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.     

Urinary incontinence following obstetric fistula repair

Prolonged and/or obstructed labour is the most common cause of genital tract fistula world-wide, in particular, sub-Saharan Africa and parts of Asia where emergency obstetric services are unavailable or suboptimal to afford timely delivery of the baby. This results in pressure necrosis by the fetal presenting part at the level of the obstruction in the maternal pelvis. Other reasons for obstetric fistula include trauma from vaginal deliveries (spontaneous or instrumental) and iatrogenic from cesarean section/hysterectomy. The majority of women develop the fistula during their first labour and most babies are stillborn. Women with a fistula suffer from leakage of urine and/or faeces from the vagina and surgery is the treatment for an established fistula. Long-term complications of fistulas include recurrent fistula, urinary incontinence, reproductive dysfunction, sexual dysfunction, mental health dysfunction, social isolation and orthopaedic complications such as footdrop. Ongoing urinary symptoms are not uncommon after successful fistula closure. There are various reasons for residual urinary incontinence following obstetric fistula repair including urinary stress incontinence, overactive bladder, mixed urinary incontinence and voiding dysfunction. Urinary incontinence after fistula repair requires careful evaluation prior to further surgery, as in some diagnoses, continence surgery is unlikely to treat and may worsen the condition. Initial results from educational and physiotherapy programs demonstrated a positive impact on post-fistula incontinence.     

Depression among women with obstetric fistula in Kenya

Objective

To establish the prevalence of depression and describe associated factors among fistula patients attending an obstetric fistula surgical camp in Kenya.

Methods

A cross-sectional study was conducted focusing on obstetric fistula patients attending a national fistula camp held in August 2008 at Kenyatta National Hospital, Nairobi, Kenya. A structured questionnaire was used to obtain sociodemographic data and medical histories for all consenting patients before surgery. Depression measures were obtained using the Patient Health Questionnaire-9.

Results

Of the 70 women interviewed, 2 (2.9%) and 12 (17.1%) reported a history of psychiatric illness and suicidal ideations, respectively. Depression was present in 51 (72.9%) patients, with 18 (25.7%) meeting criteria for severe depression. Depression was significantly associated with women older than 20 years of age (P = 0.01), unemployment (P = 0.03), lack of social support following fistula (P = 0.04), and living with fistula for over 3 months (P = 0.01).

Conclusion

Women with obstetric fistula are predisposed to high levels of depression. A holistic management approach, including mental health care and family support, is recommended.     

Eliminating obstetric fistula: progress in partnerships.

Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003.     

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.     

Pilot community-mobilization program reduces maternal and perinatal mortality and prevents obstetric fistula in Niger

Objective

To assess the impact of a pilot community-mobilization program on maternal and perinatal mortality and obstetric fistula in Niger.

Methods

In the program, village volunteers identify and evacuate women with protracted labor, provide education, and collect data on pregnancies, births, and deaths. These data were used to calculate the reduction in maternal mortality, perinatal mortality, and obstetric fistula in the program area from July 2008 to June 2011.

Results

The birth-related maternal mortality fell by 73.0% between years 1 and 3 (P < 0.001), from 630 (95% confidence interval [CI] 448–861) to 170 (95% CI 85–305) deaths per 100 000 births. Early perinatal mortality fell by 61.5% (P < 0.001), from 35 (95% CI 31–40) to 13 (95% CI 10–16) deaths per 1000 births. No deaths due to obstructed labor were reported after the lead-in period (February to June 2008). Seven cases of community-acquired fistula were reported between February 2008 and July 2009; from August 2009 to June 2011 (23 months; 12 254 births), no cases were recorded.

Conclusion

Community mobilization helped to prevent obstetric fistula and birth-related deaths of women and infants in a large, remote, resource-poor area.     

Duration of bladder catheterization after surgery for obstetric fistula

Objective

To compare the surgical outcome at discharge and at 6-months follow up in patients who underwent repair of obstetric fistulae with postoperative bladder catheterization for 10, 12, or 14 days.

Methods

A retrospective study of 212 obstetric fistula patients who underwent repair with postoperative bladder catheterization for 10 days (group 1), 12 days (group 2), and 14 days (group 3) at the Bahir Dar Hamlin Fistula Center in Ethiopia. Fistulas were classified according to Goh's system.

Results

There were 68 women (32%) in group 1, 62 women (29%) in group 2, and 82 women (39%) in group 3. There was a significant difference in the extent of urethral involvement, fistula size, and degree of vaginal scarring among the 3 groups, with the more extensively damaged patients catheterized for longer. Breakdown of repair was seen in 1.5% of patients in group 1, none in group 2, and 2% in group 3 (P = 0.47).

Conclusion

Postoperative catheterization for 10 days may be sufficient for management of less complicated obstetric vesicovaginal fistulae.     

Risk factors for developing residual urinary incontinence after obstetric fistula repair

Obstetric vesicovaginal fistula is a devastating cause of urinary incontinence worldwide. More attention is being focused on treating these patients by various philanthropic societies but very little is known about the complications of surgery. One of the most common complications is that the woman is left with residual urinary incontinence despite the defect being successfully closed. If risk factors for this could be identified, then perhaps more appropriate surgical techniques could be developed with the aim of remedying the incontinence.     

A bill of rights for patients with obstetric fistula

According to the seven categories of vulnerability proposed by Kipnis (cognitive, juridical, deferential, medical, allocational, social, and infrastructural), and the four generally accepted principles of biomedical ethics (respect, beneficence, non-maleficence, and fairness), women with obstetric fistulas are an exceptionally vulnerable population. Therefore, they merit special consideration in both clinical care and research settings. Adoption of a formal bill of rights for patients with fistula similar to the one proposed in the present report should be encouraged at all facilities where these women are treated. Acknowledgment of their rights would help to improve their care and end the abuses they are exposed to in institutional settings.     

Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: Do they reduce delay and what do they cost?

OBJECTIVES: To assess whether motorcycle ambulances placed at rural health centers are a more effective method of reducing referral delay for obstetric emergencies than a car ambulance at the district hospital, and to compare investment and operating costs with those of a 4 wheel drive car ambulance at the district hospital. METHODS: Motorcycle ambulances were placed at 3 remote rural health centers in Malawi. Data were collected over a 1-year period, from October 2001 to September 2002, using logbooks, cashbooks, referral forms, and maternity registers. RESULTS: Depending on the site, median referral delay was reduced by 2-4.5 hours (35%-76%). Purchase price of a motorcycle ambulance was 19 times cheaper than for a car ambulance. Annual operating costs were US dollars 508, which was almost 24 times cheaper than for a car ambulance. CONCLUSIONS: In resource-poor countries motorcycle ambulances at rural health centers are a useful means of referral for emergency obstetric care and a relatively cheap option for the health sector.     

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.     

Impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery

Objective

Surgery is the only successful treatment for most obstetric fistulae. The present study measured the impact of a structured program of pre- and postoperative physiotherapy and health education on the outcome of surgery for obstetric fistula.

Methods

We compared the postoperative outcomes of 2 consecutive groups of women with obstetric fistulae who were recruited and followed-up by 2 local nongovernmental organizations at a hospital in Tanguiéta, Benin. The first group of women (n = 99) had fistula repair using standardized techniques. The second group (n = 112) had a standardized surgical approach plus a structured program of pre- and postoperative health education and physiotherapy.

Results

The program had a significant positive impact on recovery in general and on urinary incontinence in particular. After physiotherapy, the odds of recovery were 2.72 times greater for women in the physiotherapy group than for control patients, and the probability of postoperative stress incontinence was considerably higher for patients in the control group than for those in the physiotherapy group (P < 0.001).

Conclusion

A structured program of health education and physiotherapy by experienced nurses and physiotherapists improves the likelihood of a successful outcome after surgical repair of obstetric fistula.     

The immediate management of fresh obstetric fistulas

OBJECTIVE: It has been a general rule to wait with the repair of an obstetric fistula for a minimum period of 3 months allowing the patient to become an outcast. In a prospective way an immediate management was studied and antibiotics were not used, all according to basic surgical principles. METHODS: A total of 1716 patients with a fistula duration of 3 to 75 days after delivery were treated immediately on presentation by catheter and/or early closure. Instead of antibiotics, a high oral fluid regimen was instituted. The fistulas were classified according to anatomic and physiologic location in types I, IIAa, IIAb, IIBa, and IIBb, and according to size in small, medium, large, and extensive. The operation became progressively more complicated from type I through type IIBb and from small through extensive. RESULTS: At first attempt 1633 fistulas (95.2%) were closed and another 57 could be closed at further attempt(s), accounting for a final closure in 1690 patients (98.5%); 264 patients (15.4%) were healed by catheter only. Of these 1690 patients with a closed fistula, 1575 (93.2%) were continent and 115 (6.8%) were incontinent. The results as to closure and to continence became progressively worse from type I through type IIBb and from small through extensive. Postoperative wound infection was not noted; postoperative mortality was encountered in 6 patients (0.4%). CONCLUSION: This immediate management proves highly effective in terms of closure and continence and will prevent the patient from becoming an outcast with progressive downgrading medically, socially, and mentally.     

Obstetric fistula in low-income countries

Objective

To identify, survey, and systematically review the current knowledge regarding obstetric fistula as a public health problem in low-income countries from the peer-reviewed literature.

Methods

The Medline and Science Citation Index databases were searched to identify public health articles on obstetric fistula in low-income countries. Quantitative evidence-based papers were reviewed.

Results

Thirty-three articles met the criteria for inclusion: 18 hospital-based reviews; 6 on risk factors/prevention; 4 on prevalence/incidence measurement; 3 on consequences of obstetric fistula; and 2 on community-based assessments.

Conclusion

Obstetric fistula has received increased international attention as a public health problem, but reliable research on the burden of disease and interventions is lacking.     

产科尿瘘修补时机的临床探讨

目的:探讨产科尿瘘的治疗时机和方法。方法:对427例分娩后产科瘘发生的病例进行即刻处理,方法为应用导尿管和(或)尽早行修补术,大量饮水而不用抗生素。按解剖生理位置分类将产科瘘分为Ⅰ型、ⅡAa型、ⅡAb型、ⅡBa型、ⅡBb型、Ⅲ型,按照瘘孔的大小分为小、中、大、超大型。结果:经首次处理407例(95.3%)瘘孔关闭,另外14例再处理后瘘孔关闭,最后共治愈421例患者,占98.6%。其中66例患者经放置导尿管治愈,占15.5%。所有治愈患者中,术后排尿正常392例(93.11%),并发尿失禁29例(6.89%)。瘘孔关闭率从Ⅰ型到ⅡBb型和从小瘘孔到超大瘘孔逐渐降低。术后无一例切口感染。结论:产科瘘孔发生后的即刻处理对瘘孔的关闭和减少尿失禁发生率效果非常明显,并且大大降低了患者的身心痛苦。此方法方便、简易、有效,是一种非常可行的尿瘘处理方法。     

Emergency obstetric care: how do we stand in Malawi?

OBJECTIVE: To assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. METHODS: A complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. RESULTS: Almost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500,000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. CONCLUSION: Malawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.     

The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria

OBJECTIVE: The purpose of this study was to describe the characteristics of women with obstetric vesicovaginal fistulas at a hospital in north central Nigeria. STUDY DESIGN: A retrospective record review was conducted of all women who were seen with vesicovaginal fistulas at Evangel Hospital in Jos, Plateau State, Nigeria, between January 1992 and June 1999. RESULTS: A total of 932 fistula cases were identified, of which 899 cases (96.5%) were associated temporally with labor and delivery. The "typical patient" was small and short (44 kg and <150 cm); had been married early (15.5 years) but was now divorced or separated; was uneducated, poor, and from a rural area; had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus. CONCLUSION: Obstetric vesicovaginal fistula is extremely common in north central Nigeria. A complex interaction that involves multiple biologic and socioeconomic factors appears to predispose young women to this devastating childbirth injury.     

Prevalence and risk factors of severe obstetric haemorrhage

Objective  To determine the prevalence, causes, risk factors and acute maternal complications of severe obstetric haemorrhage.
Design  Population-based registry study.
Population  All women giving birth (307 415) from 1 January 1999 to 30 April 2004 registered in the Medical Birth Registry of Norway. Information about socio-economic risk factors was obtained from Statistics Norway.
Methods  Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models.
Main outcome measure  Severe obstetric haemorrhage (blood loss of > 1500 ml or blood transfusion).
Results  Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of ≥30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity, more than three and two times higher for emergency caesarean delivery and elective caesarean than for vaginal birth, respectively, and substantially higher for multiple pregnancies, von Willebrand's disease and anaemia (haemoglobin <9 g/dl) during pregnancy. Admissions to an intensive care unit, postpartum sepsis, hysterectomy, acute renal failure and maternal deaths were significantly more common among women with severe haemorrhage.
Conclusion  The high prevalence of severe obstetric haemorrhage indicates the need to review labour management procedures. Demographic and medical risk factors can be managed with extra vigilance.