ABSTRACT
There have been numerous epidemiological studies of obstetric fistula patients from various parts of the globe. Typically the patient is primiparous 43% to 62.7% ( 2 , 3 ), but a significant number are multiparous (up to 20-25% having had four or more deliveries) ( 4 , 2 ), presumably due to delivering larger children or a malpresented delivery. Interestingly a number of studies have shown these women to be of short stature, often <150 cm in Nigeria ( 4 ), India ( 5 ), Ethiopia ( 6 ), and Niger ( 7 ). Ampofo showed them to be 7 cm shorter than the general female population ( 8 ). The women are largely uneducated, more than 92% having had no formal education ( 3 , 9 , 10 ). They are also young. Although it is difficult to get a true estimate of their age as it is often unknown, it is evident from their appearance that most are in their teens or early twenties. If their age is asked and the answer relied upon, a 42% are aged <20, with 65% being <25 years old ( 3 ). Other studies confirm this trend ( 9-12 ). The majority have had home deliveries with no skilled attendant present and typically more than 50% have been divorced by their husbands due to their offenses ( 3 ). It has been noted in Nigeria and Ethiopia that if the woman is childless, she is more likely to be divorced, whereas those women who have live children are more likely to
be attending those children and the husband has remained with her ( 10 , 13 ). What is unclear is the association of obstetric fistula and female genital cutting. The opinion of many fistula surgeons is that the obstructed labor occurs against the mothers’ bony pelvis and not against the scarred tissues resulting from a circumcision at the outlet. A recent as yet unpublished series (Browning, Wall) concluded that the presence of type I and II female circumcisions (that is clitoris or clitoris with labia minora removed) made no impact on the presentation, type, and outcome of fistula, concluding that it was an independent variable in obstetric fistula formation ( 14 ). From the experience in Ethiopia, fistula can result from a type III circumcision, or infundibulation, indirectly when a traditional health attendant may cut the circumcision open during labour, cutting anteriorly, damaging the urethra, bladder neck, and bladder base.
