Eliminating obstetric fistula: progress in partnerships

Knowledge and practice of obstetric care providers on prevention of obstetric fistula 2023: an institution-based cross-sectional study

Background

Obstetric fistula is a preventable devastating condition that is mostly caused by obstructed labour. About 22% of obstructed labor is complicated by obstetric fistula. Skilled birth attendants during delivery are essential for the prevention of obstetric fistula. However, little is known about the status of the knowledge and practice of obstetric fistula prevention in the Gamo zone.

Objective

We aimed to assess the knowledge, practice, and associated factors of obstetric caregivers on the prevention of obstetric fistula in public health facilities of the Gamo zone in southwest Ethiopia 2023.

Method

A cross-sectional study was employed among 372 obstetric caregivers in selected public health facilities of the Gamo zone in southwest Ethiopia from 1 December 2022 to 30 January 2023. Study participants were selected by a simple random sampling technique, and data were collected by using a pre-tested and self-administered questionnaire. The collected data were coded and entered into Epi-Data version 4.6 computer software and exported to SPSS version 27 for analysis purposes. Bivariable and Multivariable Logistic analyses were applied. The level of significance was declared at a P-value ≤0.05 and a 95% confidence interval.

Results

About 57% [95% CI (53.00-62.00)] of participants had good knowledge, and about 55.4% [95% CI (50.00-60.00)] of obstetric caregivers showed good practice for obstetric fistula prevention. The factors significantly associated with knowledge were service year [AOR = 2.50, 95% CI = (1.12-6.73)], types of a health facility [AOR = 1.99, 95% CI = (1.01-3.92)], age [AOR = 2.38, 95% CI = (1.03-5.49)], and in-service training [AOR = 4.61, 95% CI = (2.35-9.05)]. In-service training [AOR = 14.86, 95% CI = (12.75-18.73)], service year [AOR = 3.58, 95% CI = (1.24-10.29)], and knowledge [AOR: 13.24, 95% CI = (6.18-14.34)] were factors which were significantly associated with the practice of obstetric caregivers towards obstetric fistula prevention.

Conclusion

The knowledge and practice of obstetric caregivers on the prevention of obstetric fistula was low in public health facilities of the Gamo zone. In this study, practicing at a hospital was a factor significantly associated with the knowledge of obstetric caregivers. Having in-service training, advanced service year, and age were factors significantly associated with the knowledge and practice of obstetric caregivers. Regular in-service training of health professionals can enhance their knowledge and practice of obstetric fistula prevention.

Variability and awareness of obstetric fistula among women of reproductive age in sub-Saharan African countries: A systematic review and meta-analysis

BACKGROUND

Obstetric fistula among women of reproductive age is a significant public health issue in developing countries, including Sub-Saharan Africa. However, the pooled awareness of obstetric fistula among women of reproductive age in Sub-Saharan Africa and its variation between countries have not yet been studied. Hence, the review aims to assess variability and awareness of obstetric fistula among women of reproductive age in Sub-Saharan African Countries.

METHOD

Articles were searched using different electronic databases, such as PubMed, Web of science, science direct (Scopus), Google scholar, and HINARI and manual search without regard to publication date. A random-effects model was used to ascertain the pooled prevalence of obstetric fistula awareness among women of reproductive age in Sub-Saharan Africa. Publication bias was checked by using funnel plot and Egger's test at a 5% level of significance. I2 test statistics was performed to evaluate heterogeneity among included studies. In addition, to identify the possible reason for the potential heterogeneity between the studies, sub-group and meta-regression analyses were conducted. A sensitivity analysis was performed to determine the impact of individual research on the overall results. The data were extracted by using Microsoft excel and analyzed using statistical software STATA/SE version 17.

RESULT

A total of 22 studies with 79,693 women of reproductive age were included in this systematic review and meta-analyses. In Sub-Saharan Africa, the pooled prevalence of awareness towards obstetric fistula among women of reproductive age was 40.85% (95% CI: 33.48, 48.22%). Analysis of the subgroups by specific countries revealed significant variation. The highest awareness of obstetric fistula was found among Tanzanian women of reproductive age (61.10%, 95% CI: 55.87-66.33%), whereas the lowest awareness was found in research from the Gambia (12.80%, 95% CI: 12.20-13.40%).The likelihood of obstetric fistula awareness were lower by a factor of 0.424 among studies with sample sizes greater than 3542 (β = -0.424 (95% CI: -0.767 to 0.081), p -value <0.05).

CONCLUSION

According to the current review, there is a low level of awareness about obstetric fistula among women of reproductive age in sub-Saharan Africa, and the results of the sub-group analysis by country showed wide variations. Therefore, we emphasize the need for country-specific public health initiatives to raise awareness about obstetric fistula among women of reproductive age, which could reduce the risk of delayed treatment.

Systematic review and meta-analysis of women's awareness of obstetric fistula and its determinants in Ethiopia

Background

Although obstetric fistula has been extensively eliminated in high-income countries due to comprehensive obstetric health care services, in developing countries including Ethiopia, many women and girls are still silently suffering from obstetric fistula due to early marriage, poor socioeconomic status, lack of access to skilled birth attendants, and limited awareness of obstetric fistula.

Objective

To determine the magnitude of women's awareness of obstetric fistula and its contributing factors in Ethiopia.

Methods

To perform this analysis, we strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations. To evaluate publication bias, we employed an Egger's test and an eye assessment of the funnel plot's symmetry. To look for signs of study heterogeneity, the Cochrane Q-test and I2 statistics were used. A Microsoft Excel spreadsheet was used to extract the data, and STATA version 14 was used to analyze it.

Results

A total of six studies involving 3,024 women were included. The pooled prevalence of women's awareness of obstetric fistula in Ethiopia was 41.24% (95% CI; 32.94%-49.54%). Urban residence (AOR = 2.32, 95% CI: 1.40-3.85), giving birth at a health institution (AOR = 2.84, 95% CI: 1.92-4.21), having secondary or above educational status (AOR = 3.27, 95% CI: 2.15-4.97), receiving antenatal care follow-up (AOR = 2.73, 95% CI: 1.71-4.35), and participation in pregnant women's conferences (AOR = 4.64, 95% CI: 2.88-7.49) were factors associated with good awareness of obstetric fistula in women in Ethiopia.

Conclusion

The pooled prevalence of women's awareness of obstetric fistula was low. Urban residence, giving birth at a health institution, having secondary and above educational status, having antenatal care follow-up, and participating in pregnant women's conferences were factors associated with women's awareness of obstetric fistula. Therefore, enhancing women's awareness of obstetric fistula and promoting institutional delivery and antenatal follow-up is recommended. Furthermore, policymakers and stakeholders should empower women and pay particular attention to the neglected but important public health problem that is obstetric fistula.

Estimating the Prevalence and Risk Factors of Obstetric Fistula in Ethiopia: Results from Demographic and Health Survey

Introduction

Obstetric fistula is the most common obstetric problem in low- and middle-income countries where maternal care is inaccessible. Obstetric fistula has serious social and economic consequences resulting in devastating health problems for women. There is a lack of national studies that show the burden of obstetric fistula and risk factors; as a result, this study aimed to estimate the prevalence of obstetric fistula, its symptoms, and risk factors in Ethiopia.

Methods

A population-level cross-sectional study was conducted with a total of 7590 women who gave birth in the last 5 years, using data from the 2016 Ethiopian Demographic and Health Survey. Complex sample analysis and normalized weighting were used to compensate for the disproportionate sampling in the survey. A multivariable logistic regression model was fitted to find a significant association between obstetric fistula and covariates. Both odds ratios (crude and adjusted) with their corresponding 95% confidence intervals (CI) were reported.

Results

Among the 7590 women having given birth in the last 5 years, 32 (0.42%) women with obstetric fistula were identified. Of these, 64% developed obstetric fistula after live birth and 23.1% developed obstetric fistula after stillbirth. More than 72.8% were associated with prolonged and very difficult labor. No history of contraceptive use (AOR = 3.43; 95% CI: 1.05-11.21), having a big problem of distance from the health facility (AOR = 3.7; 95% CI: 1.05-11.21), early marriage (AOR = 1.52; 95% CI: 1.12-3.5), and being a rural resident (AOR = 1.5; 95% CI:1.2-5.05) were risk factors associated with obstetric fistula.

Conclusion

This study finding revealed that obstetric fistula is the most common devastating obstetric problem in Ethiopia. Early marriage, early initiation of sexual intercourse, distance from the health facility, no history of contraceptive use, and rural residence were the predisposing factors to develop an obstetric fistula. Thus, interventions should focus on creating community awareness regarding early marriage and its consequences, early seeking of health facility visiting, and avoiding unintended pregnancy to minimize the subsequent complications.

[Socio-Anthropological Determinants of the High Prevalence of Obstetric Fistula in Guinea]

Objective

The purpose of this study was to analyse the socio-anthropological determinants (representations, beliefs, practices and perceptions of health services) of the high prevalence of obstetric fistulas in Guinea.

Patients and methods

From January 15 to February 15, 2018, we carried out a qualitative study in three health centres (one urban and two rural). The study focused on biological mothers who attended the centres to get vaccinated their children. The data were collected by semi-structured individual interview.

Results

None of the 42 respondents could link the occurrence of obstetric fistulas and obstructed labour. Participants at all three study sites believed that obstructed labour and obstetric fistula have a mystical origin. In Kissidougou, the respondents thought that obstructed labour and obstetric fistulas are caused either by soubaya, sorcery in Malinké or the evil spell korte in Malinké cast by an enemy, or the bad behaviour of the parturient which means either she practices adultery or if she behaves disrespectfully towards elders. In Dubréka, the respondents linked the occurrence of labour dystocia and obstetric fistula to witchcraft koromikhi in Sousou. In Labé, some respondents thought that obstructed labour and obstetric fistula are due to divine punishment in local dialect lette Allah when the woman does not respect her husband or has contracted the pregnancy out of the legal union. Others deemed that childbirth is difficult because of the narrowness of the delivery route in Fulani lawol ngol no faadhi in parturients who do not have sex during pregnancy or when the woman had not adequately had female circumcision, in local dialect o suuwaaki laabhi which means, part of the clitoris was left in place during the excision. The majority of respondents had a poor perception of health services (male staff, lack of privacy, poor hygiene, abuse). Several cultural practices (early wedlocks, genital mutilations, dietary restrictions, home deliveries) also induce obstetric fistulas.

Conclusion

Respondents' cultural beliefs and practices regarding childbirth limit women's attendance at maternity hospitals during childbirth and favour obstetric fistulas.

Modelling allocation of resources in prevention and control of obstetric fistula in Ugandan women

In spite of reliable and skilled healthcare resources, the prevalence rate of obstetric fistula in Uganda is high. The risk factors for obstetric fistula cut across due to high poverty rates and cultural barriers. The main objective of this study was to assess the impact of inability to access skilled healthcare at delivery and implications to the economy. The specific objective was to determine the best way of investment in getting women access to skilled healthcare before, during and after child birth. The question to be answered was whether it was more economical to invest in getting women access to skilled healthcare, or in expanding healthcare. The study was conducted using data from the Uganda Demographic Health Survey 2016. The data was from 18,506 women in the age group of 15-49 in 15 regions around the country. Results show that the highest investment in providing access to skilled healthcare is required when there are few skilled healthcare centres. On the other hand, if there is little investment in providing access to skilled healthcare during child birth, many skilled healthcare centres are required. Results show further that the minimum time taken to reduce fistula prevalence is attained when there are many women accessing skilled healthcare in the few equipped health centres. However, if there are many skilled healthcare centres but a few women treated for obstetric fistula, then it will take longer to reduce fistula prevalence. Fitting the model to data suggested that Uganda has a big backlog of women to treat for obstetric fistula as in all skilled healthcare centres, there were less women treated than expected. Although still under the expected figure, the benefit of these treatments for obstetric fistula is that for every one woman treated, 8 more would seek treatment for the condition. This would however cost the country a great deal in that the treatment funds would perhaps give more returns if diverted to outreach activities aimed to get women seek skilled healthcare during child birth.

Awareness and Its Associated Factors of Obstetrics Fistula among Antenatal Care Attendees in Injibara Town Health Institutions, Awi Zone, North West, Ethiopia, 2019

Background

Obstetric fistula is abnormal passageway between the vagina and bladder or rectum, and it has the most devastating effects on physical, social, and economic levels and represents a major public health issue of thousands of women, which failed to provide accessible and appropriate intrapartum care for women within a developing country, particularly in Ethiopia. Therefore, we tried to assess the awareness and its associated factors of obstetrics fistula among pregnant mothers attending antenatal care clinics.

Methods

A health institutional-based cross-sectional study was employed from March 4 to 29/2019 among 413 pregnant women. Data was collected by a systematic random sampling technique and entered into a computer using Epi data 3.5, edited and analyzed using Statistical Package of Social Sciences 23.0 version. Bivariate and multivariate logistic regression analyses were employed to estimate the crude and adjusted odds ratio with a confidence interval of 95% and p value of less than 0.05 considered statically significant.

Result

This study identified that 39.5% with 95% confidence interval (34.6-44.6%) of pregnant women had good awareness about obstetrics fistula. Multivariate logistic regression analysis showed that living in urban [AOR = 1.98, 95% CI = 1.07 - 3.69], attending formal education [AOR = 2.11, 95% CI = 1.06 - 4.12], having history antenatal care [AOR = 3.87, 95% CI = 1.60 - 9.68], and childbirth at health institution [AOR = 7.10, 95% CI = 2.52 - 2.02] were significantly associated with awareness of obstetrics fistula. Conclusion and recommendation. This study showed that awareness of obstetrics fistula was low. Residency, education, and occupation of the women, having history of antenatal care and childbirth at health institution was significantly associated with awareness of obstetrics fistula. Still, there is a gap on awareness of obstetrics fistula; therefore, it is good to emphasize on providing information on maternal health care issues, particularly about obstetrics fistula.

Childbirth experiences of Sudanese women living with obstetric fistula - A qualitative study

BACKGROUND

Obstetric Fistula results from failure to manage obstructed labor in a timely manner; the failure can be attributed to many factors. Therefore, the study seeks to provide a better understanding of the circumstances surrounding the occurrence of Obstetric Fistula using the Three-Delays model.

METHODS

Semi-structured interviews were conducted with 19 women living with OF. Study participants were recruited from the Dr. Abbu Fistula Center and the Fistula Re-integration Center in Khartoum, Sudan. Thematic analysis was used to analyze the study findings. The Three-Delays Model guided the analysis and discussion of these findings.

RESULTS

The majority (11 out of 19) experienced more than one delay and six of the participants had all the three delays. Women were kept at home by midwives or family members for days until the baby was dead or the woman showed severe signs of complications. Many of the participants went through injurious vaginal labor which could have been prevented if they had had timely access to a caesarian section.

CONCLUSION

In order to reduce the delays in seeking care, special attention must be paid to raising women's, husbands' and the community's awareness about danger signs that may arise before and during childbirth, the benefits of skilled birth attendance, and where and when to seek help. In addition, the provision of information regarding where to find Emergency Obstetric Care services and a birth preparedness plan would facilitate prompt care-seeking behavior. More resources must be allocated to strengthen the quality and coverage of reproductive health services.

Nurse-midwives' ability to diagnose acute third- and fourth-degree obstetric lacerations in western Kenya

BACKGROUND

Obstetric fistula devastates the lives of women and is found most commonly among the poor in resource-limited settings. Unrepaired third- and fourth-degree perineal lacerations have been shown to be the source of approximately one-third of the fistula burden in fistula camps in Kenya. In this study, we assessed potential barriers to accurate identification by Kenyan nurse-midwives of these complex perineal lacerations in postpartum women.

METHODS

Nurse-midwife trainers from each of the seven sub-counties of Siaya County, Kenya were assessed in their ability to accurately identify obstetric lacerations and anatomical structures of the perineum, using a pictorial assessment tool. Referral pathways, follow-up mechanisms, and barriers to assessing obstetric lacerations were evaluated.

RESULTS

Twenty-two nurse-midwife trainers were assessed. Four of the 22 (18.2%) reported ever receiving formal training on evaluating third- and fourth-degree obstetric lacerations, and 20 of 22 (91%) reported health-system challenges to adequately completing their examination of the perineum at delivery. Twenty-one percent of third- and fourth-degree obstetric lacerations in the pictorial assessment were incorrectly identified as first- or second-degree lacerations.

CONCLUSION

County nurse-midwife trainers in Siaya, Kenya, experience inadequate training, equipment, staffing, time, and knowledge as barriers to adequate diagnosis and repair of third- and fourth-degree perineal tears.

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review

OBJECTIVE

To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps.

METHODS

A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature.

RESULTS

A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death.

CONCLUSION

Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed.

Healthcare access and quality of birth care: narratives of women living with obstetric fistula in rural Tanzania

BACKGROUND

Increasing births with skilled attendants and increasing health facilities with Emergency Obstetric Care (EmOC) can reduce maternal mortality and are considered critical interventions for ensuring safe motherhood. Despite Tanzania's policy to support women to give birth with the assistance of skilled personnel, some women do not access this care. This article uses women's stories to illustrate the challenges that caused them to fail to access adequate obstetric care in a timely manner, hence causing the development of fistulas.

METHODS

This paper presents the narratives of 16 women who were conveniently selected based on their experiences of not being able to access adequate obstetric care in timely manner. The analysis was guided by recommendations for the identification and interpretation of narratives, and identified important components of women's experiences, paying attention to commonalities, differences and areas of emphasis. Semi-structured interviews were carried out at CCBRT hospital in Dar es Salaam.

RESULTS

Four (4) general story lines were identified from women description of their inability to access quality obstetric care in a timely manner. These were; failing to decide on a health care facility for delivery, lacking money to get to a health care facility, lacking transportation to a health care facility and lacking quality birth care at the health care facility.

CONCLUSION

Women were unable to reach to the health care facilities providing comprehensive emergency obstetric care (CEmOC) in time because of their lack of decision-making power, money and transportation, and those who did reach the facilities received low quality birth care. Empowering women socially and financially, upgrading primary health care facilities to provide CEmOC and increased numbers of skilled personnel would promote health care facility deliveries.

[Study of knowledge, attitudes and practices in social reintegration of women victims of obstetric fistula: region of the far-North, Cameroon]

Introduction

La fistule obstétricale est un orifice entre le vagin et la vessie ou le rectum, voire les deux. Ses impacts sont des conséquences anatomo-fonctionnelles et sociales. On estime à plus de 19 000 le nombre de femmes qui souffrent de fistule obstétricale au Cameroun.

Méthodes

Il s'agissait d'une étude transversale descriptive conduite dans trois districts de santé de la région de l'Extrême-nord. Vingt-huit femmes victimes de fistules obstétricales, quarante-deux membres de leur entourage et vingt-quatre agents de santé ont été interviewés entre Novembre et Décembre 2013. Trois types de questionnaires ont été utilisés. Les données ont été analysées dans Epi Info version 7.1.4.0. Les moyennes et les fréquences ont été calculées avec un intervalle de confiance à 95%.

Résultats

46,4% des femmes victimes de fistule obstétricales interviewées avaient subi une intervention chirurgicale réparatrice parmi lesquelles, 61,5% bénéficiaient de la réintégration. Le fonds de commerce (62,5%) était l'aide la plus reçue. Vingt-deux membres de l'entourage savaient pourquoi on fait la réintégration. Selon eux, les considérations socioculturelles (68,2%), sont la principale barrière de la réintégration. D'après les agents de santé, le suivi psychosocial (58,3%) est la principale activité de la réintégration dans les centres de prise en charge de la fistule.

Conclusion

La prise en charge des fistules obstétricales au Cameroun souffre de manque de réintégration sociale. Ceci expliquerait en partie la persistance de cette pathologie. Un accent devrait être mis sur l'appui matériel, financier et sur le suivi psychosocial des femmes victimes de fistule obstétricale.

Risk factors for obstetric fistula in Western Uganda: a case control study

INTRODUCTION

Two million women worldwide are living with genital fistula with an annual incidence of 50,000-100,000 women. Risk factors for obstetric fistula are context bound. Studies from other countries show variation in the risk factors for obstetric fistula. This study was conducted to identify risk factors for obstetric fistula in western Ugandan context.

METHODS

A case control study comparing background factors of women with obstetric fistula (cases) and women without fistula (controls) was conducted in western Uganda. Data was collected using face-to-face interviews. Univariate, bivariate and multivariate analysis was conducted using Stata 12.

RESULTS

Altogether, 420 respondents (140 cases and 280 controls) participated in the study. Duration of labour was used to form the product terms when assessing for interaction and confounding since it was one the most significant factors at bivariate level with a narrow confidence interval and was hence considered the main predictor. After adjusting for interaction and confounding, significant risk factors associated with development of obstetric fistula in western Uganda were: Caesarean section (adjusted odds ratio [AOR] = 13.30, 95% CI = 6.74-26.39), respondent height of 150 cm or less (AOR = 2.63, 95% CI = 1.35-5.26), baby weight of 3.5 kg or more (AOR = 1.52, 95% CI = 1.15-1.99), prolonged labour (AOR = 1.06, 95% CI = 1.04-1.08. A quarter of the fistulas had resulted from iatrogenic complication during caesarean section. Compared to no education, post primary level of education was protective against obstetric fistula (AOR = 0.31, 95% CI = 0.13-0.72) and there was no difference between respondents without education and those with primary level education.

CONCLUSIONS

Surgeons contribute to a big proportion (25%) of fistula cases hence caesarean section being a risk factor in this region. Other risk factors include; prolonged labour, weight of the baby of 3.5 kg or more, respondent height of 150 cm or less (short stature), and low or no education are risk factors for obstetric fistula in western Ugandan.

Obstetric fistula in a district hospital in DR Congo: Fistula still occur despite access to caesarean section

OBJECTIVE

To study the profile of classification, etiology, and the relation between initial classification, and the results of vesicovaginal fistula surgery in a district hospital in DR Congo.

METHODS

This study was based on the analysis of all consecutive patients being treated for VVF in Kisantu between November 2006 and November 2012. The fistula was classified according to the classification of Waaldijk. The location of VVF and degree of fibrosis were noted. Post-operatively, the first examination of patients took place a few days after catheter removal and subsequent review 2-3 months later. Statistical analysis was done in Graphpad Prism 6.

RESULTS

Among 146 patients with VVF, 117 had a primary fistula. The majority of fistula was type I (56%) followed by type III (21%). The majority underwent a caesarean section (63.4%). The mean duration of labor was 30.7 hr. Delay in getting a caesarean in time was due to difficulties in reaching the hospital in 55%. Overall, the closure rate after the first surgical treatment was 65%. The continence rate of the patients with a successful closure was 63%.

CONCLUSION

VVF can occur after caesarean section because of the prolonged labor that already causes ischemia and necrosis of the bladder wall and vesicovaginal septum before or while the caesarean section is being performed. Access to general hospitals and the management of the pregnant women needs to be improved. Despite a reasonable closure rate of 65%, post-fistula incontinence remains an important clinical problem.

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.

Obstetric fistula in Burundi: a comprehensive approach to managing women with this neglected disease

BACKGROUND

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.

METHODS

Descriptive study using routine programme data.

RESULTS

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).

CONCLUSION

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.

Characterising women with obstetric fistula and urogenital tract injuries in Tanzania

INTRODUCTION AND HYPOTHESIS

World Health Organisation (WHO) data suggest that more than two million women and girls live with fistula and that an additional 50-100,000 are newly affected each year. In Tanzania, it has been estimated that there are between 1,200 and 3,000 new cases of obstetric fistula annually.

METHODS

To characterize women undergoing surgery in 2011 for obstetric fistula repair at a disability hospital associated with Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), we identified routinely collected data and input into an Access database.

RESULTS

Women affected by obstetric fistulae in Tanzania are frequently young, poorly educated, primiparous, subsistence farmers or housewives and have experienced obstructed labour as a result of delays occurring at home and/or after reaching a health facility. The majority experienced stillbirth, particularly in cases of assisted or operative delivery. Success rates for fistula closure were high, at 91 %, but residual incontinence on discharge from hospital was seen in 39 %.

CONCLUSIONS

Longer-term follow-up is required to determine rates of disabling residual incontinence and to examine demographics in greater depth, including variation between regions and in urban, periurban and rural settings in Tanzania.

Vesico-vaginal fistula repair as a day case: is it a worthy venture?

Two vesico-vaginal fistula patients who were successfully managed with outpatient care as an alternative approach, to ensure early access to care and integration into their family. The two patients had simple uncomplicated mid-vagina fistulae surgically repaired with local infiltrative anaesthesia. We suggest some selection criteria and clinical guidelines that can facilitate successful treatment by this choice of care.

Medico-social pathways of obstetric fistula patients in Mali and Niger: an 18-month cohort follow-up

OBJECTIVES

To gain understanding of care pathways and induced mobility patterns of obstetric fistula patients in French-speaking West African fistula repair centres.

METHODS

We followed prospectively during 18 months a cohort of obstetric fistula patients in Mali and Niger (2008-2009). 120 patients were recruited at different stages of their care process in 5 reference fistula repair centres. Follow-up was carried out in repair centres and communities. Quantitative data were collected through close-ended questionnaires at three time points. Medico-social pathways were explored through a longitudinal analysis focusing on six indicators: fistula duration, care process duration, patients' mobility, marital status, number of surgeries and continence status.

RESULTS

Patients' pathways were characterised by their length: fistula duration (median 4 years), care process duration (median 2.7 years), aggregated time spent in repair centres during study (median 7 months). Patients developed four mobility patterns (homebound, itinerant, institutionalised and urbanised). Adverse marital status change continued over time. Sample stratification according to number of previous surgeries revealed differences in care process duration and outcome: 23/31 new cases (≤1 surgery) gained continence with a mean of 1.5 surgeries in a median of 0.6 year while only 17/78 old cases (≥2 surgeries) became continent with a mean of 4 surgeries in a median time of 4.9 years.

CONCLUSION

The quest for continence does not end with admission to a fistula repair centre. Analysing fistula care experience across time within the varying settings highlights the twofold population and mixed medico-social outcomes that should prompt new development in obstetric fistula care management and research.

A population based survey in Ethiopia using questionnaire as proxy to estimate obstetric fistula prevalence: results from demographic and health survey

Background

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.

Objective

The aim of this study is to describe the prevalence and factors associated with Obstetric Fistula in Ethiopia.

Methods

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.

Results

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).

Conclusions

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.

"I am nothing": experiences of loss among women suffering from severe birth injuries in Tanzania

Background

Despite the increased attention on maternal mortality during recent decades, which has resulted in maternal health being defined as a Millennium Development Goal (MDG), the disability and suffering from obstetric fistula remains a neglected issue in global health. Continuous leaking of urine and the physical, emotional and social suffering associated with it, has a profound impact on women's quality of life. This study seeks to explore the physical, cultural and psychological dimensions of living with obstetric fistula, and demonstrate how these experiences shape the identities of women affected by the condition.

Methods

A cross-sectional study with qualitative and quantitative components was used to explore the experiences of Tanzanian women living with obstetric fistula and those of their husbands. The study was conducted at the Comprehensive Community Based Rehabilitation Tanzania hospital in Dar es Salaam, Bugando Medical Centre in Mwanza, and Mpwapwa district, in Dodoma region. Conveniently selected samples of 16 women were interviewed, and 151 additional women responded to a questionnaire. In addition, 12 women affected by obstetric fistula and six husbands of these affected women participated in a focus group discussions. Data were analysed using content data analysis framework and statistical package for the social sciences (SPSS) version 15 for Microsoft windows.

Results

The study revealed a deep sense of loss. Loss of body control, loss of the social roles as women and wives, loss of integration in social life, and loss of dignity and self-worth were located at the core of these experiences.

Conclusion

The women living with obstetric fistula experience a deep sense of loss that had negative impact on their identity and quality of life. Acknowledging affected women's real-life experiences is important in order to understand the occurrence and management of obstetric fistula, as well as prospects after treatment. This knowledge will help to improve women's sense of self-worth and maintain their identity as women, wives, friends and community members. Educational programmes to empower women socially and economically and counselling of families of women living with obstetric fistula may help these women receive medical and social support that is necessary.

"I am nothing": experiences of loss among women suffering from severe birth injuries in Tanzania

BACKGROUND

Despite the increased attention on maternal mortality during recent decades, which has resulted in maternal health being defined as a Millennium Development Goal (MDG), the disability and suffering from obstetric fistula remains a neglected issue in global health. Continuous leaking of urine and the physical, emotional and social suffering associated with it, has a profound impact on women's quality of life. This study seeks to explore the physical, cultural and psychological dimensions of living with obstetric fistula, and demonstrate how these experiences shape the identities of women affected by the condition.

METHODS

A cross-sectional study with qualitative and quantitative components was used to explore the experiences of Tanzanian women living with obstetric fistula and those of their husbands. The study was conducted at the Comprehensive Community Based Rehabilitation Tanzania hospital in Dar es Salaam, Bugando Medical Centre in Mwanza, and Mpwapwa district, in Dodoma region. Conveniently selected samples of 16 women were interviewed, and 151 additional women responded to a questionnaire. In addition, 12 women affected by obstetric fistula and six husbands of these affected women participated in a focus group discussions. Data were analysed using content data analysis framework and statistical package for the social sciences (SPSS) version 15 for Microsoft windows.

RESULTS

The study revealed a deep sense of loss. Loss of body control, loss of the social roles as women and wives, loss of integration in social life, and loss of dignity and self-worth were located at the core of these experiences.

CONCLUSION

The women living with obstetric fistula experience a deep sense of loss that had negative impact on their identity and quality of life. Acknowledging affected women's real-life experiences is important in order to understand the occurrence and management of obstetric fistula, as well as prospects after treatment. This knowledge will help to improve women's sense of self-worth and maintain their identity as women, wives, friends and community members. Educational programmes to empower women socially and economically and counselling of families of women living with obstetric fistula may help these women receive medical and social support that is necessary.

The role of counseling for obstetric fistula patients: lessons learned from Eritrea

OBJECTIVE

The goal of this study was to evaluate the first formal counseling program for obstetric fistula patients in Eritrea.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

PRACTICAL IMPLICATIONS

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.

Pilot study utilizing a patient educational brochure at a vesicovaginal fistula hospital in Nigeria, Africa

This paper presents a pilot study exploring the utility and feasibility of use of a vesicovaginal fistula (VVF) patient educational brochure. Women awaiting or recently having undergone VVF surgery examined a six-paneled educational brochure detailing the causes, treatment options, and prevention methods of VVF. Participants answered demographic questions and gave detailed responses to a questionnaire that addressed the brochure material. A convenience sample of 50 patients, with a mean age of 26.1 years, participated. Universally, these women felt that the information they learned from the brochure was useful. Suggestions by participants regarding prevention of VVF included laboring in a hospital (80%), educating other women (30%), and discouraging early marriage (8%). Primary barriers to prevention and treatment included financial restraints (84%) and transportation difficulties (30%). The utilization of a simple, low-cost educational brochure has the ability to educate women on the causes, treatment, and prevention of VVF.