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    • We modelled how the loss

    2019-05-13

    We modelled how the loss of health-care workers—defined here as doctors, nurses, and midwives—to Ebola might affect maternal, infant, and under-5 mortality in Guinea, Liberia, and Sierra Leone, with the aim of characterising the order of magnitude of likely effects, not providing specific predictions. We combined data on: (1) health-care worker deaths from Ebola; (2) the stock of health-care workers pre-Ebola; (3) maternal, infant, and under-5 mortality rates for each country, pre-Ebola; and (4) coefficients of health-care worker mortality, which capture the relation between health-care workers in a given country and different mortality rates (ie, maternal, infant, and under-5 mortality). For each of the three countries, we first calculated how many doctors, nurses, and midwives combined have died due to Ebola per 1000 of the population. We multiplied each pre-Ebola mortality rate (maternal, infant, and under-5) by 1 minus this fraction, multiplied by the health-care worker mortality coefficient. We then translated this figure into the percentage change in mortality relative to pre-Ebola rates ().
    We were very surprised to read the recent report by Mathieu Maheu-Giroux and colleagues (May, 2015) of a meta-analysis of Demographic and Health Survey data on fistula prevalence in sub-Saharan Africa. This study can only provide an estimate of urinary incontinence symptoms, and since there was no confirmation of fistula diagnosis, the data cannot be used to represent fistula prevalence. Indeed, Maheu-Giroux and colleagues report that women with fistula are older and of greater parity than women without fistula. This finding should have alerted them to an obvious error in the data because women classically experience fistula during their first delivery (at a young age) and frequently have no further pregnancies, whereas women with other causes of incontinence, such as uterine prolapse and stress incontinence, are older and multigravid. Moreover, the data on Ethiopia\'s fistula prevalence are in profound chemokine receptor to our experience and the results of two studies we have recently undertaken in Ethiopia, both of which are currently being considered for publication. The first is a community-based study of 23 023 women surveyed for fistula and uterine prolapse, with suspected fistula cases being followed up for diagnostic confirmation. The second is of surgical fistula treatment in three Ethiopian fistula hospitals, where around 70% of the country\'s treatments are provided. Both studies reveal a significant decline in fistula prevalence and illustrate that Ethiopia is far from having “deficiencies in national treatment planning”, as the linked Comment suggests; rather antibiotic resistance has been successful in improving maternal health care and delivering an effective patient identification programme and high-quality fistula treatment.
    We wholeheartedly agree with Karen Ballard and colleagues that self-reports of vaginal fistula symptoms do not have the accuracy of the gold standard of pelvic examinations. For this reason, we corrected our prevalence estimates for the imperfect sensitivity and specificity of the survey questionnaires. As noted in our paper, the difference between the uncorrected and corrected estimates suggests that, indeed, an important proportion of self-reports could be false positives due to confusion with incontinence symptoms. Ballard and colleagues used information about the age and parity of women reporting fistula symptoms to conclude that there was “an obvious error” in our data. It was not possible to correct these characteristics for misclassification using the Bayesian latent class model employed to obtain the prevalence estimates. As such, it would be misguided to judge the validity of our prevalence estimates on the basis of these unadjusted data. Besides, these characteristics are not entirely unexpected since they refer to lifetime prevalence and not incidence. Tunçalp and colleagues assessed the validity of the Demographic and Health Survey fistula module among a subpopulation of Nigerian women with perceived fistula-like symptoms. Comparing self-reports to the gold standard of medical examinations among women reporting symptoms, this study estimated the sensitivity and specificity of the module at 92% and 83%, respectively. This finding should reassure our critics that we are in fact not merely estimating “urinary incontinence symptoms”, since the inclusion of women without perceived fistula-like symptoms would have considerably improved specificity.