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Risk Factors for Obstetric Fistula : a clinical review

Dr Pierre Marie Tebeu,MD,MPH

Obstetrician Gynecologist,

University Hospital , Yaoundé Cameroon

e.mail: pmtebeu@yahoo.fr

Tel: 77 67 55 33

ISOFS 2010, Dakar , Senegal

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Plan

Introduction

Objective

Methods

Results

Summary

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Physiopathology of obstetric Fistula

Promontory

Pubis

Bladder

Rectum

Vagina

WHO, UNDP, UNICEF, World Bank. IMPAC. 2003

Obstructive labor

Com

pres

sion

VVF

RVF

-Hematoma-Asphyxia-Fetal death

Foot drop

Bladder

Rectum

Obturator nerve

Head

4

Objectives

To assess the current state of knowledge regarding the importance of obstetric fistula as a health problem, the patients’ characteristics and the circumstances of occurrence of the disease.

Discuss the contribution of the identified factors in Obstetric fistula prevention strategies

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Data Souce

• Search of the literature

• Identify all relevant articles

• Published between 1987-2008

• Database: Medline (Pubmed, Ovid), Cochrane Trials Register,

Cumulative Index to Nursing and Allied Health.

Search Strategy

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Term used:• obstetric fistula, • urinary fistula, • vesicovaginal fistula, • vesico vaginal fistula, • vesico-vaginal fistula, • recto-vaginal fistula, • rectovaginal fistula, • recto vaginal fistula

Variables of Interest

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place of birth; skilled birth attendance; duration of labour; mode of delivery; antenatal care attendance; age at marriage; age at first delivery; age at causal delivery; parity at causal delivery; use of family planning; additional factors

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Results

Teenager at first delivery

Meyer 2007; Ojanuga 1999; DHS Cameroon 2004; Wall 2004; Muleta 2004; Nafiou 2007; Ramsey 2007; Unfer 19959

• More than 84% of patients got marriage before the age of 20

• Mean age at marriage is between 14 and 16 years old

• Mean age at first delivery: 17 years

• Teenage status at operation: 2.5% -86 %

6.878.6811.5

15.7716.7719.3521.43

24.0824.8326.51

14.23

05

1015202530

Contribution of teenagers among deliveries in Cameroon %

Teenagers delivery in Cameroon

Tebeu et al. Obstet Gynecol Int 21010

Illiteracy

Illiteracy among OF patients: 78-96%

Maroua-Cameroon: 76% (Tebeu et al.2009)

Ijaiya 2004; Muleta 2004; Muleta 1997; Jokhio 2006; Meyer 2007; Gessessew 2003; Ramsey 2007; Wall 2004; Rijken 2007; Holme 2007, 11

Illiteracy in Cameroon

65.3

33.4

3.3

57.7

73.6

7

78.2

11.5 9.4

35.222.3

8

40.5

0102030405060708090

Illeteracy in Cameroon %

DHS 2004

Lack of Antenatal care

DHS Cameroon 2004; Gessessew 2003; Jokhio 2006; Ramsey 2007; Wall 2004; Home 2007; Ould el Joud 2001

Lack of antenatal care: 72-92% of patients

Maroua-Cameroon: 46%

WHO recommend at least 4 ANC during each pregnancy

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Duration of labor

Holme 2007; Arroswsmith 1994; Nafiou 2007; Muleta 2004; Ijaiya 2004; Hilton 1998; Wall 2004; Ahmad 2005; Ramsey 2007; Roenneburg 2007; Rahman 2003.

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The mean duration of labour among the fistula patients range from 2.5 to 4 days.

Labor > 24 hrs: 73- 95.7 %

OF patients have been in labour for more than 24 hours

Place of delivery

Home delivery in many studies: 30-44%

Delivery failure at home, then go to facility: 58-91%

DHS Cameroon 2004; Gessessew 20003; Ramsey 1994; Holme 2007;Meyer 2007;Hilton 1998; Ijaiya2004 15

Home delivery in Cameroon

DHS 2004

Low Cesarean section rate

Paxton 2006, DHS Cameroon 2004; Nafiou 2007; Muleta 2004; Hilton 1998; Wall 2004; Ramsey 2007; Rijken 2007; Meyer 2007; Holme 2007

By many studies: 20-54%

Some studies: 6-10%Nigeria (Ijaiya2004),

Ethiopia (Gessessew 2003)

Pakistan (Ahmad 2005

(all with labor > 24: >80% for all)

Cesarean section delivery according to the population

36.42.00.4 5.0

15.0

0.010.020.030.040.0

OF patients Far NorthProvince (DHS

2004)

Cameroon(DHS 2004)

UN (Low est) UN (Highest)

PopulationPe

rcent

age

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Cesarean delivery in Cameroon

0.6 0.7

5.1

0.80.4

4.7

0.3

3.1

2.22.9

4.4 4.7

2

0

1

2

3

4

5

6

Cesrarean delivery %

DHS 2004

Association between CS rate and maternal mortality from 118

countries

Cesarean secttion rate

Mat

erna

l mor

talit

y ra

te p

er 1

00,0

00 li

ve b

irths

Adapted from: Althabe 2006

Grand multiparity

¨ Study from Pakistan : >= 6 deliveries (54.43%) (Ahmad 2005)

¨ 1 of 6 studies from Nigeria (Mean/median Parity at 6(Hilton 1998

Sources: UN 2001; Population Reference Bureau 2002 (use of modern contraception, TFR)

Total Fertility Rate In Cameroon

4.55.5

3.2

6 6.4

4.3

6

4.7

6

4.63.7

3.2

5

01234567

Total fertility Rate

DHS 2004

Summary on OF Risk factors

Teenage conditionNulliparity/Grand multiparityHome deliveryLate arrival in the facilityPoor obstetric managementProlonged labor

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END

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WAHA GFMR

University Centre Hospital Yaoundé

LIRASEF