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VIEWS: 4 PAGES: 12

									           The Role of Delayed
    Childbearing and Obstetric
Interventions in the Prevention
            of Obstetric Fistula


    Amy Tsui, Andreea Creanga, and Saifuddin Ahmed
                                 The Gates Institute
     Johns Hopkins Bloomberg School of Public Health
                                       July 30, 2005




Questions addressed
    What impact will
      Delaying the age of childbearing
      Delaying the start of childbearing
    have on the incidence of obstetric fistulas?
    What is the relative association of risk factors with
    the likelihood of prolonged labor?
      Analysis based on national population survey data for
      Niger (1998), Nigeria (1999) and Tanzania (1999)
•   Proxy measure of prolonged labor with stillbirth
    outcome




                                                              1
 Initiation of Sexual Activity by Age 20 and
 Marital Context among Women Aged 20-24:
 Three Sub-Saharan African Countries
                100
                 90
                 80
                 70
    % sexually   60
   active before 50
      age 20     40
                 30
                 20
                 10
                  0
                             Niger       Nigeria Tanzania Burkina Mali 1996
                             1998         1999     1999    Faso
                                                           1999

                     All    Before marriage          Within marriage

Source: United Nations, World Population Monitoring 2002.




 Commonly cited characteristics of
 obstetric fistula cases in research
 literature
     Parity 1 (primagravida)
         55% of 1178 cases over 2 year period (Muleta, 1997)
         45.8% of 932 cases over 7 years (Wall et al., 2004)
         42.7% of 150 cases over 5 years (Danso et al., 2006)
         82% of 31 cases (Ibrahim et al., 2000)
     Prolonged/obstructed labor
         62.5% with 3 days labor (Muleta, 1997)
         75.9% of 241 cases over 2 year period (Ampofo et al., 1990)
         38% of 42 births (Wall et al., 2002)
     Short stature (Height <145 cm)
         51.9% of 241 cases < 150 cm (Ampofo et al., 1990)
     Stillbirth or neonatal death
         91.7% stillbirth and 1.5% neonatal mortality of 932 cases (Wall et al., 2004)
         87% stillbirth of 31 cases (Ibrahim et al., 2000)
     Young age at fistula occurrence
     •   58.8% before age 15 (Ampofo et al., 1990)
     •   60% 13-15 years (Ibrahim et al., 2000)
     •   4.5-5.5% before age 20 (Melah et al., 2003)
     •   21.3% before age 20 (Danso et al., 1996)




                                                                                         2
                                                                        Poverty
           Malnutrition                 Early marriage
                                                                        Illiteracy

                  Childbearing before pelvic growth is complete


      Relatively                Cephalopelvic disproportion
    large fetus or
   malpresentation
                                    Lack of emergency
                                     obstetric services
                                                                        Harmful
                                      Obstructed labor                 traditional
                                                                        practices
                                       Fetal death
                                    Fistula formation
                               Other outcomes related to
                             obstructed labor injury complex

                          Other physical                  Social
                          compromises                   compromises
Adapted from Worldwide Fistula Fund, “The Obstetric Fistula Pathway”




                                                                        Poverty
           Malnutrition                 Early marriage
                                                                        Illiteracy

                  Childbearing before pelvic growth is complete


      Relatively                Cephalopelvic disproportion
    large fetus or
   malpresentation
                                   Lack of emergency
                                   obstetric services
                                                                        Harmful
                                      Obstructed labor                 traditional
                                                                        practices
                                       Fetal death
                                    Fistula formation
                               Other outcomes related to
                             obstructed labor injury complex

                          Other physical                  Social
                          compromises                   compromises
Adapted from Worldwide Fistula Fund, “The Obstetric Fistula Pathway”




                                                                                     3
Clinical expert-based estimation of
progression of prolonged labor to
stillbirth and obstetric fistula
development in high-risk SSA countries

                                                          Still birth
20% Prolonged           20-30%
                                     Obstructed                     80-90%
      labor                          labor
      (> 12 hours)                                        Fistula
                                                  20%     development



      .20 x .25 x .20= .001, or 1 per 1,000 deliveries

      Danso et al., 1996: 1 per 1,000 deliveries over 5 years in Ghana
      Harrison: 3.5 per 1,000 deliveries over 3.5 years in Zaria




Percent of births in past 5 years with
prolonged labor* reported by maternal age:
Three Sub-Saharan African countries,
1998-1999 (*prolonged labor = > 12 hours)
 60
 50
 40
 30
 20
 10
  0
       <15   15    16    17     18     19   20-   25-   30-   35-   40-   45-
                                            24    29    34    39    44    49
                                       Maternal age

                        Niger        Tanzania      Nigeria      All 3




                                                                                4
 Percent of births in past 5 years with
 reported prolonged labor* by birth order:
 Three Sub-Saharan African countries,
 1998-1999 (*prolonged labor = > 12 hours)
  35

  30

  25

  20

  15

  10
          1      2       3       4      5       6         7    8      9     10+
                                            Birth order

                             Niger    Tanzania        Nigeria       All 3




 Estimates of Stillbirth and Neonatal
 Mortality Rates in Three Sub-Saharan
 African Countries
                        Still birth rates         Neonatal            % of neonatal
                          (per 1000             mortality rates       deaths where
                        deliveries and          (per 1000 live          labor was
Country                     95% CI)                 births)            prolonged

Niger                  37.6 (29.0-51.3)              39.2                   34.7


Nigeria                29.1 (22.0-38.4)              36.6                   35.2


Tanzania               29.3 (21.9-39.1)              43.9                   26.0


Source: Stillbirth rates from C. Stanton; other estimates from DHS calculations.




                                                                                      5
Multivariate Logistic Regression of
Likelihood of Prolonged Labor
 Focus on association with woman’s primagravid
 status and age ≤ 19
     Birth order: 1, 2-5, 6+
     Age group: ≤ 19, 20-34, ≥ 35
 Other maternal physical covariates
     BMI < 18.5 kg/m2
     Height <145 cm
 Other maternal covariates
     Education
     Region
     Size of place of residence




Results from Logistic Regression of
Prolonged Labor on Parity 1 and Young
Age for Three SSA Countries

Country           Crude OR    Adjusted OR    95% CI       p
Niger (n=4,714)
Parity 1             1.42           1.58    1.26, 1.97   0.000

Age ≤ 19             1.13           0.90    0.72, 1.13    ns

Nigeria
Parity 1             1.50           1.53    1.16, 2.02   0.003

Age ≤ 19             1.20           1.05    0.79, 1.39    ns

Tanzania
Parity 1             2.04           2.11    1.73, 2.56   0.000

Age ≤ 19             1.54           0.95    0.75, 1.20    ns




                                                                 6
Simulated Proportions of Recent Births
with Prolonged Labor if All Mothers
Primagravids or at Parity 6+

                                          Simulated percentages of PL
             No. of
                       % of births    If all
             recent
                          with       births                If all
Country      births    prolonged        to     % point   births to   % point
             (last 5     labor       prima-    change     women      change
               yrs)
                                     gravid              parity 6+
                                     women
Nigeria      2616*        18.9        23.8      +4.9       18.5       +0.4

Niger         4714        28.2        34.2      +6.0       28.3       +0.1

Tanzania      6356        19.8        30.6      +10.8      16.8       +2.9

*About 800 cases missing either or both maternal height and weight




Indirect Estimation of Annual
Incidence of Obstetric Fistulas
   Estimate % of recent births where prolonged labor
   (>12 hours) reported, by maternal age/birth order
   group
        22% across 3 selected countries
   Estimate % of prolonged labor cases ending in
   stillbirth by age/birth order group
        Pr(PL|SB)=0.016
        Based on Nigeria DHS (n=3,551 births in past 5 years)
   Apply to estimated number of births by age/birth
   order group
   Derive number of cases with obstetric fistula
   potential by age and birth order group




                                                                               7
Percent of difficult child deliveries in past 5 years
ending in stillbirth by parity: Nigeria 1999

 0.04
0.035
 0.03
0.025
 0.02
0.015
 0.01
0.005
      0
            1     2       3     4     5      6       7       8   9      10+
                                     Birth order




Simulation of Potential Obstetric Fistulas
Prevented in Three Sub-Saharan African
Countries: Nigeria (1999) Example
Age              Annual       Incidence of   % prolonged # of prolonged
                number of      prolonged     labor ending     labor cases
                  births          labor       in still birth ending in still
                                                                 births
<15              51,171         16,631             .016           266
15               51,171         11,514             .016           184
16               97,225         24,306             .016           389
17              149,675         30,703             .016           491
18              198,288         40,937             .016           655
19              244,342         51,171             .016           819
Total <20       791,874        175,261             .016          2,804
Total 15-49     4,819,502      950,211           .005-.016       11,849




                                                                               8
Estimated Potential for Annual Obstetric
Fistulas in Three SSA Countries: Age
                                                                     # of prolonged
                Annual        Incidence of      % prolonged            labor cases
Country/       number of       prolonged        labor ending         ending in still
Age              births           labor          in still birth           births
Niger
15-19            143,208          42,913               .016                 687
15-49            656,135         185,931           .005-.016               2,344
Nigeria
13-19            791,874         175,261               .016                2,804
13-49           4,819,502        950,211           .005-.016              11,849
Tanzania
15-19            304,560          80,007               .016                1,280
15-49           1,691,912        335,556           .005-.016               4,420




Estimated Potential for Annual Obstetric
Fistulas in Three SSA Countries: Parity
                                                                   # of
                Annual      Incidence of   % prolonged          prolonged         %
               number of     prolonged     labor ending        labor cases      prima-
Country          births         labor       in still birth    ending in still   gravid
                                                                  births
Niger
Primagravid     119,428       39,531                               632
                                                .016                              21.6
All parities    656,135       183,268                             2,932
Nigeria
Primagravid    1,007,060      249,751                             3,996
                                                .016                              26.3
All parities   4,819,502      939,803                            15,211
Tanzania
Primagravid     360,648       80,007                              1,708
                                                .016                              32.0
All parities   1,691,912      335,556                             5,342




                                                                                         9
Summary of findings
 High % of prolonged labor concentrated in women
 at parity 1 or < age 20
   RR for 1st birth ranges from 1.53 to 2.11 compared to 2-5th
   birth
   Point of opportunity for social and public health intervention
 Relative risk of OL with SB is 1.6 per 1000
 pregnancies in Nigeria
   Comparable to other clinical case research
   Estimated cases with high OF potential in 3 countries
     6,326 for 1st birth
     23,485 total
 Need replication with pooled DHS data with
 maternity indicators




Implied public health interventions to
prevent and manage obstetric fistula

 Improve childhood nutrition, especially for pre-
 adolescent girls
 Pre-nuptial family life counseling
 Delay first birth/delivery
   Delay marriage (where marital status mediates sexual
   activity)
   Promote contraceptive use prior to 1st birth among very
   young women
   Improve access to safe abortion
 Increase access to emergency obstetric services




                                                                    10
 Percent of births in past 5 years delivered
 at home by maternal age group: Three Sub-
 Saharan African countries, 1998-1999
  100
    90
    80
    70
    60
    50
    40
            15-19        20-24         25-29            30-34        35-39         40-44
                                      Maternal age group

                                   Niger       Tanzania         Nigeria




 Grounds on which abortion is
 permitted in selected countries

             Save the   Preserve    Preserve   Rape      Foetal    Economic
             woman’s    physical    mental     or        impair-   or social   On
 Country     life       health      health     incest    ment      reasons     request

 Ethiopia


 Malawi


 Niger


 Nigeria


 Tanzania



Source: United Nations, World Population Monitoring 2002




                                                                                           11
Contraceptive Prevalence and Unmet Need
among Female Adolescents (15-19 Years)
in Selected Sub-Saharan African Countries
         45
         40
         35
         30
         25
         20
         15
         10
          5
          0
              Ethiopia     Malawi        Niger      Nigeria     Tanzania
                2000        2000         1998        1999         1999

                All methods       Modern methods            Unmet need

Source: United Nations, World Population Monitoring, 2002




                                   Thank you.




                                                                           12

								
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