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.     

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.     

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.     

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.     

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.     

Social costs of skilled attendance at birth in rural Ghana.

OBJECTIVE: To examine the social costs to women of skilled attendance at birth in rural Ghana. METHOD: Ethnographic data were obtained through participant observation, interviews, case histories, and focus groups and were analyzed alongside data from a birth cohort of 2878 singletons born in the Kintampo study district between July 2003 and June 2004. RESULTS: Most women delivered at home. Home delivery raises a woman's status in her community, while seeking skilled attendance lowers it. Women feel that seeking assistance in childbirth wastes other people's time and they value secrecy in labor. Negative treatment by health providers and expensive supplies needed for delivery also act as barriers. CONCLUSION: The social costs of obtaining skilled attendance at birth must be offset by community level strategies such as mobilization of older women and husbands, and ensuring health providers extend professional, humane care to laboring women.     

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.     

Analysis of a pilot program to implement physical therapy for women with gynecologic fistula in the Democratic Republic of Congo

Objective

To describe components of a physical therapy pilot program for women with gynecologic fistula, and to report prospective data from the first 2 years of program implementation.

Methods

A single-cohort observational study with repeated measures was conducted at HEAL Africa Hospital, Goma, Democratic Republic of Congo. Hospital staff received training in pelvic floor physical therapy. Guidelines for exercise, functional training, and reproductive health education were integrated into the existing program. Demographics, clinical findings, and functional outcomes were recorded. Key stakeholders were interviewed to understand the perceived strengths and limitations of the program.

Results

A total of 205 women were followed up; 161 participated in physical therapy, with an average of 9.45 sessions. Of 161 women examined postoperatively, 102 (63.4%) reported no incontinence; they remained continent at discharge. Of 21 who indicated a change in level of incontinence during postoperative physical therapy, 15 (71.4%) improved. The program was feasible and well received by staff and patients.

Conclusion

Pelvic floor physical therapy could have significant results in women with gynecologic fistula, may be an important adjunctive treatment in comprehensive fistula care, and warrants further investigation.     

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.     

Pregnancy and delivery after successful repair of vesicovaginal fistula

Pregnant women (110) with successfully repaired vesicovaginal fistula, supervised at the Ahmadu Bello University Teaching Hospital in Zaria, Nigeria, formed the study population. The obstetric complications, mode of delivery and fetal outcome are reviewed. The obstetric complications and fetal outcome were compared with a matched hospital control group. There was a higher complication rate among the women with vesicovaginal fistulae, and the commonest complication was urinary tract infection. Perinatal mortality rate was 17.2% in the cases compared to 10.2% in the controls.     

Understanding the relationship between access to care and facility-based delivery through analysis of the 2008 Ghana Demographic Health Survey

Objective

To determine the types of access to care most strongly associated with facility-based delivery among women in Ghana.

Methods

Data relating to the “5 As of Access” framework were extracted from the 2008 Ghana Demographic Health Survey and analyzed using multivariate logistic regression.

Results

In all, 55.5% of a weighted sample of 1102 women delivered in a healthcare facility, whereas 45.5% delivered at home. Affordability was the strongest access factor associated with delivery location, with health insurance coverage tripling the odds of facility delivery. Availability, accessibility (except urban residence), acceptability, and social access variables were not significant factors in the final models. Social access variables, including needing permission to seek healthcare and not being involved in decisions regarding healthcare, were associated with a reduced likelihood of facility-based delivery when examined individually. Multivariate analysis suggested that these variables reflected maternal literacy, health insurance coverage, and household wealth, all of which attenuated the effects of social access.

Conclusion

Affordability was an important determinant of facility delivery in Ghana—even among women with health insurance—but social access variables had a mediating role.     

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。     

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.     

Clinical relevance and treatment outcomes of vesicovaginal fistula (VVF) after obstetric and gynecologic surgery

Objective

Vesicovaginal fistulas (VVF) are consequences from obstetric and gynecologic surgery. Treatment approach from either abdominal or vaginal route have its own pros and cons. The study aims to present the anatomical, clinical and lower urinary tract symptom outcomes of women with VVF.

The impact of decentralisation on sexual and reproductive health services in Ghana

This paper analyses the impact of decentralisation on the political organisation, management and provision of sexual and reproductive health services in Ghana. It draws on qualitative research and interviews with key informants from the Ministry of Health, donors, NGOs, regional and district health management teams, local government and community leaders. Within a national reproductive health policy framework, previously disparate family planning, maternal and child health, STI and HIV/AIDS programmes have become more integrated, and donors have pooled or co-ordinated their funding. Some decision-making about resource allocation is meant to happen at district and regional level but in practice, this remains centrally controlled, which may be a necessary safeguard for sexual and reproductive health services. Earmarked donor funds still ensure a regular supply of contraceptives and STI drugs. However, paying for these is problematic at local level. Sexual and reproductive health staff make up a large proportion of primary health care staff, but especially in rural areas they experience poor working conditions, and there is high turnover and vacancies. District and sub-district level links are working well in this new system, but clarity is still needed on how different national sexual and reproductive health bodies relate to each other and to regional and district health authorities. The development of formal mechanisms for priority setting and advocacy at local levels could help to secure benefits for sexual and reproductive health care.     

‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana

Objective

to explore community and health-care provider attitudes towards maltreatment during delivery in rural northern Ghana, and compare findings against The White Ribbon Alliance's seven fundamental rights of childbearing women.

Design

a cross-sectional qualitative study using in-depth interviews and focus groups.

Setting

the Kassena-Nankana District of rural northern Ghana between July and October 2010.

Participants

128 community members, including mothers with newborn infants, grandmothers, household heads, compound heads, traditional healers, traditional birth attendants, and community leaders, as well as 13 formally trained health-care providers.

Measurements and findings

7 focus groups and 43 individual interviews were conducted with community members, and 13 individual interviews were conducted with health-care providers. All interviews were transcribed verbatim and entered into NVivo 9.0 for analysis. Despite the majority of respondents reporting positive experiences, unprompted, maltreatment was brought up in 6 of 7 community focus groups, 14 of 43 community interviews, and 8 of 13 interviews with health-care providers. Respondents reported physical abuse, verbal abuse, neglect, and discrimination. One additional category of maltreatment identified was denial of traditional practices.

Key conclusions

maltreatment was spontaneously described by all types of interview respondents in this community, suggesting that the problem is not uncommon and may dissuade some women from seeking facility delivery.

Implications for practice

provider outreach in rural northern Ghana is necessary to address and correct the problem, ensuring that all women who arrive at a facility receive timely, professional, non-judgmental, high-quality delivery care.     

Unmet needs, beliefs and treatment-seeking for infertility among migrant Ghanaian women in the Netherlands

Studies on infertility in the Netherlands have little information on migrant Ghanaian women, even though Ghanaians are the third largest migrant group in Amsterdam. An exploratory study on the unmet needs, attitudes, and beliefs of migrant Ghanaian women with infertility problems living in the Netherlands, and the kinds of treatment they sought was undertaken in 1999. Qualitative data were collected from 12 women with primary or secondary infertility through narratives and 20 key informant interviews. The women described seeking treatment for infertility in Ghana, the Netherlands and other European countries, included use of infertility drugs, surgery, donor insemination and in vitro fertilisation. Illegal migrant women are not entitled to treatment paid by the national health system, and being of low income they cannot afford to pay directly for this or to obtain private health insurance. Herbalists and spiritual healers in both Amsterdam and Ghana were regularly consulted, especially for their willingness to address the social and spiritual aspects of infertility. To produce a pregnancy where male infertility was suspected, transfer of sexual rights to another man in the husband/partner's family, or a healer or priest, was a practical remedy that kept male infertility hidden. This study revealed difficulties experienced in clinical settings due to language barriers and cultural differences. Ghanaian women living in the Netherlands need much more information on the causes of infertility and their options.