OBSTETRIC FISTULA IN AFRICA
by
Hezekiah George Owojuyigbe
Bachelor of Medicine, Bachelor of Surgery (MBBS)
University of Jos, Nigeria, 1998.
Submitted to the Graduate Faculty of
Multidisciplinary Master of Public Health Program
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2013
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Hezekiah George Owojuyigbe
on
April 12, 2013
and approved by
Essay Advisor:
Ronald E. LaPorte, PhD.
Director, Multidisciplinary MPH Program
Professor, Department of Epidemiology
Graduate School of Public Health
University of Pittsburgh
_______________________________
Essay Reader:
Steven M. Albert, PhD.
________________________________
Professor and Chair
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
ii
Copyright © by Hezekiah George Owojuyigbe
2013
iii
Ronald E. LaPorte, PhD
OBSTETRIC FISTULA IN AFRICA
Hezekiah George Owojuyigbe, MPH
University of Pittsburgh, 2013
ABSTRACT
Obstetric fistula as a debilitating complication of labor obstruction is a major public health
concern that requires urgent public health interventions.
This review looked into a number of major factors that affect obstetric fistula (OF) prevalence,
prevention and management in the underdeveloped and developing countries. These contributing
factors namely cultural practices of teenage and/or forced marriages leading to earlier
pregnancies, extreme poverty, poorly equipped health care services, and lack of education and
knowledge about the causes of obstetric fistula.
Obstetric fistula is obviously a problem afflicting thousands of women in the underdeveloped
and developing nations of the world, women education and empowerment, improved health care
services, and poverty alleviation in regions in question would bring some improvement to this
“public health problem called obstetric fistula”
iv
TABLE OF CONTENTS
PREFACE ................................................................................................................................. VIII
OBJECTIVE…………………………………..………………………………..………………IX
KEYWORDS………………………………………….………………………..………………..X
1.0 INTRODUCTION…………………………………………………………………………..1
2.0 METHODOLOGY……………………………………………………………….………….5
3.0 BACKGROUND……………………………………………………………………………..7
4.0 DISCUSSION………………………………………………………………………….........14
5.0 CONCLUSION……………………………………………………………………………..17
BIBLIOGRAPHY………………………………………………………………………………20
v
LIST OF TABLES
Table 1. Case series of fistula in low income countries…………………………………..……8
Table 2. Contributing factors to vesico-vaginal fistula……………………………………….13
vi
LIST OF FIGURES
Figure 1. Maryama's story………………………………………………………………………...1
Figure 2. Obstetric vesico-vaginal fistula probe…………………………………………………..2
Figure 3. Methodology………………………………………………………………………….....6
Figure 4. Worldwide fistula center………………………………………………………………19
vii
PREFACE
Having worked as a physician in sub-Sahara Africa for a number of years, I had the opportunity
to see, manage and refer several fistula patients to a more advance care center for further reconstruction care. It is very sad to witness first-hand what these young innocent women have
been subjected to; they are been neglected, abused physically and emotionally by their spouses,
other family members and their community. They are punished, rejected and ostracized for
something they did not do to themselves. There is systemic failure; they are forced into early
marriages, there is no standard medical care, they are being subjected to crude traditional
procedures, poverty level is at its peak and literacy level is at zero.
I have great interest in dissecting and finding a long lasting solution to reducing the incidence of
fistula in African women. I believe this is achievable by incorporating better education for
women and instituting a better health care system within their reach.
I spent hours researching and reviewing a number of related-articles from the library and I also
spoke to a number medical professionals in and around the world especially in Africa.
I want to seize this opportunity to thank my parents and my siblings for their love, support and
prayers. I want to also thank my Professors, Professor Steven Albert and Professor Ronald
LaPorte for the time spent in reviewing my essay and for their constructive criticism.
Lastly, my appreciation goes to my friends and colleagues for their encouragement.
viii
OBJECTIVE
To analyze and identify pertinent factors influencing the rate of fistula occurrence and how to
prevent and manage this obstetric complication in Africa nations from a number of case series
and case-control articles reviewed.
ix
KEYWORDS
Obstetric fistula; Vesicovaginal fistula; Rectovaginal fistula; obstructed labor; Maternal
Mortality; Gishiri cutting.
x
1.0 INTRODUCTION
Obstetric fistula is an abnormal connection between two epithelial surfaces. There are different
types of obstetric fistula namely; VVF, known as vesico-vaginal fistula, this is a connection
Figure 1: Maryama’s Story
Maryama comes from a village 100 miles north of Danja, Niger. She was married and became pregnant while still
in her teens. As is the local custom – and because maternal health services are not easily accessible – Maryama
planned to deliver her baby at home. Since this was her first delivery .
Courtesy of Worldwide Fistula Fund
between the bladder and the vagina; also there is recto-vaginal fistula which is a connection
between the rectum and the vagina. Obstetric fistula is a debilitating obstetric condition resulting
1
from prolonged obstructed labor mostly affects women in the underdeveloped and developing
nations of the world especially in Africa and Asia. [1][2].
Figure 2: Obstetric vesico-vaginal fistula from prolonged obstructed labor
Probe
showing
the
connection between the
bladder and the vagina
© PLoS Negl Trop Dis. 2012 August; 6(8):e17
Obstetric fistula (OF) is a major public health problem, there is no doubt especially in Africa
where 99% of maternal deaths occur, maternal mortality ratio in developing countries is 240 per
100 000 live births versus 16 per 100 000 in developed counties. Those that did not die will go
into labor obstruction which is either unattended to or poorly managed, thus leading to one of its
ultimate complications, “fistula.”
2
Obstetric fistula prevention and/or management remain a major challenge in countries where the
complication is rampant [3]. There is increased international attention on obstetric fistula as a
global public health problem requiring quick solution.
Obstetric fistula is a very good example of a neglected tropical disorder, once rampant in western
countries, today; obstetric fistula is confined to the cultures of tropical poverty. Labor could be
obstructed or prolonged due to three Ps; large passenger (baby), too narrow a passage (birth
canal) or low power (mother’s ability to push) which will eventually lead to devitalization of the
entrapped soft tissues of the blabber, vagina, rectum and pelvis between the two opposing boney
surfaces, the entrapped tissue dies and sloughs away, creating a fistula between the urinary tract
and the vagina or between the rectum and the vagina or a combination of both. [4]
“Make every mother and child count” World Health Report 2005 says that almost 11 million
children under five years of age will die from preventable causes, 4 million of which will not
survive the first month of life and half a million women will die in pregnancy, childbirth or soon
after. The Millennium Development goals are to reduce this toll by providing access to health
care for every mother and every child from pregnancy through childbirth, from neonatal period
through childhood. [5]
The World health organization states each year between 50,000 to 100,000 are affected by
obstetric fistula. The development of obstetric fistula is directly linked to one of the major causes
of maternal mortality, which is obstructed labor. In addition, it is also estimated that more than
two million young women live with untreated obstetric fistula in Africa and Asia, and these
women suffer physical, psychological and social issues; namely nerve damage, leg paralysis,
depression, community ostracism, divorce, loss of earning potential and suicide [6]
3
There is strong evidence that major contributing factors to obstetric fistula development in Africa
are closely related to socio-cultural and religious beliefs and practices. There is insufficient
emphasis placed on community education on causes of obstetric fistula and prevention, and lack
of standard health care system in place to urgently address any ensuing obstetric emergencies.
Obstetric fistula is preventable; it can largely be avoided by discouraging earlier teenage
pregnancies, putting a stop to harmful “gishiri” traditional practices, and most importantly there
should be accessibility and affordability of obstetric care. [6]
After a prolonged pressure of the infant skull against the tissue of the birth canal, this leads to
ischemia and tissue death. The woman is left with a hole between her vagina and bladder or
vagina and rectum or both. This results in uncontrollable leakage of urine and/or feces, the view
of all these is awful. It is widely reported in scientific publications and the media that women
with obstetric fistula suffer devastating social consequences but these claims are rarely supported
with evidence. Therefore social implications of obstetric fistula are unknown. [7]
4
2.0 METHODOLOGY
This is a cross-sectional study focusing on African women of child-bearing age to determine
factors that affect prevalence, prevention and management of obstetric fistula. To achieve this,
PubMed, Ovid, Embase, World Health Organization and Global Health databases were searched
to identify articles on obstetric fistula in Africa. Searches were conducted with key words:
“obstetric Fistula in Africa, vesico-vaginal fistula, or recto-vaginal fistula,” and “obstetric
complications.” Articles that were based on case-series, case-control and regional focused on
African countries were selected for the review. Six hundred and sixty-one articles on obstetric
complication and fistula from around the world were located, a full article and review filter were
activated to narrow down the search to 79 articles that were related to Africa and low-income
countries, and this was then narrow down to 50 full articles and 21 of the full and cited articles
were looked at and reviewed in this essay.
5
661Obstetric complications articles around the
world.
344 articles on obstetric
complications other than obstetric
fistula.
238 non-African nation related
article on obstetric fistula.
79 Obstetric fistula articles related to Africa,
developing nations.
18 non-full articles, only abstract.
11 articles purely surgical
treatment/repair of fistula.
50 Full article on Obstetric fistula in Africa.
21 articles not cited.
8 inaccessible articles.
1 case-control on Obstetric fistula
in Africa.
21 Case-series and case-control articles, full and
cited articles on obstetric fistula in Africa
Figure 3. Methodology
6
3.0 BACKGROUND
Several literature searches and reviews were conducted in PubMed, Ovid, Embase and Global
Health regarding obstetric fistula amongst women in African, in one of the reviews, among the
19 selected studies, 15 were reported from sub-Saharan African and 4 from the Middle East, it
was shown that 79.4% to 100% of fistula cases were obstetrical while the remaining cases were
from other causes. Rectovaginal fistula (RVF) accounts for 1% to 8%, Vesicovaginal fistula
(VVF) for 79% to 100% of cases, and combined vesicovaginal and rectovaginal fistula were
reported in 1% to 23% of cases. Teenagers accounted for 8.9% to 86% of the obstetric fistula
patients at the time of treatment, 31% to 67% of these women were primiparas, with 40% - 79%
of them being shorter than 1.5m. Among women with obstetric fistula, 57.6% to 94.8% of them
labored at home and were transferred late to health care facilities. Nine of 84% of these women
delivered at home with mean duration of labor among the fistula patients ranging from 2.5 to 4
days, of which 20% to 95.7% of them laboring for more than 24 hours and operative deliveries
were eventually performed in 11% to 60% of cases [8]
Obstructed labor is very common in underdeveloped and developing nations of Africa and part
of Asia, and vesicovaginal fistula is usually a common complication of this obstetric condition.
The formation of fistula remains largely an overlooked problem in developing nations, affecting
very young, naïve, illiterate women who live in extreme poverty in remote areas of Africa. It has
been shown by several studies and articles that the formation of obstetric fistula is as a result of
complex interactions of social, biologic, and economic influences. The key underlying
7
determinants of fistula are the combination of a lack of functional emergency obstetric care,
poverty, lack of education, and cultural practices. [9]
Table 1. Case series describing characteristics of obstetric fistula patients in low-income countries
Series
size
Time
period
Age (at
repair)
Age/parity
at fistula
Labor/delivery
experience
Sociodemographic
characteristics
Kelly [10];
Kelly and
Kwast [11]
309
(drawn
from
3000)
1983–
1988
Ave
22.4
(9–45)
63%
primiparous
Ave 3.9 days
labor (1–6)
52% deserted by
husband after
fistula
97%
obstetric
Muleta
[12]
1210
1991–
1992
Ave
21.6
(10–
50)
56% younger
than 20, 55%
primiparous
77% labored
more than
3 days
44% divorced after
fistula, 8% had
rudimentary
education
97.4%
obstetric
96%
prolonged
obstructed
labor
Gessessew
and
Mesfin
[13]
193
1993–
2001
Mean
24.7
60%
under
25
40% younger
than 19, 47%
primiparous
Ave 3.6 days
labor (1–7),
92% no PNC,
58% delivered
at home
67% married, 81%
illiterate, 93% rural
95.3%
obstetric
Muleta
[14]
639
1999–
2000
84% younger
than 20, 64%
primiparous
Ave 3.8 days
labor, 84%
labored more
than 3 days,
44% delivered
at home
Marriage age
average 14.7, first
delivery ave age
17.8, 62% owned
“nothing valuable,”
54% divorced
Ave
149 cm
70
1975–
1980
52% age 15–
19, 70%
primiparous,
18%
parity > 4
67% delivered
in hospital
93.6% married
before age 18, 95%
no education, 75%
very poor
68%
under
150 cm
Citation
Height
Etiology
Ethiopia
Nigeria
Ghatak
[15]
Table 1 Cont
8
83%
prolonged
obstructed
labor
Hilton and
Ward [16]
656
1990–
1994
Ave 28
(7–68)
31%
primiparous,
Ave parity: 3
(0–17)
Ave 2.5 days
labor, 57%
managed labor
at home
Gharoro
and Abedi
[17]
49
1992–
1997
Ave 31
(20–
65)
Ave parity: 3
(1–11)
Ave 3 days
labor, 65%
operative
delivery
Ibrahim et
al. [18]
31
1996–
1997
60% age 13–
15, Ave age
15, 81%
primiparous
Ave: 4 days
labor
55% divorced, 6%
literate, 60% rural
Ave
149 cm
(140–
159)
100%
prolonged
obstructed
labor
Wall et al.
[19]
932
1992–
1999
45.8%
primiparous,
20%
parity > 4
24% home
delivery
26% married, ave
age at marriage
15.5, 78% illiterate,
common
occupation in
manual labor
Typical
44 kg,
under
150 cm
96.5%
obstetric
Ijaiya and
Aboyeji
[20]
24
1989–
1998
26% age 15–
19 yrs, Ave
age 23.9,
50%
primiparous,
32%
parity > 5
91%
attempted
home delivery
94.1% illiterate,
24%
separated/divorced
164
1977–
1992
Ave 27
62.5% married,
29% could sign
name, 37% aware
of own age
92.2%
obstetric
80%
prolonged
obstructed
labor
(2389
cases
1970–
1994)
82%
prolonged
obstructed
labor
Ghana
Danso et
al. [21]
Ave
26.6
43%
primiparous,
Ave parity
2.6
Table 1 Cont
Niger
9
91.5%
obstetric
Meyer et
al. [22]
58
2005–
2006
Ave
26.1
(16–
44)
45%
primigravida
Ave 2.6 days
labor, 95%
began labor at
home, 91% at
health center
by delivery
62% married, ave
age at marriage
15.6, ave first
pregnancy at 17.3,
all illiterate
Median
148 cm
254
2003–
2005
Median
25 (15–
59)
Median age
22 (11–45),
49%
primiparous,
27.6% parity
>
67.5%
2 days + in
labor, Delays
to EmOC
mostly due to
transport,
97.5%
attended PNC,
84.% in labor
1–3 days
15% divorced,
median marriage
age 18, 69% did
not complete
primary education
68%
under
150 cm
Median
25 (14–
65)
Median age
22 (13–46),
45%
primigravida,
median third
delivery
11.5%
perinatal
survival, 80%
delivered in
hosital, 25%
labor ≥ 2 days
40% separated or
never married, 31%
ompleted primary
education,
2%comleted
seconday
education
70%
shorter
than
156 m
Zambia
Holme et
al. [23]
Kenya, Tanzania, Uganda
Raassen et
al. [24]
581
2001–
2003
100%
obstructed
labor
© University of Michigan Medical School, Department of Obstetrics and Gynecology, Ann Arbor, Michigan, USA.
Abbreviations: Ave, average; EmOC, emergency obstetric care; PNC, prenatal care.
Obstetric causes include prolonged obstructed labor, cesarean delivery, and uterine rupture.
Obstetric fistula as one of the complications of pregnancy and/or childbearing has a number of
determinants which is simply analyzed using a framework which begins with remote general
socioeconomic and cultural environment such as chaotic socio-economic and political systems,
poverty, discrimination, power hierarchies, low self-esteem and lack of social support for
10
women. Secondly, intermediate determinants such as women’s health and reproductive status
during their pregnancies, access to and use of health care resources are in most cases reflections
of general socio-economic and cultural environment. Lastly, intermediate determinants set a
stage for acute clinical determinants which refers to the intrapartum factors that arise when active
labor becomes obstructed as well as post-obstruction period with the likelihood of fistula
formation as an obstetric complication. [25]
It has been widely reported in a number of articles that age at first pregnancy plays a major role
in obstetric fistulation, reports from Ethiopia and Niger clearly indicate that affected women are
often very young, in their early teens, carrying their first pregnancy and have low educational
level while the opposite is the case in some countries like Nigeria, Ghana and Zambia where
most women affected tended to be older, with higher parity (prior 4 or 5 pregnancies or children)
with some being subjected to the crude traditional Hausa surgery popularly referred to as “gishiri
cutting” (gishiri = salt; random cuts within the vagina with a “salt slashing knife” to enlarge the
birth canal once labor obstruction sets in). These studies have common denominators which are
factors like accessibility to health facilities, distance to health institutions, transportation,
financial constraints and poor knowledge were frequently cited problems in many parts of
Africa. In Cameroon Far North Province, amongst fistula patients aged 15-49 years, the illiteracy
rate was as high as 78%, and 86% of them were teenagers at first delivery. [26] Based on
comparative study from North-Eastern Nigeria, data analyzed shows that majority of patients
analyzed were Fulani/Hausa, 91.2% were Muslims, 93.7% had labor obstruction, majority
married early (average 14 years), and short stature (average height 146.2cm) was also a factor.
Some other article states in support of the above statistics that amongst these young women,
96.3% were illiterate, no gainful employment and low social class. Ninety-six point seven
11
percent (96.7%) failed to register for antenatal care while majority lives in the rural areas, far
away from a health care facility (>3km). [27]
A university Hospital in Northern Nigeria reported that gishiri cutting leading to fistula
accounted for 13% of cases in about 1443 patients operated upon; this practice along with
packing the vagina with caustic and local medicines is common among the Hausa, Fulani and
Kanuri tribes in the sub-Sahara Africa. [28]
In Sudan, a descriptive, cross-sectional community-based study of 52 patients with vesicovaginal fistula who presented at the Fistula Center in Khartoum Teaching Hospital was
conducted. It is clearly in support of determinants of fistula from other parts of Africa as stated in
the table below even though circumcision leading to vesico-vaginal fistula (VVF) stands out in
Sudan compare to other countries. [29]
12
Table 2: Contributing factors of vesico-vaginal fistula
© Contributing factors of vesico-vaginal fistula (VVF) among fistula patients in Dr.Abbo's National Fistula & Urogynecology Centre - Elsadig
Yousif Mohamed et al
In northern Nigeria, a case-control study was carried out involving 241 fistula cases and 148
patients without fistula as controls, both cases and controls were interviewed and their records
over the last 2 years were reviewed and analyzed. This retrospective study, is consistent with
other studies, showed that prolonged labor constituted 75.6% of all cases of fistula, Gishiri cut
constituted 6.2% of cases and other factors like earlier age of marriage (26.9%), height of women
(51.9% below 150cm with the relative risk of 1.8), surgical trauma (3.1%), infection (2.1%),
cervical carcinoma (1.7%) are of great importance. More so, about 49.9% of women with fistula
were married as compared to 85.3% of the controls, a higher percentage of fistula patients were
divorced than controls. [30]
13
4.0 DISCUSSION
The purpose of this essay is to perform a peer-review and to substantiate some of the factors
influencing prevalence, prevention and treatment of obstetric fistula in Africa. There is no doubt
that obstetric fistula (OF) has been and is still a major public health problem. The social and
economic impact of this on underdeveloped and developing nations cannot be over emphasized.
OF affects thousands of women yearly and a couple of millions of them go about with fistula,
mostly in Africa. There is strong relationship between OF and a number of factors like sociocultural practices, economic situation of the continent of Africa, educational status, political
influences and health care availability/accessibility/affordability and these have been proven in
many studies.
Looking at Africa, it is a common cultural practice in part that young teenage girls are married
away or actually forced into marrying older men when there are physically and psychological
immature for marriage and ultimately pregnancy. Studies have shown that very high percentage
of obstetric fistula occurs in very young, primipara and/or short stature women. Level of
community education and knowledge of the etiology of fistula, the better the awareness of the
causes of fistula at the community level the more we are likely to reduce its rate of occurrence.
The truth is that OF as an obstetric complication can be reduced by delaying or discouraging teen
marriages which will eventually reduce teen pregnancies. Women empowerment in Africa will
change the equation, women should have a say in their sexual and reproductive life, they should
not be forced or coerced into it.
14
Obviously, most affected African countries are either underdeveloped or still developing; people
are living in extreme poverty, lack of good food, poor growth and development, poor living
conditions and little or no financial means to cater for the family’s medical need. Poverty
alleviation programs will go a long way in Africa; this will bring improvement to women and
children’s health, living standard and the ability to seek medical care when deemed necessary.
Women living in the remote areas of Africa where there are very few or no schools are highly
uneducated; literacy level has great effect on how a woman sees her body, sees her pregnancy
and her ability to make decisions in seeking medical care. Furthermore, political instabilities in
most Africa nations have contributed greatly to high rate of poverty, lack of basic amenities and
lack of standard health care system outside major cities.
In Africa, as mentioned before there are a number of well-equipped medical centers in most
African major cities, except in the in remotes areas where, in reality, majority of the people
especially women and children live. Health care services are not available, non-affordable, nonaccessible, or in few area where this is available, the care is poor and inadequate in terms of
equipment and staffing. Health is unaffordable for these women; some would rather stay and
attempt to have a domiciliary delivery, which is affordable to them. Majority of these women
who stayed at home to deliver would either develop some intra-partum or post-partum
complications like fistula following labor obstruction and/or traditional gishiri cutting. The
gishiri cutting is a common practice among the Hausa, Fulani and the Kanuri tribes of the subSahara region of Africa; this factor is peculiar and is one of the major contributors to high rate of
fistula in this region.
15
Community education regarding problems associated with teenage pregnancy, danger in forced
marriage, signs and symptoms of obstructed labor, as well as better access to medical care in
order to benefit from standard care during delivery.
16
5.0 CONCLUSION
Obstetric fistula (OF) is a major public health problem there is no doubt, and most importantly
this is multi-factorial in etiology that could be related directly or indirectly to factors like
cultural, socio-economic and religious practices, biologic, regional poverty and lack of women
education and empowerment, poor health care system and political instability. The question is
how do we prevent, reduce or manage fistula?
We all understand and agree at this juncture that we can safely conclude that high incidence of
fistula in sub-Sahara Africa is a reflection of medically inappropriate cultural practices by
forcing women that are not physically and mentally mature (some have height < 150 cm) into
marriages and lack of accessible, affordable and/or a well-equipped health care services.
In some of these fistula “infested” regions, more government and non-governmental organization
campaigns are needed and should be implemented. Better funding to educate families and
communities to really understand the causes and prevention of fistula and the importance of
antenatal care.
There should be robust governmental policies and funding that is aimed at discouraging
forced/teen marriages, teen pregnancies which will subsequently have a positive effect on
maternal/child morbidity and mortality rate reduction. Health care facilities that is well equipped
with well-trained health personnel. Governmental and non-governmental organizations should be
put in place in these regions for quick and better obstetric intervention when necessary.
17
Conflicts, corruption and political instabilities in most Africa nations has led to increased poverty
level, governments should invest more in their citizens; there should be poverty alleviation
programs and fast-track education for women should be put in place, and most importantly laws
should be promulgated to empower women.
Lastly, more research is required to statistically establish the full impact of “gishiri cutting” on
obstetric fistula prevalence in Africa. In addition, very few case-control studies on fistula in is
currently available, there should more governmental and non-governmental funding to carry out
more extensive studies on obstetric fistula.
18
“The opening of the Danja Fistula Center marks a great step forward for the women of Niger and all of sub-Saharan
Africa . . . The fistula hospital is truly a beacon of hope which will permeate throughout the sub-Saharan region and
into the rest of the world”.
United States Senators James M. Inhofe, Christopher Coons,
John Boozman, Mike Enzi and John Barrasso
Figure 4 Worldwide Fistula Center
Courtesy of Worldwide Fistula Fund
19
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[1] Worldwide Fistula Fund. Africa: Obstetric Fistula fact sheet. 7 February 2012.
[2] Ahmad-Rufai Abdullah. Socio-cultural and religious factors affecting obstetric fistula in an Islamic population in
Northern Nigeria: An exploratory study. American Public Health Association 28 October 2008
[3] S. Ahmed, R. Genadry, C. Stanton, A.B. Lalonde. Dead women walking: neglected millions with obstetric fistula
Int J Gynecol Obstet, 99 (Suppl 1) (2007), pp. S1–S3
[3] International Journal of Gynecology & Obstetrics, Volume 104, Issue 2, February 2009, Pages 85–89
[4] Obstetric Fistula is a “Neglected Tropical Disease” - Wall LL (2006) Obstetric vesicovaginal fistula as an
international public health problem. Lancet 368: 1201–1209
[5] World Health Organization. The world health report 2005: make every mother and child count. WHO, Geneva,
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fistulae in north-eastern Nigeria. Journal of Obstetrics and Gynaecology; 2007. 27: 8, 819-823. 20 ref.
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[10]. Kelly. Ethiopia: an epidemiological study of vesico-vaginal fistula in Addis Ababa. World Health Stat Quart,
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[11] J. Kelly, B.E. Kwast. Epidemiologic study of vesicovaginal fistulas in Ethiopia. Int Urogynecol J, 4 (5) (1993),
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