ABSTRACT
BACKGROUND: Obstetric fistula (OF) is a significant cause of maternal morbidity in lower resource settings where women experience obstructed labor without timely access to skilled obstetric care. The true prevalence of OF is unknown; however, it is estimated to affect 2 to 3.5 million women globally. The Demographic and Health Surveys' (DHS) Fistula Module includes the OF symptom questions most frequently used for prevalence estimates, but these questions have not been validated. The aim of this study is to validate a symptom-based screening questionnaire for OF, including a question in the DHS' Fistula Module. METHODS: With an international panel of fistula surgeons, we developed and face-validated a screening questionnaire that assessed for symptoms of lower urinary tract fistula (LUTF) and lower gastrointestinal tract fistula (LGTF), as well as urinary and fecal incontinence (UI, FI). We evaluated the discriminative ability of the questionnaire using a case-control study design in a 1:2:2 ratio: cases were parous women with fistula confirmed on examination, controls included parous women without fistula on examination, with and without UI symptoms. All women underwent screening for fistula symptoms and a physical examination, with examiners blinded to screening results. RESULTS: Of the 367 Rwandan women who completed the questionnaires and underwent clinical examination, 59 women had LUTFs and 34 had LGTFs, 274 women were classified as controls with and without symptoms of UI. All LUTF screening questions performed well, including the DHS fistula question. The combination of two LUTF screening questions had the highest sensitivity (100%; 95% CI 94%, 100%), specificity (96%; 95% CI 93%, 98%), and area under the curve (AUC) (0.98). The combination of a LGTF screening question and FI question demonstrated the highest sensitivity (97%; 95% CI 85%, 100%), specificity (98%; 95% CI 95%, 99%) and AUC (0.98). CONCLUSIONS: Our OF screening questionnaire, including the DHS fistula question, demonstrated high sensitivities, specificities, and AUC.
Obstetric fistula (OF) is a birth injury which may occur in women living in lower resource settings who experience obstructed labor (not progressing normally) without access to skilled obstetric care. This injury causes a woman to constantly leak urine and/or feces from her birth canal. As OF affects poor women who live far from healthcare it is difficult to fully understand how many women worldwide have an OF. Furthermore, although some Demographic and Health Surveys (DHS) include OF symptom questions, the accuracy of these questions in identifying women with OF has not been studied.To more accurately determine which women may have an OF, we developed an OF screening questionnaire after consulting OF experts worldwide, which included a DHS OF question. We asked women from Rwanda this questionnaire and then examined these women to see if they have OF. Through this process we identified 59 women with a LUTF, 34 with a LGTF, and 274 without an OF. The best performing questions were able to identify women with LUTF 100% of the time and women with LGTF 97% of the time. We also showed that one DHS question detects women with LUTF and LGTF 100% and 85% of the time, respectively. Public health officials can now use the questions we studied to more accurately estimate how many women worldwide have OF, and best direct resources and skilled health care workers to the areas with the greatest need.
