1. 1 Risk Factors for Obstetric Fistula : a clinical review Dr Pierre Marie Tebeu,MD,MPH Obstetrician Gynecologist, University Hospital, Yaoundé Cameroon e.mail: pmtebeu@yahoo.frpmtebeu@yahoo.fr Tel: 77 67 55 33 ISOFS 2010, Dakar, Senegal

2. 2 Plan  Introduction  Objective  Methods  Results  Summary

3. 3 Physiopathology of obstetric Fistula Promontory Pubis Bladder Rectum Vagina WHO, UNDP, UNICEF, World Bank. IMPAC. 2003 Obstructive labor Compression VVF RVF - Hematoma -Asphyxia -Fetal death Foot drop Bladder Rectum Obturator nerve Head

4. 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

5. 5 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.

6. Search Strategy 6 Term used: obstetric fistula, urinary fistula, vesicovaginal fistula, vesico-vaginal fistula, recto-vaginal fistula, rectovaginal fistula, recto vaginal fistula

7. Variables of Interest 7  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

8. 8 Results

9. Teenager at first delivery Meyer 2007; Ojanuga 1999; DHS Cameroon 2004; Wall 2004; Muleta 2004; Nafiou 2007; Ramsey 2007; Unfer 1995 9 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 %

10. Teenagers delivery in Cameroon Tebeu et al. Obstet Gynecol Int 21010

11. 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

12. Illiteracy in Cameroon DHS 2004

13. 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 13

14. 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. 14  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

15. 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

16. Home delivery in Cameroon DHS 2004

17. 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) 17

18. Cesarean delivery in Cameroon DHS 2004

19. Association between CS rate and maternal mortality from 118 countries Cesarean secttion rate Maternal mortality rate per 100,000 live births Adapted from: Althabe 2006

20. 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)

21. Total Fertility Rate In Cameroon DHS 2004

22. Summary on OF Risk factors Teenage condition Nulliparity/Grand multiparity Home delivery Late arrival in the facility Poor obstetric management Prolonged labor 22

23. END 23 WAHAGFMR University Centre Hospital Yaoundé LIRASEF