally, in an effort to begin to generate a patient profile, several indicators of fistula patients that were collected from the patient charts were compared to corresponding DHS data from the southeastern region of Nigeria.
The correlation between fistula prevalence and poverty at the LGA level was significant at the.01 level. =.74; P-value = 0.006 The correlation between treatment and poverty at the LGA level was not significant at any level. =-.03; P-value = 0.92
Starfish One by One Foundation South East Regional Fistula Centre Staff Ebonyi State University Teaching Hospital Staff University of Denver Social Science Foundation
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