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.     

A new technique for the surgical management of urinary incontinence after obstetric fistula repair

Obstetric vesicovaginal fistula is a debilitating injury still occurring widely throughout the developing world. Fortunately, now more and more surgeons are becoming aware of this previously hidden problem, and many thousands of women are receiving treatment each year. What is difficult for the fistula surgeon are those women, who after having their vesicovaginal fistula successfully closed, return to their doctor, still just as incontinent as they were with the fistula still open. This study describes a new, simple and cheap surgical procedure that promises to improve the lot of these unfortunate women.     

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.     

Pregnancy following obstetric fistula repair, the management of delivery

Obstetric fistula patients invariably have dreadful obstetric histories. The antecedent delivery usually ends in a stillbirth and even multiparous obstetric fistula patients often have previous histories of multiple stillbirths and neonatal deaths. There is very little published on subsequent pregnancies following obstetric fistula repair or even on reproductive capabilities after repair. This study examines 49 pregnancies following obstetric fistula repair and the management and outcome of delivery.     

Lack of value of the Martius fibrofatty graft in obstetric fistula repair.

OBJECTIVE: To ascertain if the Martius graft is of benefit to successful surgical outcome in obstetric fistula repair. METHOD: A retrospective analysis of 440 consecutive obstetric fistula repairs performed by the author in the Addis Ababa Fistula Hospital, Ethiopia or the Barhirdar Hamlin Fistula Center, Ethiopia, with or without the Martius fibrofatty graft. These were further divided into 13 subgroups of vesicovaginal fistula and all groups compared against two outcomes; fistula closure and presence of residual urethral incontinence following repair. Results were statistically analyzed with the Fisher's exact or Chi-squared test. RESULTS: There was no statistical difference between groups with regards to breakdown of repair but a higher rate of residual incontinence in 3 subgroups with the Martius graft. CONCLUSION: The Martius graft can be safely omitted from obstetric fistula repair if the surgeon is experienced, and performs the same type of repair as used in this analysis.     

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.     

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.     

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.     

Outcome of obstetric fistula repair after 10-day versus 14-day Foley catheterization

ObjectiveTo compare outcome between 10-day and 14-day bladder drainage after obstetric fistula repair.MethodsIn a randomized prospective study at Hamlin Fistula Center, Bahir Dar, Ethiopia, patients presenting with obstetric vesicovaginal fistula between 2007 and 2010 were randomized to undergo 10-day (group 1) or 14-day (group 2) postoperative catheterization. Fistulas were categorized via Goh classification. The inclusion criteria were any type of vesicovaginal fistula except circumferential or recurrent.ResultsIn total, 189 women were enrolled: 107 in group 1, and 82 in group 2. The groups were similar in age, parity, duration of labor, and time from injury to surgical repair. There was no significant difference in fistula stage according to the Goh classification (urethral length, P = 0.3; fistula size, P = 0.9; and vaginal scarring, P = 0.3). There were 3 fistula breakdowns in group 1, and 6 in group 2. The difference in cure was not significant (P = 0.15, confidence interval –0.009 to 0.1). There was no significant difference in non-fistula-related incontinence or urinary retention after repair.ConclusionThe outcome of postoperative catheterization for 10 days was not inferior to that for 14 days. A similar treatment outcome with a shorter duration of catheterization will have a significant impact on reducing infection and cost.     

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.     

The impact of surgical treatment on the mental health of women with obstetric fistula

Obstetric fistula is estimated to affect 2 million women worldwide and has considerable social and psychological effects on affected individuals. In this prospective study, 51 consecutive women with obstetric fistula admitted to the Barhirdar Hamlin Fistula Centre in the north of Ethiopia were screened using the General Health Questionnaire (GHQ-28) for potential mental health disorder before and 2 weeks after fistula surgery. Prior to surgery, all women screened positive. By 2 weeks after, this had dropped to 36% ( P = 0.005). 27% of the 45 women who were cured of their incontinence screened positive, while all 6 of those with severe residual incontinence continued to screen positive. We conclude that surgical treatment of obstetric fistula results in marked improvements in mental heath.     

Still living with fistula: an exploratory study of the experience of women with obstetric fistula following corrective surgery in West Pokot,Kenya

Obstetric fistula is a complication of pregnancy that affects women following prolonged obstructed labour. Although there have been achievements in the surgical treatment of obstetric fistula, the long-term emotional, psychological, social and economic experiences of women after surgical repair have received less attention. This paper documents the challenges faced by women following corrective surgery and discusses their needs within the broader context of women's health. We interviewed a small sample of women in West Pokot, Kenya, during a two-month period in 2010, including eight in-depth interviews with fistula survivors and two focus group discussions, one each with fistula survivors and community members. The women reported continuing problems following corrective surgery, including separation and divorce, infertility, stigma, isolation, shame, reduced sense of worth, psychological trauma, misperceptions of others, and unemployment. Programmes focusing on the needs of the women should address their social, economic and psychological needs, and include their husbands, families and the community at large as key actors. Nonetheless, a weak health system, poor infrastructure, lack of focus, few resources and weak political emphasis on women's reproductive health do not currently offer enough support for an already disempowered group.     

Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency

OBJECTIVE: We reviewed the cases of 23 patients who were admitted to the hospital with a primary diagnosis of histopathologically confirmed necrotizing fasciitis in the lower abdomen or pelvis. Rapid demise of a healthy postpartum women piqued our interest in trying to identify the early signs and symptoms that may lead to earlier diagnosis and treatment of this often fatal disease. STUDY DESIGN: A retrospective analysis of charts of all patients who were admitted to the gynecology and obstetrics services of our hospital systems with a diagnosis of necrotizing fasciitis for the past 14 years was performed. Age, comorbid factors, precipitating events, weight, symptoms and signs, microbiologic factors, radiographs, surgical therapy, and morbidity were correlated. RESULTS: Definitive operation was accomplished within 48 hours of the diagnosis of necrotizing fasciitis in all but 3 patients. Of the 17 patients who were not puerperal, 88% of the women were obese; 65% of the women were hypertensive, and 47% of the women were diabetic. Of the total 23 patients, 70% of the women complained of severe pain, and 35% of the women had radiographic diagnostics for necrotizing fasciitis ("gas"). Four patients had diverting colostomies, and 39% of the patients had flaps or synthetic grafts. Three patients died (mortality rate, 13%). One patient who was puerperal died of a severe rapid septicemia; the 2 late deaths were the result of systemic candidiasis. CONCLUSION: Necrotizing fasciitis is a rapidly progressive, often lethal, infectious disease process that requires early aggressive debridement. Any patient with inordinate pain and unilateral edema in the pelvis, especially in the puerperium, should be suspected of having this disease. Radiographic studies are often diagnostic of this condition. The triad of pelvic pain, edema, and any sign of septicemia carries an extremely grave prognosis and mandates immediate surgical intervention.     

Early surgical repair of iatrogenic ureterovaginal fistula secondary to gynecologic surgery

Objective

To describe the early surgical repair of iatrogenic ureterovaginal fistula (UVF) secondary to gynecologic surgery, and evaluate the efficacy and feasibility of early surgical intervention.

Methods

Data were retrospectively reviewed for 52 patients with iatrogenic UVF who underwent early surgical repair between January 1996 and January 2011 at the Sir Run Run Shaw Hospital, Hangzhou, China. Preoperative patient characteristics and postoperative endpoints, including type of index procedure, repair technique, operative time, perioperative complications, and postoperative follow-up data were assessed.

Results

All early surgical repairs were uneventful. The mean time from diagnosis to surgery was 15.7 days (range, 14–21 days). The mean operative time was 73.4 min (range, 51–110 min) for ureteroneocystostomy, and 104 min (range, 91.5–153 min) for Boari flap procedure. The mean estimated blood loss was 57.8 mL (range, 35–80 mL). No major intraoperative complications occurred, although 5 patients had postoperative surgical site infections. Forty-three patients were followed for a mean of 18.4 months (range, 10.5–24.0 months). Ureteral stricture with asymptomatic hydronephrosis occurred in 2 (4.7%) patients. Ipsilateral renal function was preserved in all patients.

Conclusion

Early surgical repair of UVF secondary to gynecologic surgery was safe and effective, and preserved ipsilateral renal function.