title: Association between parity and fistula location in women with obstetric fistula: a multivariate regression analysis.
abstract: OBJECTIVE
  To compare primiparous and multiparous women who develop obstetric fistula (OF) and to assess predictors of fistula location.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  Fistula Care Centre at Bwaila Hospital, Lilongwe, Malawi.
  
  
  METHODS
  Women with OF who presented between September 2011 and July 2014 with a complete obstetric history were eligible for the study.
  
  
  METHODS
  Women with OF were surveyed for their obstetric history. Women were classified as multiparous if prior vaginal or caesarean delivery was reported. The location of the fistula was determined at operation: OF involving the urethra, bladder neck, and midvagina were classified as low; OF involving the vaginal apex, cervix, uterus, and ureters were classified as high.
  
  
  METHODS
  Demographic information was compared between primiparous and multiparous women using chi-squared and Mann-Whitney U-tests. Multivariate logistic regression models were implemented to assess the relationship between variables of interest and fistula location.
  
  
  RESULTS
  During the study period, 533 women presented for repair, of which 452 (84.8%) were included in the analysis. The majority (56.6%) were multiparous when the fistula formed. Multiparous women were more likely to have laboured <1 day (62.4 versus 44.5%, P < 0.001), delivered a live-born infant (26.8 versus 17.9%, P = 0.026), and have a high fistula location (37.5 versus 11.2%, P < 0.001). Multiparity [adjusted odds ratio (aOR) = 4.55, 95% confidence interval (CI) 2.27-9.12)] and history of caesarean delivery (aOR = 4.11, 95% CI 2.45-6.89) were associated with development of a high fistula.
  
  
  CONCLUSIONS
  Multiparity was common in our cohort, and these women were more likely to have a high fistula. Additional research is needed to understand the aetiology of high fistula including potential iatrogenic causes.
  
  
  CONCLUSIONS
  Multiparity and caesarean delivery were associated with a high tract fistula in our Malawian cohort.
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: A M
authors: AM
authors: Sih
authors: UNC Project-Malawi, Lilongwe, Malawi.|University of North Carolina Department of Obstetrics & Gynecology, Chapel Hill, NC, USA.
authors: D M
authors: DM
authors: Kopp
authors: UNC Project-Malawi, Lilongwe, Malawi.|University of North Carolina Department of Obstetrics & Gynecology, Chapel Hill, NC, USA.|Department of Obstetrics & Gynaecology, Malawi College of Medicine, Blantyre, Malawi.
authors: J H
authors: JH
authors: Tang
authors: UNC Project-Malawi, Lilongwe, Malawi.|UNC Department of Medicine, Chapel Hill, NC, USA.
authors: N E
authors: NE
authors: Rosenberg
authors: Bwaila Hospital, Lilongwe District Health Office, Lilongwe, Malawi.|Fistula Care Centre, Lilongwe, Malawi.
authors: E
authors: E
authors: Chipungu
authors: UNC Project-Malawi, Lilongwe, Malawi.|Department of Surgery, Temple University, Philadelphia, PA, USA.
authors: M
authors: M
authors: Harfouche
authors: Fistula Care Centre, Lilongwe, Malawi.
authors: M
authors: M
authors: Moyo
authors: Bwaila Hospital, Lilongwe District Health Office, Lilongwe, Malawi.
authors: M
authors: M
authors: Mwale
authors: Fistula Care Centre, Lilongwe, Malawi.|Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX, USA.
authors: J P
authors: JP
authors: Wilkinson
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D016015:Logistic Models; D008295:Malawi; D015999:Multivariate Analysis; D016017:Odds Ratio; D010298:Parity; D011247:Pregnancy; D012307:Risk Factors; D014548:Urinary Fistula / Q000175:diagnosis / Q000209:etiology*; D014591:Uterine Diseases / Q000175:diagnosis / Q000209:etiology*; D014624:Vaginal Fistula / Q000175:diagnosis / Q000209:etiology*
keywords: Caesarean section; iatrogenic injury; multiparity; obstetric fistula