title: The changing face of obstetric fistula surgery in Ethiopia.
abstract: OBJECTIVE
  To examine the incidence and type of obstetric fistula presenting to Hamlin Fistula Ethiopia over a 4-year period.
  
  
  METHODS
  This is a 4-year retrospective survey of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia, where approximately half of all women in the country are treated. The operation logbook was reviewed to identify all new cases of obstetric fistula presenting from 2011 to 2015. New cases of urinary fistula were classified by fistula type (high or low), age, and parity of the woman.
  
  
  RESULTS
  In total, 2,593 new cases of urinary fistulae were identified in the study period. The number of new cases fell by 20% per year over the 4 years (P<0.001). A total of 1,845 cases (71.1%) were low (ischemic) fistulae, and 804 cases (43.6%) of these had an extreme form of low circumferential fistula. A total of 638 (24.6%) women had a high bladder fistula, which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy, and 110 (4.2%) women had a ureteric fistula. The incidence of high fistulae increased over the study period from 26.9% to 36.2% (P<0.001). A greater proportion of multiparous women had a high bladder fistula (70.3%) compared with primigravid women (29.7%) (P<0.001). Conversely, a greater proportion of primiparous women experienced a low circumferential fistulae (68.6%) compared with multiparous women (31.4%) (P<0.001).
  
  
  CONCLUSIONS
  There appears to be a decline in the number of Ethiopian women being treated for new obstetric urinary fistulae. However, the type of fistula being presented for treatment is changing, with a rise in high fistulae that very likely occurred following cesarean section and a decline in the classic low fistulae that arise following obstructed childbirth.
authors.affiliation: Hamlin Fistula Ethiopia, Addis Ababa, Ethiopia; School of Health Studies, University of Surrey, Guildford, Surrey, UK.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Wright
authors.affiliation: Hamlin Fistula Ethiopia, Addis Ababa, Ethiopia.
authors.forename: Fekade
authors.initials: F
authors.lastname: Ayenachew
authors.affiliation: Hamlin Fistula Ethiopia, Addis Ababa, Ethiopia; School of Health Studies, University of Surrey, Guildford, Surrey, UK.
authors.forename: Karen D
authors.initials: KD
authors.lastname: Ballard
keywords: Ethiopia; changing incidence; iatrogenic fistulae; obstetric fistulae; parity