Risk factors for obstetric fistula in western uganda: A case control study

PLoS ONE, Volume 9, No. 11, Year 2014

Ukuhunyushwa

Introduction: Two million women worldwide are living with genital fistula with an annual incidence of 50,000-100,000 women. Risk factors for obstetric fistula are context bound. Studies from other countries show variation in the risk factors for obstetric fistula. This study was conducted to identify risk factors for obstetric fistula in western Ugandan context. The study was conducted at Kagadi and Kyenjojo general hospitals and Hoima regional referral hospital in western Uganda. The three sites are established sites for fistula outreach treatment. Data was collected from November 2011 to May 2012. This area is a rural, predominantly farming area with poor reproductive health indicators, and have the highest prevalence of fistula (4%) in the country [10]. Maternal health care utilization is low with only 56 per cent of women giving birth assisted by skilled birth attendants [11]. A case control study design was used in which 140 cases and 280 controls were included using face-to-face interviews. The interviewers were four research assistants, the first author, who is a gynaecologist trained in fistula surgery and three trained midwives from Mulago and the respective hospitals. Cases were patients confirmed by a doctor to have obstetric fistula irrespective of type and duration. The controls were other women without fistula who had ever given birth and were seeking treatment or attending to patients in the study units. Since these are community units, it was assumed that both cases and controls had a similar environmental exposure and were representative of the population in the area. The sample size was calculated apriori using OpenEpi, based on the formula described by Kelsey et al [30], with 95% two sided confidence level, 80% power and two controls per case. The exposure factor was the proportion of women delivering with no skilled birth attendant. We assumed that women with fistula were likely to have had no skilled labour monitoring and delivery. We also assumed that the controls were like any other Ugandan women reported in the 2006 Uganda demographic and health survey, where 58 per cent of the women were delivering with no skilled attendance [10]. With the resources at our disposal we aimed to have an effect difference of 14 per cent and hypothetically assumed that the proportion of those with fistula delivering without skilled attendance was 72.4 per cent. From the OpenEpi calculator, our sample size was hence fixed at 140 cases and 280 controls (one case to two controls). Cases were then recruited consecutively and for each case two controls were identified and interviewed. Women from the study area, who presented for treatment, were screened, confirmed to have obstetric fistula and then enrolled as cases. The cases were confirmed to have obstetric fistula through history and pelvic examination. Controls were women, who had delivered before, with similar or higher parity corresponding to the pregnancy that resulted into fistula in the corresponding case and were frequency age-matched within a range of 5 years. Women with fistula not following labour process or its management like those with carcinoma, trauma, infections and others were excluded. Also women who were not from the study geographical location were excluded as either cases or controls. The study variables included socio-demographic, physical and obstetric factors highlighted in the literature to predispose women to fistula. The socio-demographic factors were; age at interview, age at marriage, age at first pregnancy, marital status, religion, respondent’s education, spouse’s education, occupation of spouse, occupation of respondent, and distance to the nearest health facility providing emergency obstetric care including caesarean section. The physical characteristics were height of the respondent and the baby’s weight. The obstetric factors were: parity, antenatal care attendance, number of antenatal visits, being accompanied by husband, having a delivery plan, use of herbs in pregnancy and labour, attending antenatal health education classes, and being told the babies presentation. Other obstetric factors included mode of delivery, delivery attendant, and whether there was delay at facility (time spent at the health facility before delivery) or delay in making a decision to seek care, and the duration of labour. The data were collected using an interviewer-administered questionnaire by the first author assisted by trained research assistants who were midwives. A similar questionnaire was administered to both women who were the cases and those without fistula in the control group. Women who fulfilled the inclusion criteria were interviewed from a quiet and private room identified from outpatient department of the respective hospitals. The interviewers were knowledgeable in the local language and would translate the information and fill the data directly in English. The first author checked that data were filled in before respondents left the study site. All the data were double entered in a computer and cleaned using Epidata version 3.1. Prior to data entry, the Epidata computer screen had been fitted with range and consistency checks. The data were exported to STATA version 12 [31] for further cleaning and then analysed by the first author assisted by the second author. All variables were tested for significance at bivariate level using chi-square and the student’s t-test for categorical variables and continuous variables respectively. Covariates that were significant at bivariate level with a P-value of less than 0.1 were entered in a multivariate stepwise (backwards and forwards) logistic regression model and the covariates included were tested for interaction and confounding. Odds ratios and 95% confidence interval were computed. The backward likelihood ratio method was used to select the best fitting model. Duration of labour in hours was the most significant variable in the model and was hence taken as the main predictor for obstetric fistula. Interaction terms for duration of labour and other variables were added in the models. We used the log ratio test where the fitness of the model with all the interaction terms included was compared with a fit of the model with none of the interaction terms. During the log ratio tests, the negative two-log likelihood (-2LL) of the full model and the reduced models were compared. Interaction was considered present when the difference between the -2LL were significant at P≤0.5 with a chi square test. Confounding was considered present if the difference between crude and adjusted odds ratios was greater than or equal to ten per cent. Depending on contribution to the goodness of fit of the model, variables left out were brought back into the model. Hosmer and Lemeshow’s goodness of fit test was applied to check on quality of the model [32]. Respondents were given detailed information about the study: that participation was voluntary, no one would be denied access to services because of refusal to participate in the study, and that information obtained was confidential and would be used only for the purpose of the study. The study received ethical approval from institutional review boards in Uganda and Sweden (requirement for the Makerere University and Karolinska Institutet collaboration). In Uganda, the study received ethical approval from Makerere University, School of Medicine Research and Ethics Committee (#REC REF 2011-104). We also received ethical clearance and approval from the Uganda National Council for Science and Technology (UNCST) registration number HS 1337. We got verbal permission from the respective medical directors/superintendents of Hoima, Kagadi and Kyenjojo hospitals to conduct the study in the respective hospitals. From Sweden, the study protocol was presented and we received approval from the Regional Ethics Committee in Stockholm, (Protocol 2012/2∶4). Informed written consent was obtained from respondents before inclusion in the study. The three participants who were under 18 years assented and also their accompanying parents/guardians gave a written consent. The study conformed to the principles in the Helsinki declaration. All the data were kept confidential and participants were compensated for their time spent during the interviews with 5000 Uganda shillings (USD 2). Those cases not yet operated had their fistulas closed in the week following the interviews by the first author who is trained and skilled in fistula surgery.

I-AI Digest

Study Justification:

– Obstetric fistula is a significant global health issue affecting millions of women worldwide.
– The risk factors for obstetric fistula vary across different contexts and countries.
– This study aimed to identify the risk factors for obstetric fistula in the western Ugandan context, where the prevalence of fistula is high and reproductive health indicators are poor.

Study Highlights:

– The study was conducted at three hospitals in western Uganda, which are established sites for fistula outreach treatment.
– Data was collected from November 2011 to May 2012.
– A case control study design was used, with 140 cases and 280 controls included.
– The study variables included socio-demographic, physical, and obstetric factors known to predispose women to fistula.
– The data were collected through face-to-face interviews with trained research assistants.
– The data were analyzed using statistical methods, including logistic regression.

Study Recommendations:

– The study identified duration of labor as the most significant risk factor for obstetric fistula.
– Other significant risk factors included lack of skilled birth attendance, delay in seeking care, and low utilization of antenatal care.
– These findings highlight the importance of improving access to skilled birth attendants, promoting timely decision-making for seeking care, and increasing antenatal care utilization.
– The study recommends targeted interventions to address these risk factors and reduce the incidence of obstetric fistula in western Uganda.

Key Role Players:

– Gynaecologists and obstetricians
– Midwives
– Research assistants
– Hospital administrators
– Policy makers
– Community health workers

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers
– Infrastructure and equipment for healthcare facilities
– Outreach and awareness campaigns
– Antenatal care services
– Skilled birth attendants
– Transportation and logistics for healthcare delivery
– Monitoring and evaluation of interventions
– Research and data collection

Amandla Obufakazi

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is a case-control study, which is a commonly used design for investigating risk factors. The study included a sufficient number of cases and controls, and the data collection methods were described. However, there is no mention of blinding or randomization, which could introduce bias. To improve the strength of the evidence, the study could have included a larger sample size and used a randomized controlled trial design. Additionally, the abstract could have provided more information on the statistical analysis methods used and the results obtained.

Abstract

The study was conducted at Kagadi and Kyenjojo general hospitals and Hoima regional referral hospital in western Uganda. The three sites are established sites for fistula outreach treatment. Data was collected from November 2011 to May 2012. This area is a rural, predominantly farming area with poor reproductive health indicators, and have the highest prevalence of fistula (4%) in the country [10]. Maternal health care utilization is low with only 56 per cent of women giving birth assisted by skilled birth attendants [11]. A case control study design was used in which 140 cases and 280 controls were included using face-to-face interviews. The interviewers were four research assistants, the first author, who is a gynaecologist trained in fistula surgery and three trained midwives from Mulago and the respective hospitals. Cases were patients confirmed by a doctor to have obstetric fistula irrespective of type and duration. The controls were other women without fistula who had ever given birth and were seeking treatment or attending to patients in the study units. Since these are community units, it was assumed that both cases and controls had a similar environmental exposure and were representative of the population in the area. The sample size was calculated apriori using OpenEpi, based on the formula described by Kelsey et al [30], with 95% two sided confidence level, 80% power and two controls per case. The exposure factor was the proportion of women delivering with no skilled birth attendant. We assumed that women with fistula were likely to have had no skilled labour monitoring and delivery. We also assumed that the controls were like any other Ugandan women reported in the 2006 Uganda demographic and health survey, where 58 per cent of the women were delivering with no skilled attendance [10]. With the resources at our disposal we aimed to have an effect difference of 14 per cent and hypothetically assumed that the proportion of those with fistula delivering without skilled attendance was 72.4 per cent. From the OpenEpi calculator, our sample size was hence fixed at 140 cases and 280 controls (one case to two controls). Cases were then recruited consecutively and for each case two controls were identified and interviewed. Women from the study area, who presented for treatment, were screened, confirmed to have obstetric fistula and then enrolled as cases. The cases were confirmed to have obstetric fistula through history and pelvic examination. Controls were women, who had delivered before, with similar or higher parity corresponding to the pregnancy that resulted into fistula in the corresponding case and were frequency age-matched within a range of 5 years. Women with fistula not following labour process or its management like those with carcinoma, trauma, infections and others were excluded. Also women who were not from the study geographical location were excluded as either cases or controls. The study variables included socio-demographic, physical and obstetric factors highlighted in the literature to predispose women to fistula. The socio-demographic factors were; age at interview, age at marriage, age at first pregnancy, marital status, religion, respondent’s education, spouse’s education, occupation of spouse, occupation of respondent, and distance to the nearest health facility providing emergency obstetric care including caesarean section. The physical characteristics were height of the respondent and the baby’s weight. The obstetric factors were: parity, antenatal care attendance, number of antenatal visits, being accompanied by husband, having a delivery plan, use of herbs in pregnancy and labour, attending antenatal health education classes, and being told the babies presentation. Other obstetric factors included mode of delivery, delivery attendant, and whether there was delay at facility (time spent at the health facility before delivery) or delay in making a decision to seek care, and the duration of labour. The data were collected using an interviewer-administered questionnaire by the first author assisted by trained research assistants who were midwives. A similar questionnaire was administered to both women who were the cases and those without fistula in the control group. Women who fulfilled the inclusion criteria were interviewed from a quiet and private room identified from outpatient department of the respective hospitals. The interviewers were knowledgeable in the local language and would translate the information and fill the data directly in English. The first author checked that data were filled in before respondents left the study site. All the data were double entered in a computer and cleaned using Epidata version 3.1. Prior to data entry, the Epidata computer screen had been fitted with range and consistency checks. The data were exported to STATA version 12 [31] for further cleaning and then analysed by the first author assisted by the second author. All variables were tested for significance at bivariate level using chi-square and the student’s t-test for categorical variables and continuous variables respectively. Covariates that were significant at bivariate level with a P-value of less than 0.1 were entered in a multivariate stepwise (backwards and forwards) logistic regression model and the covariates included were tested for interaction and confounding. Odds ratios and 95% confidence interval were computed. The backward likelihood ratio method was used to select the best fitting model. Duration of labour in hours was the most significant variable in the model and was hence taken as the main predictor for obstetric fistula. Interaction terms for duration of labour and other variables were added in the models. We used the log ratio test where the fitness of the model with all the interaction terms included was compared with a fit of the model with none of the interaction terms. During the log ratio tests, the negative two-log likelihood (-2LL) of the full model and the reduced models were compared. Interaction was considered present when the difference between the -2LL were significant at P≤0.5 with a chi square test. Confounding was considered present if the difference between crude and adjusted odds ratios was greater than or equal to ten per cent. Depending on contribution to the goodness of fit of the model, variables left out were brought back into the model. Hosmer and Lemeshow’s goodness of fit test was applied to check on quality of the model [32]. Respondents were given detailed information about the study: that participation was voluntary, no one would be denied access to services because of refusal to participate in the study, and that information obtained was confidential and would be used only for the purpose of the study. The study received ethical approval from institutional review boards in Uganda and Sweden (requirement for the Makerere University and Karolinska Institutet collaboration). In Uganda, the study received ethical approval from Makerere University, School of Medicine Research and Ethics Committee (#REC REF 2011-104). We also received ethical clearance and approval from the Uganda National Council for Science and Technology (UNCST) registration number HS 1337. We got verbal permission from the respective medical directors/superintendents of Hoima, Kagadi and Kyenjojo hospitals to conduct the study in the respective hospitals. From Sweden, the study protocol was presented and we received approval from the Regional Ethics Committee in Stockholm, (Protocol 2012/2∶4). Informed written consent was obtained from respondents before inclusion in the study. The three participants who were under 18 years assented and also their accompanying parents/guardians gave a written consent. The study conformed to the principles in the Helsinki declaration. All the data were kept confidential and participants were compensated for their time spent during the interviews with 5000 Uganda shillings (USD 2). Those cases not yet operated had their fistulas closed in the week following the interviews by the first author who is trained and skilled in fistula surgery.

Izinto zokwakha

N/A

Emisha

Based on the provided description, here are some potential innovations that could be recommended to improve access to maternal health:

1. Increase the availability and accessibility of skilled birth attendants: Implement programs to train and deploy more skilled birth attendants in rural areas, where maternal health care utilization is low. This would ensure that women have access to trained professionals during childbirth, reducing the risk of obstetric fistula.

2. Improve antenatal care attendance: Develop initiatives to promote and encourage pregnant women to attend regular antenatal care visits. This could include community outreach programs, education campaigns, and incentives for attending appointments. Regular antenatal care can help identify and address potential risk factors for obstetric fistula.

3. Enhance emergency obstetric care services: Strengthen the capacity of health facilities in the study area to provide emergency obstetric care, including access to caesarean sections. This would help reduce delays in receiving appropriate care during childbirth, which can contribute to the development of obstetric fistula.

4. Increase awareness and education on safe delivery practices: Conduct community-based education programs to raise awareness about the importance of safe delivery practices, such as delivering in a health facility with skilled birth attendants. This could involve partnerships with local leaders, community health workers, and women’s groups to disseminate information and address cultural beliefs and practices that may hinder access to maternal health services.

5. Address socio-economic barriers: Implement interventions to address socio-economic barriers that prevent women from accessing maternal health services, such as poverty, lack of transportation, and distance to health facilities. This could involve providing financial support for transportation, improving infrastructure, and establishing mobile health clinics in remote areas.

6. Strengthen data collection and research: Continue conducting research and collecting data on risk factors for obstetric fistula in different contexts. This would help inform targeted interventions and policies to prevent and manage obstetric fistula effectively.

It is important to note that these recommendations are based on the specific context described in the study and may need to be adapted to suit the local conditions and resources available in other settings.

AI Innovations Description

Based on the information provided, the study conducted in western Uganda aimed to identify risk factors for obstetric fistula in the context of low maternal health care utilization and poor reproductive health indicators. The study used a case-control design, with 140 cases and 280 controls included in the analysis. The study variables included socio-demographic, physical, and obstetric factors that have been highlighted in the literature as predisposing women to fistula.

The main recommendation that can be developed into an innovation to improve access to maternal health based on this study is to increase the availability and utilization of skilled birth attendants during childbirth. The study found that a significant proportion of women with fistula had delivered without skilled attendance, indicating a lack of access to quality maternal health care. By ensuring that all women have access to skilled birth attendants, the risk of obstetric fistula can be reduced.

To implement this recommendation, several strategies can be considered:

1. Strengthening health systems: This includes improving infrastructure, staffing, and equipment in health facilities to ensure the availability of skilled birth attendants. It also involves training and capacity building for health care providers to provide quality maternal health care.

2. Community education and awareness: Conducting community-based education programs to raise awareness about the importance of skilled birth attendance and the risks associated with delivering without skilled assistance. This can help change cultural norms and beliefs that may discourage women from seeking skilled care during childbirth.

3. Improving transportation and referral systems: Ensuring that women have access to reliable transportation to reach health facilities during labor and delivery. This may involve establishing emergency transportation systems and strengthening referral networks between lower-level health facilities and higher-level facilities equipped to handle obstetric complications.

4. Addressing financial barriers: Implementing strategies to reduce financial barriers to accessing skilled birth attendance, such as providing free or subsidized maternal health services, health insurance coverage, or conditional cash transfer programs.

5. Empowering women and promoting gender equality: Addressing social and cultural factors that may limit women’s decision-making power and autonomy in seeking skilled care during childbirth. This can be achieved through promoting women’s education, economic empowerment, and gender equality initiatives.

By implementing these recommendations, access to skilled birth attendance can be improved, leading to a reduction in the incidence of obstetric fistula and improved maternal health outcomes in the study area.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Increase the availability and accessibility of skilled birth attendants: This can be done by training and deploying more skilled birth attendants in rural areas, where access to healthcare services is limited.

2. Improve transportation infrastructure: Enhancing road networks and transportation systems can help pregnant women reach healthcare facilities more easily and quickly, especially in remote areas.

3. Strengthen antenatal care services: By providing comprehensive antenatal care services, including regular check-ups, health education, and early detection of complications, the risk of obstetric fistula and other maternal health issues can be reduced.

4. Promote community awareness and education: Conducting community-based awareness campaigns and educational programs can help increase knowledge about maternal health, encourage women to seek timely care, and reduce stigma associated with obstetric fistula.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the percentage of women receiving care from skilled birth attendants, the average travel time to healthcare facilities, or the number of women attending antenatal care.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area, including the existing utilization of skilled birth attendants, transportation infrastructure, and antenatal care services.

3. Simulate the impact: Use statistical modeling techniques to simulate the potential impact of the recommendations on the identified indicators. This can involve creating different scenarios based on the implementation of each recommendation and estimating the resulting changes in the indicators.

4. Analyze the results: Evaluate the simulated impact of the recommendations on improving access to maternal health. Compare the indicators before and after the implementation of the recommendations to assess the effectiveness of each recommendation.

5. Refine and adjust: Based on the analysis, refine the recommendations and adjust the simulation model if necessary. Iterate the process to further optimize the recommendations and improve the accuracy of the simulation.

6. Communicate the findings: Present the results of the simulation to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the findings to advocate for the implementation of the recommendations and support decision-making processes.

Umbhali

Dima Health

Statistics:

Citations: 28

Identifiers:

DOI: 10.1371/journal.pone.0112299

Research Areas:

Cancer, Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Uganda

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: