Social Implications of Obstetric Fistula: An Integrative Review

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub‐Saharan Africa.     

Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix

An obstetric fistula is classically regarded as an "accident of childbirth" in which prolonged obstructed labor leads to destruction of the vesicovaginal/rectovaginal septum with consequent loss of urinary and/or fecal control. Obstetric fistula is highly stigmatizing and afflicted women often become social outcasts. Although obstetric fistula has been eliminated from advanced industrialized nations, it remains a major public health problem in the world's poorest countries. Several million cases of obstetric fistula are currently thought to exist in sub-Saharan Africa and south Asia. Although techniques for the surgical repair of such injuries are well known, it is less clear which strategies effectively prevent fistulas, largely because of the complex interactions among medical, social, economic, and environmental factors present in those countries where fistulas are prevalent. This article uses the Haddon matrix, a standard tool for injury analysis, to examine the factors influencing obstetric fistula formation in low-resource countries. Construction of a Haddon matrix provides a "wide angle" overview of this tragic clinical problem. The resulting analysis suggests that the most effective short-term strategies for obstetric fistula prevention will involve enhanced surveillance of labor, improved access to emergency obstetric services (particularly cesarean delivery), competent medical care for women both during and after obstructed labor, and the development of specialist fistula centers to treat injured women where fistula prevalence is high. The long-term strategies to eradicate obstetric fistula must include universal access to emergency obstetric care, improved access to family planning services, increased education for girls and women, community economic development, and enhanced gender equity. Successful eradication of the obstetric fistula will require the mobilization of sufficient political will at both the international and individual country levels to ensure that adequate resources are devoted to this problem and that maternal health becomes a high priority on national political agendas. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After participating in this CME activity, physicians should be better able to apply the Haddon matrix, a tool commonly used for injury analysis, to the field of obstetrics and gynecology; analyze the problem of obstructed labor and obstetric fistula formation in low-resource countries using the Haddon matrix, and implement possible strategies for the prevention of obstetric fistulas and the mitigation of harm in cases of obstructed labor that arise from the use of the Haddon matrix.     

Maternal height and external pelvimetry to predict cephalopelvic disproportion in nulliparous African women: a cohort study

Objective To assess external pelvimetry and maternal height, as predictors of cephalopelvic disproportion.
Design Prospective cohort study.
Setting Four hospitals in Zaire.
Population Six hundred and five nulliparous women.
Methods Maternal height and external pelvimetry were assessed during the third trimester antenatal visit. Cut off values for considering women at risk for cephalopelvic disproportion were height < 150 cm and external pelvic distances < 10th centile for the population. Logistic regression analysis, combining height and pelvic measurements, was performed to predict women at risk for cephalopelvic disproportion.
Main outcome measure Cephalopelvic disproportion was considered when there was caesarean section for failure to progress, vacuum or forceps delivery or intrapartum stillbirth.
Results Cephalopelvic disproportion was present in 42 women. In univariate analysis, height, intertrochanteric diameter and the transverse diagonal of Michaelis sacral rhomboid area were found to be associated with cephalopelvic disproportion. Logistic regression analysis showed that maternal height < 150 cm and/or transverse diagonal < 9.5 cm were the variables most associated with cephalopelvic disproportion. The adjusted odds ratios were 2.2 (95% CI 0.9 to 5.4) and 6.5 (95% CI 3.2 to 13.2), respectively. The positive predictive value and likelihood ratio were 24% and 4.0 (95% CI 2.8 to 5.8), respectively. The addition of transverse diagonal to maternal height increased the sensitivity in predicting cephalopelvic disproportion from 21% to 52%.
Conclusion In addition to height, transverse diagonal measurement is able to predict one out of two cases of cephalopelvic disproportion in nulliparous women. After validation in a separate cohort, this simple predictive method may be used in peripheral centres for timely referral of pregnant women at risk for cephalopelvic disproportion.     

Pregnancy outcome in unmarried teenage nulligravidae in Singapore

Singapore, like other newly industralized countries, has seen a dramatic transformation in the social standards of its population in a particularly short space of time. Unfortunately, this period of development has been accompanied by an escalation in the number of pregnancies to unmarried teenage girls. This paper examines the obstetric and social implications of 150 such pregnancies in younger and older teenagers. Poor intrauterine growth in the younger teenager appears to be the most important adverse obstetric outcome in that mean birthweight was significantly reduced (2738 g compared to 3054 g; P < 0.02). We believe this to be an important explanation for the five-fold increase in perinatal mortality seen in this group of mothers. Unlike some other reports, we found no significant increase in the incidence of cephalopelvic disproportion, anemia or pregnancy induced hypertension in these mothers. The social implications of teenage pregnancy in Singapore are also examined and recommendations made for methods to curb the problem     

Factors that are associated with cesarean delivery in a large private practice: the importance of prepregnancy body mass index and weight gain

OBJECTIVE: The purpose of this study was to examine body mass index and pregnancy weight gain as risk factors for primary cesarean delivery in nulliparous women in a middle-class private practice. STUDY DESIGN: Primiparous women who delivered in a private practice setting between February 1993 and July 13, 2001, were included. CIs along with Z statistics for paired count data were used to assess the statistical significance and relative importance of the relationships of body mass index and maternal weight gain to cesarean delivery. The effect of body mass index was examined as related to known confounders such as gestational age, birth weight, maternal age, and maternal height. RESULTS: The overall cesarean delivery rate for primiparous women was 21.76%. Risk of cesarean delivery increased consistently and significantly (P <.0001) with increasing body mass index. This effect was primarily mediated through an increase in cesarean delivery carried out for cephalopelvic disproportion/failure to progress. In our practice, the primiparous woman whose body mass index is >30 kg/m(2) is six times more likely to have a cesarean delivery for the diagnosis of cephalopelvic disproportion/failure to progress than the primiparous woman whose body mass index is <20 kg/m(2). This differential in cesarean delivery rate persisted when controlled for birth weight and gestational age and continues to persist when maternal age and height are also controlled. Excessive pregnancy weight gain exerted a statistically significant effect on cesarean delivery rate. This increase was primarily related to cephalopelvic disproportion/failure to progress among the nonobese women. CONCLUSION: Maternal body mass index is related strongly to the ability of primiparous women to be delivered vaginally without great difficulty. In fact, lean patients are excellent labor performers, particularly in contrast with obese patients. The relationship of increased body mass index to increased cesarean delivery is due to an increased rate of cephalopelvic disproportion/failure to progress. Excessive pregnancy weight gain is associated with a doubling of cephalopelvic disproportion/failure to progress rate in nonobese patients.     

Amphetamine abuse in pregnancy: the impact on obstetric outcome

Objective To determine whether pregnant women with amphetamine abuse developed more obstetric complications than non-drug abuser pregnant women. Materials and methods A retrospective case control study was undertaken. Pregnant women with amphetamine abuse who delivered between January 2002 and December 2003 were compared to control pregnant women. Results Pregnant women who abused amphetamine were more likely to develop anemia, preterm delivery, thick meconium stained amniotic fluid, and delivered small for gestational age neonates. However, cephalopelvic disproportion was less frequently found in the amphetamine abuse group. Conclusion Pregnant women who abuse amphetamine experience more obstetric complications than the non-drug abuser. This information may be useful to medical personnel who are caregivers of these pregnant women to provide adequate perinatal care.     

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.     

Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries

Background

An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.

Discussion

Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women’s agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.

Summary

Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.     

Genital Tract Fistula Repair on 116 Women

Summary: A personal series of 130 genital tract fistula repairs in 116 women is presented. All fistulas were repaired vaginally. The majority of the fistulas were due to obstetric injuries, especially prolonged obstructed labour. Obstetric fistula continue to be a cause of personal and social morbidity to sufferers.     

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.     

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.     

Vesicovaginal fistula: obstetric causes

PURPOSE OF REVIEW: Obstetric fistula has a devastating impact on the lives of women in poor countries. Currently, there is an international campaign by the World Health Organisation, United Nations Population Fund and other bodies to address this problem. This article reviews recent literature and highlights the paucity of evidence-based data. RECENT FINDINGS: Articles on the pathophysiology, co-morbidities and sequelae including physical injury to 'multiorgan systems' and social consequences associated with obstetric fistula, are discussed. In particular, the devastating social, economic and psychological effects on the health and well-being, reintegration and rehabilitation are addressed. There is a need for prevalence and incidence studies to measure the extent of this problem. The creation of well-equipped fistula centres with multidisciplinary teams to evaluate patients should be the aim. Expert surgeons and optimal databases with personnel to do research will benefit patients. SUMMARY: Prevention should involve alleviation of poverty and improvement in education, maternity services and health. Research on issues such as persistent stress incontinence following fistula closure, management of reduced bladder capacity, best technique for fistula repair, role of vaginoplasty, role of early repair in selective obstetric fistula, future reproductive function, dermatological management, and social and cultural issues must be done to improve women's health.     

Maternal height and the outcome of labor in rural Tanzania.

The influence of maternal height (standardized for parity and birthweight) on obstetrical outcome is studied in 1095 women giving birth in Lugarawa hospital and 3869 women delivering in Mbozi hospital, both rural hospitals in the South Western Highlands of Tanzania. Short stature was found to increase the need for augmentation of labor in primiparae, the need for operative delivery (cesarean section/symphyseotomy) in all parity groups and the need for vacuum extraction in multiparae. The absence of such an effect of height on perinatal mortality is interpreted as the result of obstetric intervention. It is concluded that maternal height, which is easy to measure, remains a useful tool to predict difficult childbirth and cephalopelvic disproportion.     

Development of risk scoring scheme for prediction of cesarean delivery due to cephalopelvic disproportion in Lamphun Hospital, Thailand

AIM: To develop a simple risk scoring scheme for the prediction of cesarean delivery due to cephalopelvic disproportion (CPD) in Lamphun Hospital, Thailand. METHODS: A case-control study was conducted including 116 pregnant women with cesarean delivery due to CPD and 307 pregnant women delivering by normal labor. Obstetric information was retrieved from medical records. Risk indicators measurable at the time of admission were analyzed by a stepwise logistic regression to obtain a set of statistically significant predictors. Regression coefficients were transformed into item scores and added up to a total score. Risk of cesarean delivery due to CPD was analyzed using total scores as the only predictor. RESULTS: A risk scoring scheme was developed from five obstetric predictors: maternal age, height, parity, pregnancy weight gain and symphysis-fundal height. Item scores ranged from 0 up to 3.5 and the total score from 0-14.5. The scheme explained, by the area under the receiver operating characteristic curve, 88% of cesarean delivery due to CPD. The likelihood of cesarean delivery due to CPD in pregnant women with low risk (scores below 5), moderate risk (scores 5-9.5) and high risk (scores 10 and over) were 0.09, 0.86 and 10.11, respectively. CONCLUSIONS: The risk of cesarean delivery due to CPD may be forecasted by a simple scoring scheme using five predictors that correctly identified women with low, moderate and high risk. This scheme may be applicable to physicians and midwives for identifying high-risk pregnant women in order to take appropriate action.     

产科尿瘘发生高危因素及预防

产科尿瘘是指由于分娩所致的泌尿生殖道瘘, 临床表现为阴道漏尿,患者身心负担极重。导致产科尿瘘的高危因素有梗阻性难产、产伤和手术损伤。预防措施包括重视产前检查、严密观察产程、提高助产手术及剖宫产手术的操作技巧。     

Obstetric anesthesia: Past present and future

Obstetric anesthesia is science and art combined, and obstetric anesthesiologists must be concerned simultaneously with the lives of (at least two) intricately interwoven patients – the mother and her baby (ies). Obstetric anesthesia, by definition, is a subspecialty of anesthesia devoted to peripartum, perioperatvie, pain and anesthetic management of women during pregnancy and the puerperium. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the peripartum care team, who closely works with the obstetrician, perinatologist, midwife, neonatologist and labor and delivery nurse to ensure the highest quality care for the pregnant woman and her baby. Exchange on information and communication skills in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. Changes in maternal–fetal and neonatal medicine and obstetric anesthesia have continued to develop rapidly during the recent years. The purpose of this article is to explore a number of important issues in modern practice of obstetric anesthesia.     

An analysis of the prediction of cephalopelvic disproportion

Summary Since cephalopelvic disproportion inevitably leads to cesarean section it seems to be mandatory to identify patients with an absolute discrepancy between the size of the fetus and the birth canal in order to avoid unnecessary trials of labour. In a case control study, comparing a group of patients who delivered by cesarean section because of cephalopelvic disproportion with an age matched control group, routinely assessed pelvic measurements and measurements of the newborn were correlated to cephalopelvic disproportion. Multivariate linear regression was applied to each group to determine, which of the maternal and fetal factors had the strongest influence on the mode of delivery. In the study group external conjugate showed the strongest positive relation to maternal body height (P<0.01), the biparietal diameter of the newborn was negatively correlated (P<0.01). None of the analyzed variables reached statistical significance in the control group. Differences between the two groups were marginal, thus providing no safe basis for decision making even in a population at high risk for developing cephalopelvic disproportion.     

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.     

Access to sexual and reproductive health for young people: Bridging the disconnect between rights and reality

Of the 1.5 billion young people globally, 78% live in Asia and Africa, the poorest regions of the world. The majority of young people infected with HIV are female and adolescent girls have a significant increased risk for maternal mortality and morbidity, such as fistula. Trends to delay marriage do not decrease the age of onset of sexual activity, but highlight the need for access to sexual and reproductive information, and skills and services to learn healthy sexuality and prevent unwanted pregnancy and sexually transmitted infections. Youth-friendly services require confidentiality, privacy, and non-judgmental attitudes, and rights of adolescents include the consideration of their evolving capacities to consent to services. Denial of young people's sexuality and rights by conservative and traditional forces has lethal consequences, especially for women and girls. Countries have committed to these rights through numerous international instruments and many are making progress, but challenges at the community level are significant.