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.
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.
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.
Obstetric fistula prevention; Vesicovaginal fistula; Obstructed labor; Phases of delay; Trust
Obstetric Fistula (OF) remains a major public health problem in areas where unattended obstructed labor is common and maternal mortality is high. Obstetric Fistula was able to be prevented, treated and eradicated in high-income countries; however, it still affects many women in low-income countries. To our knowledge, only few studies have described the prevalence and factors associated with Obstetric Fistula in Ethiopia in population-based surveys.
The aim of this study is to describe the prevalence and factors associated with Obstetric Fistula in Ethiopia.
The study used women’s dataset from the 2005 Ethiopian Demographic and Health Survey. The survey sample was designed to provide national, urban/rural, and regional representative estimates of key health and demographic indicators. The sample was selected using a two-stage stratified sampling process. OF was measured using questionnaire. The data is analyzed using descriptive and multivariate statistical methods to determine factors associated with Obstetric Fistula.
A total of 14,070 women of reproductive age group were included in the survey. Of which 23.2% ever heard of obstetric fistula. Among women who ever given birth (9,713), some 103 (1.06%, 95% CI; 0.89%-1.31%) experienced obstetric fistula in their lifetime, which means 10.6 per 1000 women who ever gave birth. It is estimated that in Ethiopia nearly 142,387 (95% CI: 115,080-169,694) of obstetric fistula patients exist. Those women who are circumcised had higher odds of reporting the condition (Chi square = 4.41, p-value = 0.036). In the logistic regression model women from rural areas were less likely to report obstetric fistula than their urban counterparts (OR = 0.21, 95% CI: 0.06-0.69). Women who gave birth 10 or more had higher odds of developing obstetric fistula than women with 1-4 child (OR = 4.34; 95% CI; 1.29-14.55).
Obstetric fistula is a major public and reproductive health concern in Ethiopia. This calls for increased access to emergency obstetric care, expansion of fistula repair service and active finding of women with OF with campaigns of ending fistula is recommended.
Every pregnant woman faces risk of life-threatening obstetric complications. A birth-preparedness package promotes active preparation and assists in decision-making for healthcare seeking in case of such complications. The aim was to assess factors associated with birth preparedness and complication-readiness as well as the level of male participation in the birth plan among emergency obstetric referrals in rural Uganda.
This was a cross-sectional study conducted at Kabale regional hospital maternity ward among 140 women admitted as emergency obstetric referrals in antenatal, labor or the postpartum period. Data was collected on socio-demographics and birth preparedness and what roles spouses were involved in during developing the birth plan. Any woman who attended antenatal care at least 4 times, received health education on pregnancy and childbirth danger signs, saved money for emergencies, made a plan of where to deliver from and made preparations for a birth companion, was deemed as having made a birth plan. Multivariate logistic regression analysis was conducted to analyze factors that were independently associated with having a birth plan.
The mean age was 26.8 ± 6.6 years, while mean age of the spouse was 32.8 ± 8.3 years. Over 100 (73.8%) women and 75 (55.2%) of their spouses had no formal education or only primary level of education respectively. On multivariable analysis, Primigravidae compared to multigravidae, OR 1.8 95%CI (1.0-3.0), education level of spouse of secondary or higher versus primary level or none, OR 3.8 95%CI (1.2-11.0), formal occupation versus informal occupation of spouse, OR 1.6 95%CI (1.1-2.5), presence of pregnancy complications OR 1.4 95%CI (1.1-2.0) and the anticipated mode of delivery of caesarean section versus vaginal delivery, OR 1.6 95%CI (1.0-2.4) were associated with having a birth plan.
Individual women, families and communities need to be empowered to contribute positively to making pregnancy safer by making a birth plan.
The World Health Organization (WHO) proposes a successful closure rate for first repair of vesico-vaginal obstetric fistula to be at 85% in each facility, with the continence achievement among the closed cases at 90 %. We are reporting the vesico-vaginal obstetric fistula outcome at the provincial hospital of Maroua-Cameroon from 2005 to August 2007. Among the overall 32 patients with vesico-vaginal fistula operated, 25 patients were at their first operation. The complete closure of vesico-vaginal fistula (VVF) was 23/25 (92%) and among the 23 patients with complete closure 17(74%) had good continence. When we consider only the 25 patients who were at their first operation, the overall closure of VVF was 23/25 (92%) and among them 17/23 (74%) were continent. Large lesion, bladder neck lesions, vaginal adherence and rigid margin are associated with failure/incontinence. These factors must be taken into consideration when preparing patients for surgery or when assigning them to a surgeon within the surgical team.
Obstetric fistula; closure; continence; Cameroon
Improving knowledge of obstetric danger signs and promoting birth preparedness practices are strategies aimed at enhancing utilization of skilled care in low-income countries. The aim of the study was to explore the association between knowledge of obstetric danger signs and birth preparedness among recently delivered women in south-western Uganda.
The study included 764 recently delivered women from 112 villages in Mbarara district. Community survey methods were used and 764 recently delivered women from 112 villages in Mbarara district were included in study. Interviewer administered questionnaire were used to collect data. Logistic regression analyses were conducted to explore the relationship between knowledge of key danger signs and birth preparedness.
Fifty two percent of women knew at least one key danger sign during pregnancy, 72% during delivery and 72% during postpartum. Only 19% had knowledge of 3 or more key danger signs during the three periods. Of the four birth preparedness practices; 91% had saved money, 71% had bought birth materials, 61% identified a health professional and 61% identified means of transport. Overall 35% of the respondents were birth prepared. The relationship between knowledge of at least one key danger sign during pregnancy or during postpartum and birth preparedness showed statistical significance which persisted after adjusting for probable confounders (OR 1.8, 95% CI: 1.2-2.6) and (OR 1.9, 95% CI: 1.2-3.0) respectively. Young age and high levels of education had synergistic effect on the relationship between knowledge and birth preparedness. The associations between knowledge of at least one key danger sign during childbirth or knowledge that prolonged labour was a key danger sign and birth preparedness were not statistically significant.
The prevalence of recently delivered women who had knowledge of key danger signs or those who were birth prepared was very low. Since the majority of women attend antenatal care sessions, the quality and methods of delivery of antenatal care education require review so as to improve its effectiveness. Universal primary and secondary education programmes ought to be promoted so as to enhance the impact of knowledge of key danger signs on birth preparedness practices.
Obstetric fistula is a severe condition which can have devastating consequences for a woman’s life. Despite a considerable literature, very little is known about its prevalence. This project was conducted to carry out a situational analysis of fistula services in South Sudan and to pilot test the Key Informant Method (KIM) to estimate the prevalence of fistula in a region of South Sudan.
Key stakeholder interviews, document reviews and fistula surgery record reviews were undertaken. A KIM survey was conducted in a district of Western Bahr-el-Ghazal in January 2012. One hundred sixty-six community-based distributors, traditional birth attendants and village midwives were trained as key informants to identify women with fistula in the community. Women identified were subsequently examined by an obstetrician and nurse to verify whether they had a fistula.
There were limited fistula repair services in South Sudan. Approximately 50–80 women per year attend periodic campaigns, with around half having a fistula and receiving a repair. On average a further 5 women a year received fistula repair from hospital services. Ten women with potential fistula were identified via KIM; all confirmed by the obstetrician. Of these, three were from the survey area, which had 8,865 women of reproductive age (15–49 years). This gives a minimal estimated prevalence of at least 30 fistulas per 100,000 women of reproductive age (95% CI 10–100).
Routine fistula repair services available do not meet the population’s needs. The pilot study suggests that KIM can be used to identify women with fistula in the community. Data on fistula are generally poor; the KIM methodology we used in South Sudan yielded a lower fistula prevalence than estimates reported previously in the region.
In Burundi, the annual incidence of obstetric fistula is estimated to be 0.2-0.5% of all deliveries, with 1000–2000 new cases per year. Despite this relatively high incidence, national capacity for identifying and managing obstetric fistula is very limited. Thus, in July 2010, Medecins Sans Frontieres (MSF) set up a specialised Obstetric Fistula Centre in Gitega (Gitega Fistula Centre, GFC), the only permanent referral centre for obstetric fistula in Burundi. A comprehensive model of care is offered including psychosocial support, conservative and surgical management, post-operative care and follow-up. We describe this model of care, patient outcomes and the operational challenges.
Descriptive study using routine programme data.
Between July 2010 and December 2011, 470 women with obstetric fistula presented for the first time at GFC, of whom 458 (98%) received treatment. Early urinary catheterization (conservative management) was successful in four out of 35 (11%) women. Of 454 (99%) women requiring surgical management, 394 (87%) were discharged with a closed fistula, of whom 301 (76%) were continent of urine and/or faeces, while 93 (24%) remained incontinent of urine and/or faeces. In 59 (13%) cases, the fistula was complex and could not be closed. Outcome status was unknown for one woman. Median duration of stay at GFC was 39 days (Interquartile range IQR, 31–51 days).
The main operational challenges included: i) early case finding and recruitment for conservative management, ii) national capacity building in obstetric fistula surgical repair, and iii) assessing the psychosocial impact of this model.
In a rural African setting, it is feasible to implement a comprehensive package of fistula care using a dedicated fistula facility, and satisfactory surgical repair outcomes can be achieved. Several operational challenges are discussed.
Obstetric fistula; Comprehensive management; Operational research; Burundi
In Kenya, about 3000 fistula cases are estimated to occur every year with an incidence of 1/1000 women. This study sought to identify risk factors associated with developing obstetrics fistula in order to guide implementation of appropriate interventions.
An unmatched case control study was conducted in three major hospitals in Kenya between October and December 2010. Cases were patients who had fistula following delivery within the previous five years. Controls were systematically selected from women who attended obstetrics and gynecology clinics at these hospitals, and did not have present or past history of fistula. Odds ratio was used as measure of association with their corresponding 95% confidence interval. Factors with p value of <0.1 were included into forward additive logistic regression model to generate adjusted odds ratios.
Seventy cases and 140 controls were included in the study. Independent risk factors associated with obstetrics fistula included duration of labour of >24 hours (OR = 4.7, 95% CI = 2.4 -9.2), seeking delivery services after 6 hours of labour onset (OR = 6.9, 95% CI = 2.2-21.3), taking more than 2 hours to reach a health facility (OR = 5.7, 95% CI = 2.9 -11.5), having none or primary education (OR = 9.6, 95% CI = 3.3 –27.9) and being referred to another facility for emergency obstetrics services (OR = 8.6, 95% CI = 2.7 –27).
Risk factors for developing obstetrics fistula were delays in care seeking including delay in making decision to seek delivery servers after six hours of labour onset, taking more than two hours to reach a health facility, labour duration of more than 24 hours and having no formal or primary education. Efforts geared at strengthening all levels of the health system to reduce delays in access to emergency obstetric care are needed.
Obstetric fistula; Vesico vaginal fistula; Fistula
To evaluate the need for a prognostic classification system for obstetric fistula (OF) with the data obtained by a voluntarily action for OF repair in a regional hospital and Niger, Africa.
Material and methods
Obstetric fistula (OF) characteristics of 51 women with vesicovaginal fistula in a fistula campaign in Maradi Regional Hospital, Niger were evaluated. Initial basic gynecological examination, methylene blue (MBT) test and direct cystoscopy were used to describe the characteristics of the lesions. Demographic and clinical data were compared with the existing literature.
In 31 (60%) cases were the sizes of the fistula greater than 4 cm. The urethra was circumferentially lost in 8 (15.7%) women. In 18 (35.3%) women the trigone was involved. Extensive fibrosis was present in 10 (19.6%) patients. Only in 11 (21.6%) patients without any obliterating scarring, neither the trigone nor urethra were damaged. Five (9.8%) patients had severe infection. Five (9.8%) had multiple lesions. Thirty-four (66.6%) had a history of at least one previous attempt for fistula repair. A significant proportion of women were divorced or abandoned from their husband, and socially isolated.
A simple, reproducible and universally accepted scientific classification or staging system for OF dealing with outcomes rather than anatomic landmarks should replace the present proposed classification systems for prognostic and ethical purposes.
obstetric fistula; classification system; surgical outcome
Long-term results after obstetric anal sphincter injury (OASI) are poor. We aimed to improve the long-term outcome after OASI by lessening symptoms of anal incontinence.
In a prospective study at Malmö University Hospital, twenty-six women with at least grade 3B OASI were classified and sutured in a systematic way, including separate suturing of the internal and external sphincter muscles with monofilament absorbable sutures. The principal outcome assessed by answers given to six questions, was a difference in anal incontinence score, between the study group and two control groups (women with prior OASI [n = 180] and primiparous women delivered vaginally without a diagnose of OASI [n = 100]).
An anal incontinence score of zero (i.e., no symptoms) was found in 74% of the study group, 47% of the OASI control group, and 66% of the vaginal control group (p = 0.02 and 0.5, as compared to the study group).
A modified suturing technique was followed by significant improved one-year symptoms of anal incontinence as compared to historical cases.
To determine predictors of fistula repair outcomes 3 months postsurgery.
We conducted a multicountry prospective cohort study between 2007 and 2010. Outcomes, measured 3 months postsurgery, included fistula closure, and residual incontinence in women with a closed fistula. Potential predictors included patient and fistula characteristics, and context of repair. Multivariable generalized estimating equation models were used to generate adjusted risk ratios (ARR) and 95% confidence intervals (CI).
Women who returned for follow-up 3 month postsurgery were included in predictors of closure analyses (n=1,274). Small bladder size (ARR 1.57; 95% CI 1.39–1.79), prior repair (ARR 1.40; 95% CI 1.11–1.76), severe scarring (ARR 1.56; 95% CI 1.20–2.04), partial urethral involvement (ARR 1.36; 95% CI 1.11–1.66), and complete urethral destruction/circumferential defect (ARR 1.72; 95% CI 1.33–2.23) predicted failed fistula closure. Women with a closed fistula at 3 month follow-up were included in predictors of residual incontinence analyses (n=1041). Prior repair (ARR 1.37; 95% CI 1.13–1.65), severe scarring (ARR 1.35; 95% CI 1.10–1.67), partial urethral involvement (ARR 1.78; 95% CI 1.27–2.48), and complete urethral destruction or circumferential defect (ARR 2.06; 95% CI 1.51–2.81) were significantly associated with residual incontinence.
The prognosis for genital fistula closure is related to preoperative bladder size, previous repair, vaginal scarring, and urethral involvement.
The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.
To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.
Patients and Methods:
This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.
Statistical analysis used:
X2 test and Fisher's exact test.
The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.
The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.
Hypospadias; tunicavaginalis; urethrocutaneous fistula; waterproofing layer
Obstetric fistula is a physically and socially disabling obstetric complication that affects about 3,000 women in Tanzania every year. The fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, often associated with delays in seeking and receiving appropriate and adequate birth care. Using the availability, accessibility, acceptability and quality of care (AAAQ) concept and the three delays model, this article provides empirical knowledge on birth care experiences of women who developed fistula after prolonged labour.
We used a mixed methods approach to explore the birthing experiences of women affected by fistula and the barriers to access adequate care during labour and delivery. Sixteen women were interviewed for the qualitative study and 151 women were included in the quantitative survey. All women were interviewed at the Comprehensive Community Based Rehabilitation Tanzania in Dar es Salaam and Bugando Medical Centre in Mwanza.
Women experienced delays both before and after arriving at a health facility. Decisions on where to seek care were most often taken by husbands and mothers-in-law (60%). Access to health facilities providing emergency obstetric care was inadequate and transport was a major obstacle. About 20% reported that they had walked or were carried to the health facility. More than 50% had reported to a health facility after two or more days of labour at home. After arrival at a health facility women experienced lack of supportive care, neglect, poor assessment of labour and lack of supervision. Their birth accounts suggest unskilled birth care and poor referral routines.
This study reveals major gaps in access to and provision of emergency obstetric care. It illustrates how poor quality of care at health facilities contributes to delays that lead to severe birth injuries, highlighting the need to ensure women's rights to accessible, acceptable and adequate quality services during labour and delivery.
The goal of this study was to evaluate the first formal counseling program for obstetric fistula patients in Eritrea.
To evaluate the impact of the counseling program, clients were interviewed both before pre-operative counseling and again after post-operative counseling. A questionnaire was used in the interviews to assess women's knowledge about fistula, self-esteem, and their behavioral intentions for health maintenance and social reintegration following surgical repair. In addition, two focus groups were conducted with a total of 19 clients assessing their experiences with the surgical care and counseling.
Data from the questionnaires revealed significant improvements in women's knowledge about fistula, self-esteem, and behavioral intentions following counseling. Focus group data also supported increased knowledge and self-esteem.
Evaluation of the short-term impact of an initial formal counseling program for fistula patients in sub-Saharan Africa affirmed the positive effects that such a program has for fistula patients, with increased knowledge about the causes of fistula, fistula prevention and enhanced self-esteem.
Culturally appropriate counseling can be incorporated into services for surgical repair of obstetric fistula in low-resource settings and has the potential to improve the physical and mental well-being of women undergoing fistula repair.
Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate, even though childbirth services are available, even in the poorest countries. Reducing them is the aim of two of the main Millennium Development Goals. Many initiatives have been undertaken to remedy this situation, such as the Advances in Labour and Risk Management (ALARM) International Program, whose purpose is to improve the quality of obstetric services in low-income countries. However, few interventions have been evaluated, in this context, using rigorous methods for analyzing effectiveness in terms of health outcomes. The objective of this trial is to evaluate the effectiveness of the ALARM International Program (AIP) in reducing maternal mortality in referral hospitals in Senegal and Mali. Secondary goals include evaluation of the relationships between effectiveness and resource availability, service organization, medical practices, and satisfaction among health personnel.
This is an international, multi-centre, controlled cluster-randomized trial of a complex intervention. The intervention is based on the concept of evidence-based practice and on a combination of two approaches aimed at improving the performance of health personnel: 1) Educational outreach visits; and 2) the implementation of facility-based maternal death reviews.
The unit of intervention is the public health facility equipped with a functional operating room. On the basis of consent provided by hospital authorities, 46 centres out of 49 eligible were selected in Mali and Senegal. Using randomization stratified by country and by level of care, 23 centres will be allocated to the intervention group and 23 to the control group. The intervention will last two years. It will be preceded by a pre-intervention one-year period for baseline data collection. A continuous clinical data collection system has been set up in all participating centres. This, along with the inventory of resources and the satisfaction surveys administered to the health personnel, will allow us to measure results before, during, and after the intervention. The overall rate of maternal mortality measured in hospitals during the post-intervention period (Year 4) is the primary outcome. The evaluation will also include cost-effectiveness.
The QUARITE trial is registered on the Current Controlled Trials website under the number ISRCTN46950658 .
Maternal outcomes in most countries of the developed world are good. However, in many developing/resource-poor countries, maternal outcomes are bleaker: Every year, more than 500,000 women die in childbirth, mostly in resource-poor countries. Those who survive often suffer from severe and long-term morbidities. One of the most devastating injuries is obstetric fistula, occurring most often in south Asia and sub-Saharan Africa. Fistula treatment and care are available in many countries across Africa and Asia, but there is a lack of reliable data around clinical factors associated with the success of fistula repair surgery. Most published research has been retrospective. While these studies have provided useful information about the care and treatment of fistula, they are limited by the design. This study was designed to identify practices in care that could lead to the design of prospective and randomized controlled trials.
Self-administered questionnaires were completed by 40 surgeons known to provide fistula treatment services in Africa and Asia at private and government hospitals. The questionnaire was divided into three parts to address the following issues: prophylactic use of antibiotics before, during, and after fistula surgery; urethral catheter management; and management practices for patients with urinary incontinence following fistula repair.
The results provide a glimpse into current practices in fistula treatment and care across a wide swath of geographic, economic, and organizational considerations. There is consensus in treatment in some areas (routine use of prophylactic antibiotics, limited bed rest until the catheter is removed, nonsurgical treatment for postsurgical incontinence), while there are wide variations in practice in other areas (duration of catheter use, surgical treatments for postsurgical incontinence). These findings are based on a small sample and do not allow for recommending changes in clinical care, but they point to issues for possible clinical trial research that would contribute to more efficient and effective fistula care.
The findings from the survey allowed us to consider clinical practices most influential in the cost, efficacy, and safety of fistula treatment. These considerations led us to formulate recommendations for eight randomized controlled trials on the following subjects: 1) Efficacy/safety of short-term catheterization; 2) efficacy of surgical and nonsurgical therapies for urinary incontinence; 3) technical measures during fistula repair to reduce the incidence of post-surgery incontinence; 4) identification of predictive factors for "incurable fistula"; 5) usefulness of urodynamic studies in the management of urinary incontinence; 6) incidence and significance of multi-drug resistant bacteria in the fistula population; 7) primary management of small, new fistulas by catheter drainage; and 8) antibiotic prophylaxis in fistula repair.
Aim. Genitourinary fistulas are bothersome clinical entities not only for the patient but also for the treating surgeon as well. A lot of surgical procedures have been proposed; however, most of the fistulas can be easily treated with plain surgical techniques, such as the simple surgical closure of the fistula tract. Material and Method. The study was carried out in the urogynecology department of Ankara Etlik Zübeyde Hanım Maternity Training and Research Hospital. The study included 12 cases with vesicovaginal fistulas and 15 cases with rectovaginal fistulas. Twenty-six patients underwent simple surgical closure technique. The age, the referral time to the hospital, the longest diameter of the fistula opening, the hospitalization time, the follow-up period and identifiable risk factors of the patients were evaluated. Results. Caeserean section was detected as primary risk factor for vesicovaginal fistulas and prolonged labor was detected as the most important risk factor for rectovaginal fistulas. In our study, we found that the simple closure technique cured 91% of vesicovaginal fistulas and 93% of rectovaginal fistulas. Conclusion. The simple closure technique has very high cure rates for both vesicovaginal and rectovaginal fistulas when the longest diameter of the fistula openings is ≤5 mm.
In this perspective, Andrew Browning of the Fistula Hospital in Addis Ababa discusses a study on obstetric fistula in Ilorin, Nigeria. The study was originally published in the West African Journal of Medicine . With the journal's permission, we have made a PDF of the full-text article freely available on our website (see Text S1).
Obstetric fistula causes women enormous distress and social isolation in developing countries like Nigeria. What do we know about the condition?
Closure of salvage laryngectomy defects with vascularized tissue remains controversial.
We evaluate outcomes in patients who required repair of a fistula after attempted primary closure of salvage laryngectomy defect and assess risk factors for persistent fistula. Between 2001 and 2010, 20 patients were treated for pharyngocutaneous fistulae after primary closure of a salvage laryngectomy. All patients required free flap repair for definitive fistula management.
Patients presented with fistulae from one to 18 months in duration; median time to closure was seven days. Radial forearm free flap was used in 86% of patients. With free flap alone 50% of patients achieved fistula closure. Additional procedures improved closure rate to 85%. Recipient vessels were used in the neck in 54.5%, compared to internal mammary vessels in 45.5%. Hypothyroidism was identified as a risk factor for persistent fistula (p = 0.01). Chronic steroid use (p = 0.08) did not reach significance as a risk factor for fistula closure. Gastroesophageal reflux disease was newly diagnosed or noted as a comorbidity in 14 patients (70%) in this study. It did not reach statistical significance as a risk factor in refistulization (p = 0.12). Complications included leak, carotid blowout, infection, free flap loss, and late refistulization. Overall flap failure in this study was 4.5%.
Delayed secondary repair of pharygocutaneous fistulas after salvage laryngectomy is associated with a higher complication rate and poor success rates compared to use of vascularized tissue at the time of salvage laryngectomy. Prolonged wound healing in these patients is associated with hypothyroidism.
Laryngectomy; Free flap; Pharyngocutaneous fistula; Head and neck cancer; Wound reconstruction; Hypothyroidism; Salvage
The abdominal route of genitourinary fistula repair may be associated with longer term hospitalisation, hospital-associated infection and increased resource requirements. We examined: (1) the factors influencing the route of repair; (2) the influence of the route of repair on fistula closure 3 months following surgery; and (3) whether the influence of the route of repair on repair outcome varied by whether or not women met the published indications for abdominal repair.
Prospective cohort study.
Eleven health facilities in sub-Saharan Africa and Asia.
The 1274 women with genitourinary fistula presenting for surgical repair services.
Risk ratios (RRs) and 95% confidence intervals (95% CIs) were generated using log-binomial and Poisson (log-link) regression. Multivariable regression and propensity score matching were employed to adjust for confounding.
Main outcome measures
Abdominal route of repair and fistula closure at 3 months following fistula repair surgery.
Published indications for abdominal route of repair (extensive scarring or tissue loss, genital infibulation, ureteric involvement, trigonal, supratrigonal, vesico-uterine or intracervical location or other abdominal pathology) predicted the abdominal route [adjusted risk ratio (ARR), 15.56; 95% CI, 2.12–114.00]. A vaginal route of repair was associated with increased risk of failed closure (ARR, 1.41; 95% CI, 1.05–1.88); stratified analyses suggested elevated risk among women meeting indications for the abdominal route.
Additional studies powered to test effect modification hypotheses are warranted to confirm whether the abdominal route of repair is beneficial for certain women.
Developing countries; genitourinary fistula; observational study; propensity score; route of repair; surgery
Obstetric fistula is the presence of a hole between a woman’s genital tract and either the urinary or the intestinal tract. Better knowledge of the risk factors for obstetric fistula could help in preventing its occurrence. The purpose of this study was to assess the characteristics of obstetric fistula patients. We conducted a search of the literature to identify all relevant articles published during the period from 1987–2008. Among the 19 selected studies, 15 were reports from sub-Saharan Africa and 4 from the Middle East. Among the reported fistula cases, 79.4% to 100% were obstetrical while the remaining cases were from other causes. Rectovaginal fistulae accounted for 1% to 8%, vesicovaginal fistulae for 79% to 100% of cases, and combined vesicovaginal and rectovaginal fistulae were reported in 1% to 23% of cases. Teenagers accounted for 8.9% to 86% of the obstetrical fistulae patients at the time of treatment. Thirty-one to 67% of these women were primiparas. Among the obstetric fistula patients, 57.6% to 94.8% of women labor at home and are secondarily transferred to health facilities. Nine to 84% percent of these women delivered at home. Many of the fistula patients were shorter than 150 cm tall (40–79.4%). The mean duration of labor among the fistula patients ranged from 2.5 to 4 days. Twenty to 95.7% of patients labored for more than 24 h. Operative delivery was eventually performed in 11% to 60% of cases. Obstetric fistula was associated with several risk factors, and they appear to be preventable. This knowledge should be used in strengthening the preventive strategy both at the health facility and at the community level.
Risk factors; Obstetric; Vesicovaginal fistula; Rectovaginal fistula
Assistance by skilled birth attendants (SBAs) during childbirth is one of the strategies aimed at reducing maternal morbidity and mortality in low-income countries. However, the relationship between birth preparedness and decision-making on location of birth and assistance by skilled birth attendants in this context is not well studied. The aim of this study was to assess the influence of birth preparedness practices and decision-making and assistance by SBAs among women in south-western Uganda.
Community survey methods were used to identify 759 recently delivered women from 120 villages in rural Mbarara district. Interviewer-administered questionnaires were used to collect data. Logistic regression analyses were conducted to assess the relationship between birth preparedness, decision-making on location of birth and assistance by SBAs.
35% of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was 68%. The final decision regarding location of birth was made by the woman herself (36%), the woman with spouse (56%) and the woman with relative/friend (8%). The relationships between birth preparedness and women decision-making on location of birth in consultation with spouse/friends/relatives and choosing assistance by SBAs showed statistical significance which persisted after adjusting for possible confounders (OR 1.5, 95% CI: 1.0–2.4) and (OR 4.4, 95% CI: 3.0–6.7) respectively. Education, household assets and birth preparedness showed clear synergistic effect on the relationship between decision-maker on location of birth and assistance by SBAs. Other factors which showed statistical significant relationships with assistance by SBAs were ANC attendance, parity and residence.
Women’s decision-making on location of birth in consultation with spouse/friends/relatives and birth preparedness showed significant effect on choosing assistance by SBAs at birth. Education and household assets ownership showed a synergistic effect on the relationship between the decision-maker and assistance by SBAs.
AIM: To compare the efficacy and safety of acellular dermal matrix (ADM) bioprosthetic material and endorectal advancement flap (ERAF) in treatment of complex anorectal fistula.
METHODS: Ninety consecutive patients with complex anorectal fistulae admitted to Anorectal Surgical Department of First Affiliated Hospital, Xinjiang Medical University from March 2008 to July 2009, were enrolled in this study. Complex anorectal fistula was diagnosed following its clinical, radiographic, or endoscopic diagnostic criteria. Under spinal anesthesia, patients underwent identification and irrigation of the fistula tracts using hydrogen peroxide. ADM was securely sutured at the secondary opening to the primary opening using absorbable suture. Outcomes of ADM and ERAF closure were compared in terms of success rate, fecal incontinence rate, anorectal deformity rate, postoperative pain time, closure time and life quality score. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up examination was performed 2 d, 2, 4, 6, 12 wk, and 5 mo after surgery, respectively.
RESULTS: No patient was lost to follow-up. The overall success rate was 82.22% (37/45) 5.7 mo after surgery. ADM dislodgement occured in 5 patients (11.11%), abscess formation was found in 1 patient, and fistula recurred in 2 patients. Of the 13 patients with recurrent fistula using ERAF, 5 (11.11%) received surgical drainage because of abscess formation. The success rate, postoperative pain time and closure time of ADM were significantly higher than those of ERAF (P < 0.05). However, no difference was observed in fecal incontinence rate and anorectal deformity rate after treatment with ADM and ERAF.
CONCLUSION: Closure of fistula tract opening with ADM is an effective procedure for complex anorectal fistula. ADM should be considered a first line treatment for patients with complex anorectal fistula.
Acellular dermal matrix; Surgery; Transsphincteric complex fistula
Studies of the association between transportation barriers and HIV-related health outcomes have shown both positive and negative effects, possibly because a reliable, validated measure of transportation barriers has not been identified.
Prospective cohort study of HIV-infected patients in rural Uganda.
Participants were enrolled from the HIV clinic at the regional referral hospital in Mbarara, Uganda as part of the Uganda AIDS Rural Treatment Outcomes (UARTO) Study. We collected the following measures of transportation barriers to HIV clinic: global positioning systems (GPS)-tracked distance measured by driving participants to their homes along their typical route; straight-line GPS distance from clinic to home, calculated with the Great Circle Formula; self-reported travel time; and self-reported travel cost. We assessed inter-measure agreement using linear regression, correlation coefficients and κ statistics (by measure quartile) and validated measures by fitting linear regression models to estimate associations with days late for clinic visits.
One hundred and eighty-eight participants were tracked with GPS. Seventy-six percent were women, with a median age of 40 years and median CD4 cell count of 193 cells/μl. We found a high correlation between GPS-based distance measures (β = 0.74, P < 0.001, R2 = 0.92, k = 0.73), but little correlation between GPS-based and self-reported measures (all R2 ≤ 0.4). GPS-based measures were associated with days late to clinic (P < 0.001); but neither self-reported measure was associated (P > 0.85).
GPS-measured distance to clinic is associated with HIV clinic absenteeism and should be prioritized over self-reported measures to optimally risk-stratify patients accessing care in rural, resource-limited settings.
distance to clinic; global positioning systems; HIV/AIDS; linkage to care; sub-Saharan Africa; transportation; Uganda
Urologic injuries occur frequently during surgery in the pelvic cavity. Inadequate diagnosis and treatment may lead to severe complications and side effects. This investigation examined the clinical features of urologic complications following obstetric and gynecologic surgery.
Materials and Methods
We accumulated 47,318 obstetric and gynecologic surgery cases from 2007 to 2011. Ninety-seven patients with urological complications were enrolled. This study assessed the causative disease and surgical approach, type, and treatment method of the urologic injury.
Of these 97 patients, 69 had bladder injury, 23 had ureteral injury, 2 had vesicovaginal fistula, 2 had ureterovaginal fistula, and 1 had renal injury. With respect to injury rate by specific surgery, laparoscopic-assisted radical vaginal hysterectomy was the highest with 3 of 98 cases, followed by radical abdominal hysterectomy with 15 of 539 cases. All 69 cases of bladder injury underwent primary suturing during surgery without complications. Of 14 cases with an early diagnosis of ureteral injury, 7 had a ureteral catheter inserted, 5 underwent ureteroureterostomy, and 2 underwent ureteroneocystostomy. Of nine cases with a delayed diagnosis of ureteral injury, ureteral catheter insertion was carried out in three cases, four cases underwent ureteroureterostomy, and two cases underwent ureteroneocystostomy.
Bladder injury was the most common urological injury during obstetric and gynecologic surgery, followed by ureteral injury. The variety of injured states, difficulty of diagnosis, and time to complete cure were much greater among patients with ureteral injuries. Early diagnosis and urologic intervention is important for better outcomes.
Gynecologic surgical procedures; Iatrogenic disease; Urinary tract; Wounds and injuries