Paucity of Urogynaecology Research in Africa: time for change

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1 Paucity of Urogynaecology Research in Africa: time for change SASOG 2014 Maki L, Brouard K, Jeffery S Department of Obstetrics and Gynaecology, University of Cape Town Urogynaecology and Pelvic floor reconstruction

2 Background Recent years have seen a global growth in research into Urogynaecology and Pelvic Floor Dysfunction. The extent of the problems associated with pelvic organ prolapse, urinary incontinence and bowel dysfunction is now well understood in Europe, the Americas, Australia and parts of Asia.

3 Urinary incontinence, pelvic organ prolapse and anal incontinence no doubt affect the quality of life of African women HOWEVER The continent of Africa with its female population of more than 500 million has unique challenges which could impact on the nature of pelvic floor disorders access to investigations and treatment type of treatment offered

4 Africa s unique challenges: Life expectance <60 years (world median 74 years) World s poorest continent corruption, human rights violations, high levels of illiteracy, military conflicts Quality and availability of Obstetric services Burden of infectious diseases Women not empowered regarding their (reproductive) health Public health spending War deaths Maternal mortality Infectious and parasitic deaths

5 Obstetric fistula overshadow all other issues related to pelvic floor dysfunction in Africa Many doctors underestimate the impact of pelvic organ prolapse and urinary incontinence in African women because the number of women seeking care for these problems are significantly lower than in well-resourced areas HOWEVER The limited number of prevalence studies suggest that the proportion of women suffering from these problems is comparable to wealthier regions

6 Aims and Objectives Decision making with regards to assessment and appropriate treatment is based on evidence from good quality research The aim of this study was to obtain an overview of the subject matter and regional distribution of published research on pelvic floor dysfunction in Africa.

7 Methods All countries in Africa were identified and divided into regions Northern, Southern, Western, Eastern and Central regions The PubMed online database was used to perform the search Using a broad range of keywords we identified papers published on a wide range of urogynaecological conditions including Lower urinary tract symptoms (LUTS) Pelvic organ prolapse Sexual dysfunction Painful bladder syndrome / Interstitial cystitis Urinary incontinence Fistula The search was concluded in December 2012 The number of papers published in each African country and region was calculated Descriptive analysis

8 Results Nigeria, Egypt, South Africa, Ethiopia and Guinea produced more that three quarters of the total number of papers produced by all 54 African countries. 1% 1% 1% 1% 1% 1% 1% 2% 1% 3% 3% 3% Guinea, 9% Ethiopia, 11% 3% Nigeria Egypt South Africa, 15% Nigeria, 23% Egypt, 19% South Africa Guinea Uganda Malawi Kenya Senegal Benin Eritrea Ethiopia Ghana Tunisia DRC Uganda Zambia Morocco Other

9 The majority of African papers published in were on the topic of Fistula and Urinary incontinence (14) 4% (26) 7% (22) 6% (21) 5% Non-fistula urinary incontinence (93) 25% Fistula (200) 53% Fistula Non-fistula urinary incontinence LUTS Anal incontinence Prolapse Sexual dysfunction

10 24 countries published research on Fistula more than a third of these papers were from Nigeria and Ethiopia Fistula Nigeria Rest of Africa 50% Nigeria 24% Ethiopia 13% South Africa 9% Egypt 4% Ethiopia South Africa Egypt rest of Africa

11 Urinary incontinence Many of the papers retrieved after searching for urinary incontinence had fistula as their primary focus and were included in the fistula section Papers published on Non-fistula urinary incontinence were evenly split between stress urinary incontinence and urgency urinary incontinence Guinea produced the highest number of papers on urinary incontinence all on urgency urinary incontinence, but has published no other papers on pelvic floor disorders

12 Even in the countries producing the highest number of papers, published research on anal incontinence, pelvic organ prolapse and sexual dysfunction were low. 100% 90% Prolapse 80% 70% Sexual dysfunction 60% 50% LUTS 40% 30% 20% 10% 0% Nigeria Egypt South Africa Ethiopia Guinea Anal incontince Urinary incontinence Fistula

13 Egypt is the only country to have contributed significantly to the continent s data on Anal incontinence Anal incontinence 4% 5% 5% Egypt Nigeria 9% South Africa 9% Egypt 68% South Africa Nigeria Kenya Benin Cote d 'Ivoire

14 Only 14 papers on Sexual dysfunction were identified in Africa The majority of these were on sexual function in postmenopausal women or in women following genital cutting There was only one paper on patient perceptions of prolapse which was from the Central African Republic. South Africa produced the only paper in Africa on complications of vaginal mesh.

15 Epidemiological data was sparse for the whole continent with only 21 papers published on the subject (6% of all papers) 6% 94% All studies Epimediology Other Epidemiology (2) 9% Sexual dysfunction (4) 19% (1) 5% Fistula (6) 29% Urinary incontinence (8) 38% Fistula Urinary incontinence Sexual dysfunction Prolapse LUTS

16 Discussion Appropriate that a large proportion of pelvic floor dysfunction research in Africa is on fistula Prevalence / rural women Prospective population study of women in West Africa 2.2 / 1000 women of childbearing age (1.5/1000 untreated) Crossectional study in Ethiopia 1557 / live births (lifetime prevalence 4.7%) Malawian Demographic and Health survey 2005 Avoidable factors: marry and conceive young, access to Obstetric servi ces Consequences: rejection, isolation, poverty The profound problem of fistula-related incontinence has overshadowed non-fistula urinary incontinence and pelvic organ prolapse in Africa

17 Without robust epidemiological research we can not determine the extent of the burden of pelvic floor dysfunction (incontinence, pelvic organ prolapse, sexual dysfunction) in African women Hurdles associated with obtaining useful data in Africa Broad range of languages spoken Unavailability of suitable questionnaires Lack of funding Small cohort of clinicians with an interest in pelvic floor dysfunction

18 Hurdles associated with obtaining useful data in Africa Broad range of languages Unavailability of suitable questionnaires Kings Health Questionnaire validated for use in Afrikaans and Xhosa (Juul 2012) UDI-6 and IIQ-7 validated for use in Arabic - spoken by 178 million Africans (Al-Azab 2019) Prevalence of urinary incontinence using UDI-6: 54% (stress 15%, urge 15%, mixed 25%) Lack of funding Small cohort of clinicians with an interest in pelvic floor dysfunction Partnerships and sustained collaboration with members of the international urogynaecology community

19 Conclusion There is an urgent need for us to increase epidemiological research into pelvic floor disorders in our female African population. In order for us to appropriately manage women in Africa, it is essential that we also increase specific training and research into assessment and management of incontinence, pelvic organ prolapse and sexual dysfunction in an African setting.

20 `

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