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  • Ideally assessment of obstetric interventions and


    Ideally, assessment of obstetric interventions and outcomes should be based on high-quality, recent data from the entire population or a representative sample. A key feature of the Robson classification is that it uses information that is available at the onset of labour or delivery, is routinely collected (although this is not necessarily so, even in high-income countries), and is reliably reported. Data validity is unknown for this study, and the increase over time in maternal records that could not be classified (an indicator of data quality) and the higher than expected relative size of Group 9 (which has been suggested as a self-validation group within the Robson classification) is of concern. Vogel and colleagues\' study represents an important step in exploring and understanding how obstetric intervention rates are both increasing and also vary widely between countries and levels of development. In the absence of country-specific information about maternal and child health outcomes, caution is needed before recommending strategies aimed at modifying practices. However, this is not to suggest that any efforts to improve the availability of a skilled workforce and health services should be stalled.
    For every maternal death, an additional 20–30 women develop serious pregnancy-related complications. Among all maternal morbidities, obstetric fistula is one of the most devastating. It is caused by injury during childbirth, resulting in an abnormal opening between the vagina and the Hydroxyzine 2HCl what (vesicovaginal fistula) or rectum (rectovaginal fistula), leading to continuous urinary or fecal incontinence. Obstructed labour is the most common cause of vesicovaginal fistula in low-income countries. Worldwide, an estimated 2–3 million women have obstetric fistula, almost exclusively in sub-Saharan Africa and south Asia. However, this is a rough estimate and few data exist about the epidemiology of obstetric fistula. In , Mathieu Maheu-Giroux and colleagues estimate lifetime and point prevalence of vesicovaginal fistula in 19 sub-Saharan African countries. This paper is the first to estimate the prevalence of vaginal fistula (both obstetric and from other causes) based on population-level data from a large number of countries, using nationally representative surveys. The two most common sources of data for obstetric fistula are medical records and self-reported surveys. Medical records grossly underestimate the prevalence and incidence of obstetric fistula, as a result of the population affected by fistula and their limited access to medical care. Conversely, self-reported data from surveys, such as those used by Maheu-Giroux and colleagues, have low diagnostic value for maternal complications. Furthermore, Maheu-Giroux and colleagues limited their sample to women aged 15–49 years who were available for household interviews; institutionalised women at rehabilitation centres, women at facilities undergoing or awaiting surgical treatments, and women older than 49 years with fistula were not accounted for. Finally, there is an additional risk of misclassification because postpartum incontinence is common. Maheu-Giroux and colleagues used Bayesian statistics in an attempt to correct for misclassification bias and improve their estimates. Their results are crucial for quantifying the disease burden and for the development of country-specific policy and planning strategies to prevent and treat obstetric fistula. Take the example of Ethiopia. The shows the numbers of women treated between 2010 and 2013, in Ethiopia, Uganda, and Nigeria. Fistula surgery is rarely done at private facilities and outside of the listed centres, and thus underestimating fistula surgery is unlikely. From 2010 to 2013, on average, fewer than 2000 women each year had surgery for obstetric fistula in Ethiopia. Maheu-Giroux and colleagues show that more than 110 000 women in Ethiopia presently have vaginal fistula. These data imply that if no new cases occur, it will take at least 55 years to treat the existing patients in Ethiopia at the current rate. Clearly, Ethiopia has deficiencies in national treatment planning—most women will never receive surgical treatment despite living in a country with one of the world\'s best treatment facilities for obstetric fistula, including a dedicated fistula treatment and training facility at Addis Ababa Fistula Hospital. The situation in other countries is unlikely to be better.