Obstetric fistula in Southern Sudan: situational analysis and Key Informant Method to estimate prevalence

Abstract

BackgroundObstetric fistula is a severe condition which can have devastating consequences for a woman’s life. Despite a considerable literature, very little is known about its prevalence. This project was conducted to carry out a situational analysis of fistula services in South Sudan and to pilot test the Key Informant Method (KIM) to estimate the prevalence of fistula in a region of South Sudan.MethodsKey stakeholder interviews, document reviews and fistula surgery record reviews were undertaken. A KIM survey was conducted in a district of Western Bahr-el-Ghazal in January 2012. One hundred sixty-six community-based distributors, traditional birth attendants and village midwives were trained as key informants to identify women with fistula in the community. Women identified were subsequently examined by an obstetrician and nurse to verify whether they had a fistula.ResultsThere were limited fistula repair services in South Sudan. Approximately 50–80 women per year attend periodic campaigns, with around half having a fistula and receiving a repair. On average a further 5 women a year received fistula repair from hospital services. Ten women with potential fistula were identified via KIM; all confirmed by the obstetrician. Of these, three were from the survey area, which had 8,865 women of reproductive age (15–49 years). This gives a minimal estimated prevalence of at least 30 fistulas per 100,000 women of reproductive age (95% CI 10–100).ConclusionsRoutine fistula repair services available do not meet the population’s needs. The pilot study suggests that KIM can be used to identify women with fistula in the community. Data on fistula are generally poor; the KIM methodology we used in South Sudan yielded a lower fistula prevalence than estimates reported previously in the region.

Validation of an obstetric fistula screening questionnaire in rural Nepal: a community‐based cross‐sectional and nested case–control study with clinical examination

“…A 2013 systematic review and meta‐analysis found only ten studies that used clinically confirmed cases to estimate community‐based OF prevalence; four of these were conducted in sub‐Saharan Africa or South Asia . Subsequent to the review, two population‐based cross‐sectional studies from southern Sudan and Pakistan used confirmatory clinical examinations; however, neither of these studies used a control population to assess the validity of the screening questions used to identify cases . At present, there is no widely used, well‐validated fistula screening tool.…”

“…The OF prevalence estimates from other population‐based studies with confirmatory clinical examinations from sub‐Saharan Africa and South Asia vary widely, and were significantly higher than those found in our study: 162 per 100 000 women (95% CI 153–264) in Ethiopia ( n = 19 153); 95 per 100 000 women (95% CI 2–526) in Gambia ( n = 1038); 30 per 100 000 women (95% CI 10–100) in Southern Sudan ( n = 8865); 86 per 100 000 (95% CI 2–480) in Maharashtra, India ( n = 1167); 260 per 100 000 (95% CI 7–1439) in Karnataka, India; and 390 per 100 000 women (95% CI 220–570) or 450 per 100 000 parous women (95% CI 250–650) in Pakistan ( n = 5064) . Notably, these studies used different sampling methodologies and none of the studies examined controls (women who did not report symptoms of OF).…”

Barriers to obstetric fistula treatment in low‐income countries: a systematic review

“…Once articles included in the review were compiled, researchers reviewed details of the articles and grouped them into five categories based on the extent to which the article discussed barriers to fistula treatment: 1 Barriers are the primary focus of the study 2 Article identifies factors that the reviewers perceived as barriers 3 Barriers are mentioned briefly in introduction or discussion, and barriers are not the primary focus of the article 4 Reviews/needs assessments/annual reports with some mention of barriers 5 Interventions aiming to remove barriers to fistula treatment Based on barriers identified by articles included in the review, the reviewers looked for similarities and differences between barriers to break them down into groups. Nine themes emerged: (1) psychosocial, (2) cultural, (3) awareness, (4) social, (5) financial, (6) transportation, (7) facility shortages, (8) quality of care and (9) political leadership.…”

“…Determining the number of women suffering with fistula worldwide is difficult, however, as many of these women are marginalised from society with little economic, social or political power. A recent systematic review found a pooled prevalence of 0.29 cases of fistula per 1000 women of reproductive age, and a pooled incidence of 0.09-0.66 new cases of fistula per 1000 recently pregnant women each year [7]. These data suggest approximately one million women with fistula in sub-Saharan Africa and South Asia and more than 6000 new cases per year in these two world regions [7].…”

“…A recent systematic review found a pooled prevalence of 0.29 cases of fistula per 1000 women of reproductive age, and a pooled incidence of 0.09-0.66 new cases of fistula per 1000 recently pregnant women each year [7]. These data suggest approximately one million women with fistula in sub-Saharan Africa and South Asia and more than 6000 new cases per year in these two world regions [7]. The true number of women living with fistula may be higher, as untreated patients who never reach a medical facility are more difficult to trace and some women with fistula may have minimal contact with healthcare services.…”