Background

Obstetric fistula, which develops after a prolonged or obstructed labour, is preventable and treatable. However, many women are still afflicted with the condition and remain untreated in low-income and middle-income countries. Concerns have also been raised that an increasing trend of caesarean sections is increasing the risk and share of iatrogenic obstetric fistula in these countries. The true prevalence of this condition is not known, which makes it difficult for health planners and policy makers to develop appropriate national health strategies to address the problem. The estimation of obstetric fistula with surveys is difficult because self-reporting of incontinence symptoms is subject to misclassification bias. In this study, we aimed to estimate the prevalence and burden of obstetric fistula in Bangladesh.

Methods

For a valid estimation addressing misclassification bias, we implemented the study in two steps. First, we did the Maternal Morbidity Validation Study (MMVS) among a population of 65 740 women in Sylhet, Bangladesh, to assess the sensitivity, specificity, positive predictive values (PPVs), and negative predictive values of the survey questions. This was done through confirmation of the diagnosis with clinical examinations of suspected cases by female physicians; a sample of women who screened positive for pelvic organ prolapse and other urinary incontinence symptoms were also examined and used as controls for clinical diagnosis confirmation. Second, we used the estimated diagnostic test values, after correcting for verification bias, to adjust the reported prevalence in the nationally representative Bangladesh Maternal Mortality and Health Care Survey 2016 for the unbiased estimation of obstetric fistula prevalence in Bangladesh.

Findings

The MMVS, done from Aug 3 to Dec 9, 2016, identified 67 potential cases of obstetric fistula; of them, 57 (85%) women completed the clinical examination, and 19 were confirmed as obstetric fistula cases. The adjusted sensitivity of the self-reports of obstetric fistula was 100% (95% uncertainty interval [UI] 99·8–100) and the observed specificity was 99·9% (95% UI 99·9–100) among women aged 15–49 years. However, the PPV was low, at 31·6% (95% UI 19·2–46·2), suggesting that almost two thirds of the self-reported cases were not true obstetric fistula cases. We estimated an adjusted obstetric fistula prevalence rate of 38 (90% UI 25–58) per 100 000 women aged 15–49 years in Bangladesh. Nationally, we estimated about 13 376 (90% UI 8686–20 112) women of reproductive age living with obstetric fistula. Additionally, we estimated 4081 (1773–8790) women aged 50–64 years to be living with obstetric fistula in Bangladesh; overall, we estimated that there are 17 457 (10 459–28 902) women aged 15–64 years in Bangladesh with obstetric fistula.

Interpretation

The burden of obstetric fistula is still high in Bangladesh. Prevention and provision of surgical treatment to so many women will need coordinated efforts, planning, allocation of resources, and training of surgeons.

Funding

US Agency for International Development, Government of Bangladesh, and UKAid.

中文翻译：

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孟加拉国的产科瘘：来自全国调查的估计并经过临床验证校正

 背景

产科瘘是在长时间或难产后发生的，是可以预防和治疗的。然而，在低收入和中等收入国家，许多妇女仍然患有这种疾病并且仍未得到治疗。人们还担心，剖腹产的增加趋势正在增加这些国家医源性产科瘘的风险和比例。这种情况的真实患病率尚不清楚，这使得卫生规划者和政策制定者很难制定适当的国家卫生战略来解决该问题。通过调查估计产科瘘是很困难的，因为失禁症状的自我报告容易出现错误分类偏差。在这项研究中，我们旨在估计孟加拉国产科瘘管病的患病率和负担。

 方法

为了有效估计解决错误分类偏差，我们分两步实施了该研究。首先，我们对孟加拉国锡尔赫特市的 65 740 名妇女进行了孕产妇发病率验证研究 (MMVS)，以评估调查问题的敏感性、特异性、阳性预测值 (PPV) 和阴性预测值。这是通过女医生对疑似病例进行临床检查来确认诊断的；还检查了盆腔器官脱垂和其他尿失禁症状筛查呈阳性的女性样本，并将其用作临床诊断确认的对照。其次，在纠正验证偏差后，我们使用估计的诊断测试值来调整 2016 年全国代表性孟加拉国孕产妇死亡率和卫生保健调查中报告的患病率，以对孟加拉国产科瘘患病率进行公正的估计。

 发现

MMVS于2016年8月3日至12月9日进行，发现了67例潜在的产科瘘病例；其中，57名（85%）女性完成了临床检查，19名确诊为产科瘘病例。老年女性产科瘘自我报告的调整敏感性为 100%（95% 不确定性区间 [UI] 99·8–100），观察到的特异性为 99·9%（95% UI 99·9–100） 15-49 岁。然而，PPV 较低，为 31·6%（95% UI 19·2–46·2），表明几乎三分之二的自我报告病例不是真正的产科瘘病例。我们估计，孟加拉国每 10 万名 15-49 岁女性中，调整后的产科瘘管病患病率为 38 例（90% UI 25-58）。在全国范围内，我们估计约有 13 376 名（90% UI 8686–20 112）育龄妇女患有产科瘘。此外，我们估计孟加拉国有 4081 名 (1773-8790) 名 50-64 岁女性患有产科瘘；总体而言，我们估计孟加拉国有 17 457 名 (10 459-28 902) 名 15-64 岁女性患有产科瘘。

 解释

孟加拉国产科瘘管病的负担仍然很高。为如此多的妇女提供预防和手术治疗需要协调努力、规划、资源分配和外科医生培训。

 资金

美国国际开发署、孟加拉国政府和英国援助署。