A community-based long-term follow up of women undergoing obstetric fistula repair in rural Ethiopia

Objectives  To assess urinary and reproductive health and quality of life following surgical repair of obstetric fistula.
Design  Follow-up study.
Setting  A newly established fistula clinic (2004) at Gimbie Adventist Hospital, a 71-bedded district general hospital in West Wollega Zone, in rural Western Ethiopia.
Population  Thirty-eight women (86%) of 44 who had undergone fistula repair were identified in their community.
Methods  Community-based structured interviews 14–28 months following fistula repair, using a customised questionnaire addressing urinary health, reproductive health and quality of life.
Main outcome measures  Urinary health at follow up was assessed as completely dry, stress or urge incontinence, or fistula. King's Health Questionnaire was modified and used for the quality-of-life assessment.
Results  At follow up, 21 women (57%) were completely dry, 13 (35%) suffered from stress or urge incontinence and three (8%) had a persistent fistula. Surgery improved quality of life and facilitated social reintegration to a level comparable to that experienced before fistula development for both women who were dry and those with residual incontinence ( P  =   0.001). For women still suffering from fistula no change was seen ( P  =   0.1). Four women became pregnant following their surgery, among which there was one maternal death, three stillbirths and one re-occurrence of fistula.
Conclusion  Community-based, long-term follow up after fistula repair succeeded in Western rural Ethiopia. Despite one-third still suffering stress or urge incontinence, the women reported improved quality of life and social reintegration after fistula closure.     

Fertility and pregnancy outcomes among women with obstetric fistula in rural Malawi

Objective

To assess the fertility and pregnancy experiences of rural Malawian women living with obstetric fistula and following surgical repair of fistula.

Methods

Fertility histories were collected via in-depth interviews with women identified in 2007 as having obstetric fistula and with their family members.

Results

Of the 32 affected women interviewed, 17 (53.1%) conceived after developing obstetric fistula: 13 before repair and 6 after repair (with 2 conceiving both pre- and post-repair). Complaints of infertility were more frequent and urgent among women who had undergone repair than among those who had not. Over half (53.8%) of the women who conceived while living with obstetric fistula and all of those who conceived post-repair experienced at least 1 spontaneous abortion or perinatal death. Nineteen (47.5%) of the 40 pregnancies among women living with obstetric fistula and 7 (70.0%) of the 10 pregnancies among women post-repair ended in spontaneous abortion or perinatal death.

Conclusion

Even 2 years after undergoing surgical repair, women can continue to experience the effects of obstetric fistula, which include infertility, spontaneous abortion, and perinatal mortality. The factors responsible for extensive infertility and poor pregnancy outcome in women post-repair warrant further investigation.     

Exploring the needs and challenges of women reintegrating after obstetric fistula repair in northern Ghana

Objectiveto explore the cultural, social and economic needs and challenges of women in northern Ghana as they resume their day-to-day lives post obstetric fistula repair.Designa critical ethnographic approach.Settinga state run fistula treatment center in Tamale, northern Ghana, and 24 rural communities in northern Ghana.Participantsninety-nine (N=99) participants were recruited using purposive, convenience and snowball sampling. The sample consisted of women (N=41) who had experienced an obstetric fistula repair and their family members (N=24). Health care providers (N=17) and stakeholders (N=17) who had specialised knowledge about reintegration programs at a community or national level were also included.Findingsthe needs and challenges of northern Ghanaian women post obstetric fistula repair were historically and culturally rooted. A woman's psychosocial acceptance back into her community post obstetric fistula was significant to her well-being but many women felt they had to ‘prove’ themselves worthy of acceptance and hid any signs of urinary incontinence post obstetric fistula repair. The cost of treatment compounded by a woman's inability to work while having the obstetric fistula exaggerated her economic needs. Skills training programs offered assistance but were often not suited to a woman's physical capability or geographic location. Many women who have experienced obstetric fistula along with women leaders have initiated obstetric fistula awareness campaigns in their communities with the aim of overcoming the challenges and improving the reintegration experiences of others who have had an obstetric fistula repair.Conclusiondeveloping understanding about the needs and challenges of women post obstetric fistula is an important step forward in creating social and political change in obstetric fistula care and reintegration.Implications for practiceStrategies to support women reintegrating to their communities post obstetric fistula repair include exploring alternative forms of skills training and income generation activities, creating innovative pre and post obstetric fistula health education and community awareness to reduce the perception of the condition as ‘incurable’, and promoting peer advocacy.     

Prevalence of obstetric fistula in Malawi

Objective

To estimate the prevalence of obstetric fistula in Malawi and explore the potential risk factors for developing the condition.

Methods

A community survey was conducted in 9 districts in Malawi, recruiting 3282 women aged at least 12 years using the sibling based method to identify cases of obstetric fistula. Hospital records from 9 district hospitals involved in the community survey and all hospitals offering fistula repair services in Malawi were reviewed.

Results

A total of 1107 women with obstetric fistula were identified: 575 from the community survey and 532 from hospital records. Median age was 29 years (range, 12-89 years). The prevalence of obstetric fistula was 1.6 per 1000 women. Women endured the condition for a median duration of 3 years. Comparison of women with and without obstetric fistula revealed significant differences in age (P = 0.02), occupation (P < 0.01), and tribal origin (P = 0.02), but no differences in education level (P = 0.73) or religion (P = 0.08).

Conclusion

Obstetric fistula remains a major problem in Malawi. Increased awareness of the condition, improvement of maternal care services, and an increase in skilled personnel to perform fistula repair are needed to reduce the burden of this condition.     

Contraceptive knowledge,use and intentions of Malawian women undergoing obstetric fistula repair

Objectives: Unintended pregnancy contributes to morbidities, such as obstetric fistula. Furthermore, after fistula repair, women should avoid pregnancy for a year to prevent its breakdown. Our study objective was to evaluate the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair at a centre in Malawi.

Methods: This cross-sectional study used a standardised survey to examine the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair in Lilongwe, Malawi, between September 2011 and November 2014. Log binomial models were used to examine correlates of prior and planned contraceptive use.

Results: The analysis included 569 women, of whom 61.3% had heard of, and 38.7% had used a modern method of contraception. Women aged 20–49 years, married, with secondary education or higher and with living children were significantly more likely to report prior use of a modern contraceptive method. Of the 354 women who still had reproductive potential (premenopausal women who had not undergone sterilisation) and answered questions on future contraceptive use, less than half (41.6%) planned to use a modern method of contraception after fistula repair. Planned modern contraceptive use was significantly associated with being currently married and having secondary education or higher.

Conclusions: Contraceptive knowledge, prior use and planned future use were low in our study population. To increase contraceptive use among women undergoing obstetric fistula repair, interventions in the postoperative period must seek to increase their family planning knowledge and access to contraceptive methods.     

Obstetric fistula: a preventable tragedy

Obstetric fistula disables millions of women and girls in developing countries, primarily in sub-Saharan Africa and South Asia. The United Nations Population Fund (UNFPA) recently launched a global campaign to end fistula, labeling this condition a preventable and treatable tragedy. Obstetric fistula overwhelmingly results from obstructed labor, which occurs in cases of cephalopelvic disproportion and malpresentation. Cephalopelvic disproportion often complicates deliveries in young, primiparous women of low gynecologic age. Social factors, including young age at marriage and malnutrition of girl children, can also contribute to cephalopelvic disproportion. These social etiologies must be addressed by prevention campaigns. Direct prevention of fistula can occur during delivery when skilled providers identify women and girls at risk for obstetric fistula and link them with innovative interventions, such as Fistula Prevention Centers, through which they can more readily access emergency obstetric care, and by setting strict time limits for laboring at home without progress. Community-based programs, such as the Tostan program in West Africa, use social education to prevent fistula. Moreover, effective surgical techniques for fistula repair are available in some settings and should be expanded to reach those in need. Midwives can play a key role in the prevention and treatment of this tragic obstetric complication.     

Induced abortion and risk of small-for-gestational-age birth

Objective  To investigate the possibility of an association between previous induced abortion and subsequent birth of a small-for-gestational-age (SGA) infant.
Design  Case–control study.
Setting  General and university hospitals.
Methods  Cases were 555 women who delivered SGA babies. Controls were 1966 women who gave birth at term (>37 weeks of gestation) to healthy infants of normal weight on randomly selected days at the hospital where cases had been identified. All women in the case and control categories were interviewed on the obstetric wards by one of a team of six interviewers. During the interviews, information was obtained regarding general socio-demographic factors, personal characteristics and habits, gynaecological and obstetric history, general anamnesis, family history of obstetric and gynaecological diseases, and the age of the father of the child. Further information on current pregnancy and delivery was also collected. We used conditional multiple logistic regression (with age as the matching variable), with maximum likelihood fitting, to obtain odds ratios and their corresponding 95% CIs. Included in the regression equations were terms for education, plus terms significantly associated in this data set with the risk of SGA birth (smoking in pregnancy, history of SGA, gestational hypertension and parity).
Population  Women admitted to a general and a university hospital.
Results  No significant increase in the risk of SGA birth was observed in women with a previous induced abortion [odds ratio (OR) 1.0; 95% CI 0.6–1.7]. The OR for SGA birth was 1.2 (95% CI 0.7–2.1) for preterm and 1.0 (95% CI 0.7–1.4) for term SGA births.
Conclusion  This study found no association between risk of SGA birth and induced abortion.     

Risk factors for obstetric fistula in the Far North Province of Cameroon

Objective

To describe the circumstances of occurrence and identify potential risk factors for obstetric fistula in northern Cameroon.

Methods

A case series study of 42 obstetric fistula patients seeking services at the Provincial Hospital of Maroua, Cameroon, between May 2005 and August 2007. Structured interviews were conducted prior to surgical intervention.

Results

Among obstetric fistula patients, 60% had lived with obstetric fistula for more than 5 years at the time of surgery. Eighty-one percent of patients had received no formal education and 86% were teenagers at their first delivery. Regarding the pregnancy and delivery preceding the occurrence of the fistula, 50% of women reported that they had received no prenatal care and 76% were in labor for more than 12 hours. The majority (83%) of women delivered a stillborn baby.

Conclusions

Obstetric fistula patients in the Far North Province of Cameroon had a low level of education, were married at a young age, and had poor access to quality maternal healthcare services.     

Characteristics of Women Who Do Not Seek Prenatal Care and Implications for Prevention

Objectives: To describe characteristics of women without prenatal care and their reasons for not seeking prenatal care.
Design: Retrospective record review.
Setting: Urban, academic medical center.
Participants: Women without prenatal care whose pregnancies reached the third trimester, who presented to the hospital for delivery or immediately postpartum for a 7 year period.
Methods: Records were reviewed for factors including socio-demographic factors, history of pregnancy/miscarriage/abortion, social supports, abuse history, history of substance use, toxicology results, history of mental illness or mental retardation, and the reason for lack of prenatal care.
Results: Among 211 women with no prenatal care, the primary reasons were noted: 30% had problems with substance use; 29% experienced denial of pregnancy; 18% had financial reasons; 9% concealed pregnancy; and 6% believed they did not need prenatal care due to multiparity. Women with substance use disorders were significantly more likely to be older, unemployed multigravidas.
Conclusions: Nurses should target specific groups of women for education and intervention based on their rationale for not seeking prenatal care.     

Cesarean delivery-related fistulae in the Democratic Republic of Congo

Objective

To compare the characteristics of urogenital fistulae after cesarean delivery with those after spontaneous vaginal delivery.

Methods

A retrospective analysis of hospital records of 597 consecutive patients with a urogenital fistula who received treatment at Panzi Hospital, Bukavu, Democratic Republic of Congo, during 2005-2007.

Results

Of 576 women with an obstetric fistula, 229 (40%) had had a cesarean delivery; 55 (24%) of the 229 fistulae were considered to be iatrogenic. The distribution of risk factors (age, stature, parity, and labor duration) was similar to that among 226 women with a spontaneous vaginal delivery, but the odds ratios for having a ureterovaginal or a vesicouterine fistula were 11.9 (95% confidence interval [CI] 2.8-51.2) and 9.5 (95% CI 2.8-31.9), respectively. Vesicovaginal fistulae with cervical involvement were also significantly more frequent in the cesarean delivery group. The fistulae in this group had less surrounding fibrosis and there was less treatment delay. Stillbirth rates were 87% (cesarean delivery) and 95% (spontaneous vaginal delivery).

Conclusion

The data indicate that cesarean delivery-related fistulae are a separate clinical entity. Focus on this condition is important for fistula prevention and provision of adequate obstetric care, particularly for training in surgery and alternative delivery methods.     

Ensuring financial access to emergency obstetric care: three years of experience with Obstetric Risk Insurance in Nouakchott, Mauritania.

Introduction: The high cost of emergency obstetric care (EmOC) is a catastrophic health expenditure for households, causing delay in seeking and providing care in poor countries. Methods: In Nouakchott, the Ministry of Health instituted Obstetric Risk Insurance to allow obstetric risk sharing among all pregnant women on a voluntary basis. The fixed premium (US$21.60) entitles women to an obstetric package including EmOC and hospital care as well as post-natal care. The poorest are enrolled at no charge, addressing the problem of equity. Results: 95% of pregnant women in the catchment area (48.3% of the city's deliveries) enrolled. Utilization rates increased over the 3-year period of implementation causing quality of care to decline. Basic and comprehensive EmOC are now provided 24/7.The program has generated US$382,320 in revenues, more than twice as much as current user fees. All recurrent costs other than salaries are covered. Conclusion: This innovative sustainable financing scheme guarantees access to obstetric care to all women at an affordable cost.     

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy

Objective  To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials.
Design  Observational study over 15 months (2001–02).
Setting  Four district hospitals in southeast England.
Population  Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women.
Methods  Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs.
Main outcome measures  NHS mean costs of antenatal and obstetric care for different types of pregnancy.
Results  A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54–55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (£1,153) and multiple pregnancy (£1,048) were nearly double the costs for other two groups ( P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (£3,393) was £1,000 greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (£4,442) and for women with diabetes (£4,877).
Conclusions  Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.     

Predictors of Obstetric Fistula Repair Outcomes in Lubango,Angola

ObjectiveObstetric fistulas have a significant physical and social impact on many women in Angola. The majority of the population of this sub-Saharan African nation does not have access to high-quality obstetric care, and this is associated with a risk of prolonged labour and formation of obstetric fistulas. Fistulas are challenging to correct surgically and may require repeated operations. The objective of the study was to determine predictors of successful obstetric fistula repair.MethodsIn this retrospective study, data from all recorded cases of fistula repair performed between July 2011 and December 2016 at the Centro Evangélico de Medicina do Lubango (CEML) hospital located in Lubango, Angola, were reviewed. Analysis of the data was carried out to determine factors affecting the success of fistula repair; parametric and non-parametric tests were used for group comparisons and logistic regression for outcome prediction (Canadian Task Force classification II-2).ResultsA total of 407 operations were performed on 243 women. Of these, 224 women were diagnosed with a vesicovaginal fistula and 19 with a combined vesicovaginal and rectovaginal fistula. The success rate for the attempted repairs was 42%. On multivariate analysis, the success of first surgery was negatively affected by the difficulty of repair (odds ratio 0.28; P < 0.01). For patients requiring repeat surgery, the odds of success were increased with each subsequent operation (odds ratio 5.32; P < 0.01).ConclusionAlthough fistulas rated as difficult to repair had a higher likelihood of initial failure, successive attempts at repair increased the likelihood of a successful outcome.     

A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair

Objective To test the hypothesis that intravenous antibiotics given intra-operatively reduce the failure rate of vesico-vaginal fistula repair.
Design A single blind, randomised controlled trial.
Setting A district hospital in Benin, West Africa.
Population Seventy-nine women undergoing repair of an obstetric vesico-vaginal fistula by a single surgeon at Hopital Evangelique; two women had repeat operations.
Methods Participants in the treatment group (  n = 41  ) received ampicillin 500 mg intra-operatively. Controls (  n = 40  ) received no prophylactic antibiotics.
Main outcome measures Failure of fistula closure and objective incontinence (a positive pad test) at hospital discharge. Secondary outcomes included febrile morbidity, other antibiotic use and urinary infection.
Results Antibiotic prophylaxis did not reduce the odds of failed repair (OR 2.1 95% CI 0.75–6.1) or of objective incontinence (OR 1.9; 95% CI 0.72–5.1). The women in the antibiotic prophylaxis group received less post-operative antibiotics and had less urinary infections at day 10.
Conclusions Prophylactic antibiotics should not be used in vesico-vaginal fistulae repair in the developing world outside randomised controlled trials.     

Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda.

PURPOSE: We conducted a survey to determine availability of emergency obstetric care (EmOC) to provide baseline data for monitoring provision of obstetric care services in Uganda. METHODS: The survey, covering 54 districts and 553 health facilities, assessed availability of EmOC signal functions. Following this, performance improvement process was implemented in 20 district hospitals to scale-up EmOC services. FINDINGS: A maternal mortality ratio (MMR) of 671/100,000 live births was recorded. Hemorrhage, 42.2%, was the leading direct cause of maternal deaths, and malaria accounted for 65.5% of the indirect causes. Among the obstetric complications, abortion accounted for 38.9% of direct and malaria 87.4% of indirect causes. Removal of retained products (OR 3.3, P<0.002), assisted vaginal delivery (OR 3.3, P<0.001) and blood transfusion (OR 13.7, P<0.001) were the missing signal functions contributing to maternal deaths. Most health facilities expected to offer basic EmOC, 349 (97.2%) were not offering them. Using the performance improvement process, availability of EmOC in the 20 hospitals improved significantly. CONCLUSION: An integrated programming approach aiming at increasing access to EmOC, malaria treatment and prevention services could reduce maternal mortality in Uganda.     

Strengthening emergency obstetric care in Nepal: The Women's Right to Life and Health Project (WRLHP).

INTRODUCTION: The Women's Right to Life and Health Project contributes to Nepal's National Safe Motherhood Program and maternal mortality reduction efforts by working to improve the availability, quality and utilization of emergency obstetric care services in public health facilities. METHODS: The project upgraded 8 existing public health facilities through infrastructure, equipment, training, data collection, policy advocacy, and community information activities. The total cost of the project was approximately US$1.6 million. RESULTS: In 5 years, 3 comprehensive and 4 basic emergency obstetric care (EmOC) facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9 to 16.9%; the proportion of births in EmOC project facilities increased from 3.8 to 8.3%; and the case fatality rate declined from 2.7 to 0.3%. DISCUSSION: While the use of maternity services is still low in Nepal, improving availability and quality of EmOC together with community empowerment can increase utilization by women with complications, even in low-resource settings. Partnerships with government and donors were key to the project's success. Similar efforts should be replicated throughout Nepal to expand the availability of essential life-saving services for pregnant women.     

Retrospective Review of Predisposing Factors and Surgical Outcomes in Obstetric Fistula Patients at a Single Teaching Hospital in Western Kenya

ObjectiveWe examined success rates and complications of obstetric fistula (OF) surgical repairs in association with patient and fistula characteristics, including sociocultural and socioeconomic determinants of health. A better understanding of these associations will help guide surgical management and prevent predisposing factors.MethodsWe reviewed the medical records of 86 patients who underwent OF repair at Moi Teaching and Referral Hospital in Kenya between 1999 and 2007.ResultsWomen with OF presented for repair with a variety of concurrent conditions. Seventy-eight percent had laboured for at least 24 hours; 29% had undergone previous unsuccessful surgery. Of the women who presented at postoperative follow-up, 54% still complained of incontinence. Persistent incontinence was associated with larger, more complicated fistulas and having had previous failed attempts at surgical repair.ConclusionThe association of factors such as duration of labour with OF reflects the limited availability of obstetrical care in Western Kenya. There is a significant difference in postoperative success of fistula repair between women with large fistulas or those who had previous failed surgery and other patients. This reflects the importance of primary and secondary prevention.     

The FIGO Save the Mothers Initiative: the Ethiopia-Sweden collaboration.

The overall goal of the FIGO Save the Mothers Fund was to establish basic and comprehensive emergency obstetric care (EmOC) with the specific objectives of increasing the availability and utilization of quality obstetric care as measured by the UN indicators. As a result of this commitment by FIGO, the Ethiopian Society of Obstetricians and Gynecologists (ESOG) launched the Save the Mothers Project (SMP) in West Showa Zone (WSZ), Ethiopia in 1998 to implement and test a demonstration project and evaluate the feasibility and impact of the intervention. The overall objectives matched FIGO's-reducing maternal deaths by promoting the availability, access and utilization of EmOC services for women with complications of pregnancy and childbirth. The intervention package included capacity building as a major activity, and physicians and other service providers from Ambo Hospital, Shenen and Ijaji Health Centers were trained in EmOC. This was intended to combat the high staff turnover in the area. Equipment, materials and supplies were also provided to the demonstration sites to enable them provide basic and comprehensive EmOC services. The interventions, begun in 1999, led to improvements in availability, utilization and met need, which suggests that such an approach may eventually lead to the reduction of maternal deaths. The cesarean section rate for Ambo Hospital increased from 3.7% in 1998 to 17.3% in 2001--an almost six-fold increase. At Ambo Hospital both the total number of deliveries and cases admitted with obstetric complications have increased from baseline. Patients with obstructed labor comprise 39% of all obstetric patients making it the leading cause of hospitalization. Obstetric hemorrhage comes next with 24% of all admissions. The case fatality rate (CFR) (for direct maternal deaths) decreased from 7.2% at baseline, to 4.6% in 2001--showing a definite trend of improvement. Currently, there is 24-h EmOC service at Ambo Hospital where an obstetrician and general medical practitioners with EmOC training are responsible for the service. Shenen and Ijaji health Centers are upgraded in terms of training of staff members, provision of equipment and supplies, and regular supervision so that the community in these areas has access to basic EmOC services. To replicate similar activities, in a setting like ours, EmOC projects have to be low cost to attract decision-makers. The SMP used almost US dollars 100,000 over 3 years to ensure availability of EmOC services for women in WSZ. A favorable political climate such as maintenance of relative peace, and flexibility in adapting to local conditions also contributed to the success of the SMP.