Risk factors for vaginal fistula symptoms in Sub-Saharan Africa: a pooled analysis of national household survey data

BACKGROUND Vaginal fistula (VF) is one of the most severe maternal morbidities with the immediate consequence of chronic urinary and/or fecal incontinence. The epidemiological evidence regarding risk factors for VF is dominated by facility-based studies. Our aim is to estimate the effect size of selected risk factors for VF using population-based survey data. METHODS We pooled all available Demographic and Health Surveys and Multiple Indicators Cluster Surveys carried out in sub-Saharan Africa that collected information on VF symptoms. Bayesian matched logistic regression models that accounted for the imperfect sensitivity and specificity of self-reports of VF symptoms were used for effect size estimation. RESULTS Up to 27 surveys were pooled, including responses from 332,889 women. Being able to read decreased the odds of VF by 13% (95% Credible Intervals (CrI): 1% to 23%), while higher odds of VF symptoms were observed for women of short stature (<150 cm) (Odds Ratio (OR) = 1.31; 95% CrI: 1.02-1.68), those that had experienced intimate partner sexual violence (OR = 2.13; 95% CrI: 1.60-2.86), those that reported sexual debut before the age of 14 (OR = 1.41; 95% CrI: 1.16-1.71), and those that reported a first birth before the age of 14 (OR = 1.39; 95% CrI: 1.04-1.82). The effect of post-primary education, female genital mutilation, and having problems obtaining permission to seek health care were not statistically significant. CONCLUSIONS Increasing literacy, delaying age at first sex/birth, and preventing sexual violence could contribute to the elimination of obstetric fistula. Concomitant improvements in access to quality sexual and reproductive healthcare are, however, required to end fistula in sub-Saharan Africa.