Factors Associated With Obstetric Fistula Among Reproductive Age Women in Ethiopia, Community Based, Case Control Study

Background: Obstetric stula is major public and reproductive health concerns in Ethiopia .It are most disturbing among all maternal morbidities. Method: A community-based unmatched case control study was conducted from the EDHS, 2016 dataset. All 70 cases and 210 non cases were selected using random number table from the dataset. Reproductive age mothers who had experiencing lifelong obstetric stula were considered as cases .Logistic regression was used to identify factors associated with obstetric stula at 95% condence interval. Factors signicant at p value of ≤ 0.05 were included into multivariable logistic regression model to generate adjusted odds ratios. Results: The majority of stula cases were from rural residences. Independent risk factors associated with obstetric stula included age at rst marriage, rural residence, poorest wealth index and decision making for contraceptive use mainly husband partner.


Background
Obstetric stula is an atypical link between the vagina, rectum , and/or bladder that may arise after protracted and obstructed labor. Among all maternal morbidities, obstetric stula is one of the most disturbing for the maternal health. Childbirth encounters momentous risks for women and new born. (1).Globally, each year between 50 000 to 100 000 women are pretentious by obstetric stula (2).
These risks re ect global inequity: Obstetric stula (OF) is a situation that residue prevalent in developing nations, mainly in sub-Saharan Africa and Southeast Asia where suitable and timely obstetrical care is hard to nd or scarce. It is anticipated that more than two million young women survive with untreated obstetric stula in Asia and sub-Saharan Africa (3).
Ethiopia's fertility rate is among the uppermost countries in the world and only 50% of births attend by a skilled birth attendant. Besides, rural areas where 80% of the population resides, poor and under-nourished women countenance superior risk and challenges to obstetric stula reduction (4).
Women victumed by obstetric stula are often deserted by their husbands, stigmatized by the community. Hence, leads to low self-esteem, depression and long lasting emotional trauma (5).According the USAID report ,it is estimated that nine thousand women in Ethiopia develop obstetric stula every year, and that up to hundred thousand women are living with untreated stula (6).
Information from different literature indicated that obstetric stula linked to social-economic and cultural factors including poverty, illiteracy, accessibility of health facilities, duration of labour, respondent height, young age at marriage, place of residence with lack of emergence obstetric care (7)(8)(9)(10)(11).
Community-based surveys generally provide wider coverage, better representation of national population and more opportunities to collect a wide range of data. Due to nationally representative samples and use of similar questions across surveys, the EDHS surveys provide a unique set of data to asses factors associated with obstetric stula. Identi ng factors associated with obstetric stula using various study design is mandatory.
To our knowledge, no nationally representative community based study with case control study design has documented to identify risk factors for obstetric stula in Ethiopia. The aim of this study was therefore to identify the risk factors for obstetric stula from a local context among women in Ethiopia.

Data source and sampling techniques
The study participants chosen using a strati ed, two stage cluster design, and enumeration areas were the sampling units for the rst stage. In the rst stage, 645 enumeration areas were randomly selected: 202 in urban areas and 443 in rural areas. In the second stage, a xed number of 28 households per cluster were selected randomly for each enumeration areas. The 18,060 households were randomly selected and 16,650 households were eligible and interviewed. Additional information about the methodology of EDHS 2016 can be accessed in the published report of the main ndings of the survey [12].
Every selected reproductive age women was included and data were collected on various socioeconomic, obstetric and nutrition variables. As our focus in this study was 15-49 years aged women, we extracted the EDHS 2016 data set. We found in the data set 70 women with experienced obstetric stula (Cases) and 210 (Controls) selected from the data set using random number table and 280 women were included in the nal analysis showed sampling techniques ( Figure :1).

Sample design
A community-based unmatched case-control study was conducted among reproductive age women.

Variables and measurements:
Dependent variable: The outcome variable was stula, which is de ned as reproductive aged women experiencing lifelong obstetric stula.

Independent variables:
The selection of the independent variables was guided by the literature and availability of the variables in the data set. Some of the independent variables for obstetric stula among reproductive age women 15-49 years.
Maternal characteristics: maternal age, maternal educational status, maternal antenatal care follow up, whether the mother is currently living with her husband or not, whether the mother is engaged in income generating work or not.
Household characteristics: number of household members, residence, wealth index ranked in to ve (poorest, poorer, middle, richer and richest) , sex of household head.
Obstetric characteristics: Place of delivery, ANC follow up, size of child at birth, postnatal check up, Preceding birth interval, Height(Cm) and ever had a terminated pregnancy.
Anthropometric measurements: The nutritional category of women was measured by use of height and body mass index (BMI). To calculate BMI, during EDHS measured the height and weight of women age 15-49 years. BMI is used to measure thinness or obesity. BMI is de ned as weight in kilograms divided by height in meters squared (kg/m2). A BMI below 18.5 kg/m2 shows thinness. A BMI below 12-17 kg/m2 indicates severe undernutrition BMI of 25.0 kg/m2 or above shows overweight or obesity. Height was also categorized in a single cut off point < 145 cm as short stature.

Wealth index
A wealth index in the EDHS survey was measure based on household asset data to classify individuals into 5 wealth indeces (poorest, poorer, medium, richer and richest). Variables incorporated in the wealth index were ownership of chosen household assets (television, bicycle or car), size of agricultural land, number of livestock and materials used for house construction [13].

Data Analysis
EDHS have developed recode les in order to facilitate data analysis. All data tartan for its completeness and reliability. Preliminary analysis was done to check the rst round nding. In all analysis, sample weights have done due to two stage cluster sampling design in the EDHS data set to adjust for the imbalance probability selection among the strata [12]. All the analyses were performed using STATA version 14.0 Categorical type of data was analyzed by descriptive statistics (frequency and percentage).
Logistic regression analysis was used to identify factors associated with obstetric stula. Bivariate analysis was carried out to see the crude association of each independent variable with the outcome variable (Obstetric stula). Those independent variable variables with -value ≤ 0.05 in the bivariate analysis were included in the nal multivariable logistic regression analysis to adjust for confounding and to identify the nal factors associated with obstetric stula. Logistic regression method was used during the multivariable logistic regression analysis. Before inclusion of predictors to the nal logistic regression model, the multi-collinearity was checked using VIF<10/Tolerance >0.1 for continuous independent variables. The goodness of t of the nal logistic model was tested using Hosmer and lemeshow test at p value of >0.05. The strength of association of the predictors and outcome variable have been indicated by Adjusted odds ratio at 95% con dence interval. The signi cant association was declared at p≤ 0.05 for the nal logistic regression model Ethical Considerations: The study proposal got ethical approval from Tigray health research institute and formal letter of permission was obtained from measure DHS project website to access the dataset (http://www.measuredhs.com).

Results
Socio-demographic and other characteristics for cases and controls of the mothers From a total of 280 samples size, (70 cases and 210 controls) were included in the nal analysis. Majority of the case were aged 34-49 (44%) while controls were aged 15-23 years 37.1%. More than half 57.1% of mothers in cases and 42.4% controls have no education attainment. Majority of cases 84.3% and 64.8 % controls were living in rural residence.
Regarding, wealth index poorest 30% of mothers in cases and 24.3% in controls. Majority of number of house hold members have equal or greater than four 62.1% of cases and 63.3%.non controls. The majority of mothers in cases and control group (68.6% and 58.6% respectively) were married. More than half numbers 52.9% of mothers in cases and 43.3% in controls were Orthodox believers .One third number of mothers 38.6% in cases and 46.7 % in non controls had work (Table:1).

Obstetrics characteristics of cases and controls
More than half 58.6% in cases and 62.9% in controls place of delivery in home. One from four mothers 27.6% in cases and 24.7% in controls were not following Antenatal care.Size of baby very larger 18% and larger than average 16 % in cases and 21.6% and 18.9% in controls respectively. Majority of mothers 96.6% in cases and 86.6 in controls were not follow postnatal check up. Greater than One fourth number of mothers 31.3% in cases and 23.6% in controls were less than 24 months birth interval. Almost majority of the cases 85.7% and 88.1% in controls were taller than 150 cm. Majority of mothers in cases 80% and 90.5% in controls not ever had a terminated pregnancy (Table:2).
Factors Associated with obstetric stula among mothers aged 15-49 years: In bivariate logistic regression analysis age at rst marriage, Height, wealth index place of residence, has television, literacy, number of house hold members, ever had a terminated and decision maker for using contraceptive pregnancy signi cant associated with obstetric stula. In multivariable logistic regression analysis age at rst marriage, wealth index poorest, rural residence and decision maker for using contraceptive mainly husband, partner signi cant associated with obstetric stula.

Discussion
The main goal of this unmatched case control study was to identify factors associated with obstetrics stula in Ethiopia. Despite, substantial efforts by the Ethiopia government and non-governmental organizations to raise health facilities, improve quality of services, and increase access to care, inequalities in maternal healthcare obstetric stula is still the main concern in Ethiopia.
Our analysis identi ed age at rst marriage, rural residence, poorest wealth index and decision making to use contraceptive husband only risk factors for developing obstetrics stula. Age at rst marriage less than 18 years were 3.3 times (AOR = 3.39; 95% CI: 2.832, 4.601) more likely with developing stula than greater than 18 years aged. This nding also corresponds to studies in developing countries, in Tigray, Ethiopia (7), in Sub-Saharan Africa (14) and Uganda Demographic and Health Survey (15).
The possible reason might be due to before the pelvic girdle is fully developed in young adolescent may explain the elevated risk of distress from obstetric stula women bearing children apparently. Besides, when labor happen in situations not equipped to deal with dystocia.
Rural residence more likely with developing stula than urban residence in line with study in Eretria (16) and Democratic Republic of the Congo (17).This might be in the rural residence shortage of antenatal care, extended labor and deprived health seeking behavior such as delay in accessing emergency care due to intriguing more than one move from home to reach the delivery place and no lack of decision making in emergency by family members were associated with the occurrence of obstetric stula. Besides, in rural areas associated with lower geographical ease of access to health facilities. Besides economic troubles, there are also socio-cultural issues related to lower male involvement and support for women's health care access. Wealth index poorest category more likely with developing stula than richest wealth index.This result is in agreement with the study in South-eastern rural community of India (18), Tanzania (19), Uganda: demographic and health survey data (20) and Nairobi, Kenya (21).The possible reasons might be that women who had a better wealth index may assist them easily reach to the health facilities for their paramount health outcomes. Besides, a better wealth index may lessen the di culty of obtaining resource to easily reach health care. As a result, women, who could not have enough money to pay for these expenses found it complicated or even impossible to visit health facilities.
Decision making for contraceptive use mainly by husband, partner 1more likely with developing stula than Joint decision .This nding is concurrent with in sub-Saharan Africa (22) and North Western , Nigeria (21).The possible reason might be the women for non-use of modern contraceptive methods was husband antagonism, desire for additional children, religious ban. This is not amazing as culture and religion has positioned men as the top of the family and women can not make decisions in relation to their own health.
The desire for more children given by some of the women is not surprising as the majority of the women with obstetric stula delivered a stillbirth. These study ndings present the evidence for the need of male participation in contraception and other reproductive health issues like the prevention of obstetric stula were men play an important role.
In spite of the limitations of our study, this is community based case-control study to identify factors associated with obstetric stula development and it is the only national representative and community base case control study taking place in Ethiopia. These ndings can assist and identify women who are at increased risk for developing an Obstetric stula and educate them about the risks of becoming pregnant before their bodies have matured and to identify the signs and symptoms associated with obstructed labor and emergency delivery.
Besides, the detection of at risk individuals may also help identify those who have developed obstetric stula and help them seek care more quickly to reduce morbidity in the population. Resources aimed at helping child-bearing women can also be oriented to reduce risk factors in target populations and increase protective factors to lower obstetric stula rates. We hope that the ndings of this study will bring much needed attention to this serious condition and provide information to help those who are most likely to develop an obstetric stula. Further longutidail study needed.

Strengths And Limitations Of The Study
The strength of this study was; it used national representative data which permit to generalize the results. It also functional all the DHS data principles like weighting. The limitation of this study was its cross-sectional design, cannot examine causation of the precedence in time between exposure and outcome. There were some missing values for some variables in the dataset .Being; the cases for obstetric stula were lifelong.Therefore, the authors might be fail to consider some factors which could affect the interpretation of the results and the retrospective nature of the data and maternal verbal reports, recall bias might have been introduced.

Conclusions
Obstetric stula is a major public and reproductive health concern in Ethiopia. Majority of women with obstetric stula were from rural areas. This analysis provides evidence that experience of obstetric stula signi cant associated with age at rst marriage, rural residence, poorest wealth index and decision making by husband alone. Comprehensive intervention strategies should be in place customized to different government hierarchies (national, regional, district level, house hold and individual level) including interventions for combating obstetric by giving stress on the identi ed risk factors. We advise health authorities at different hierarchies to design different intervention activities like to educating the community to avoid the risk of obstetric stula due to pregnancy and delivery, strengthening family planning, antenatal care services and increased access to emergency obstetric care should be addressed extensively.       Number of operation to x obstetric stula cases, EDHS (n=70)