The Campaign to End Fistula: what have we learned? Findings of facility and community needs assessments

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.

Treatment-seeking for vaginal fistula in sub-Saharan Africa

BACKGROUND

There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high.

METHODS

The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI).

RESULTS

Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved.

CONCLUSION

Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Marital disruption among women with genital fistula in Nigeria: who is at greatest risk?

INTRODUCTION AND HYPOTHESIS

Marital disruption is a commonly identified sequela of genital fistula in developing countries. This study is aimed at identifying factors that correlate with marital outcomes.

METHODS

All new patients presenting to Evangel VVF Centre in Jos, Nigeria, between August 2015 and August 2017, were retrospectively reviewed with regard to demographics, medical history, and fistula details to identify variables correlating with marital status, particularly whether currently married or presently divorced, separated, or divorced and remarried (cumulatively the "divorce group").

RESULTS

Among 581 new patients, 66% were married and 18% experienced marital disruption. Presence of living children in the home and having attended any level of formal education were found to be protective of marriage (p values <0.0001 and 0.0045 respectively). Patients in the divorce group were more likely to have delivered a baby before the age of 18, be of Muslim background, and have a longer time since fistula formation (p values all <0.0001), as were those married younger than 18 and those whose fistula followed a vaginal delivery (p values 0.0015 and 0.0017 respectively).

CONCLUSION

Several factors correlate with disruption of the marriage relationship. Patients at highest risk for marital disruption should be identified early and provided with interventions aimed at protecting their marriage and social support system.

Obstetric fistula policy in Nigeria: a critical discourse analysis

BACKGROUND

In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing.

METHODS

A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice.

RESULTS

The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development."

CONCLUSION

This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

"Poverty is the big thing": exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

BACKGROUND

Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women's, communities', and providers' perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services.

METHODS

A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) - including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted.

RESULTS

Women's experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women's and families' ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation.

CONCLUSIONS

The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.

Too Long to Wait: Obstetric Fistula and the Sociopolitical Dynamics of the Fourth Delay in Soroti, Uganda

Uganda has one of the highest obstetric fistula rates in the world with approximately 200,000 women currently suffering. Surgical closure successfully treats fistula in the majority of cases, yet there is a severe shortage of facilities and trained surgeons in low-resource countries. The purpose of this study was to examine Ugandan women's experiences of obstetric fistula with the aim of adding narrative depth to the clinical literature on this devastating birth injury. Data were collected through semistructured interviews, focus groups, and participant observation. Resulting narratives were consensus coded, and key themes were member-checked using reciprocal ethnography. Women who suffered from fistula described barriers in accessing essential obstetric care during labor-barriers that are consistent with the three delays framework developed by Thaddeus and Maine. In this article, we extend this scholarship to discuss a fourth, critical delay experienced by fistula survivors-the delay in the diagnosis and treatment of their birth injury.

An integrative review on women living with obstetric fistula and after treatment experiences

AIMS AND OBJECTIVES

To review literature on the experiences of women with obstetric fistula, their lived experiences after treatment; and to provide evidence for future research.

BACKGROUND

Obstetric fistula is an injury most commonly resulting from a prolonged labour. Long eradicated in developed countries, obstetric fistula remains a public health issue in sub-Saharan Africa and Asia. This is a highly stigmatised health condition, and an understanding of the women's experience is required to inform holistic approaches for care and prevention.

DESIGN

A search of literature was conducted on databases of EBSCO host (Academic Search Premier, MEDLINE, PsychINFO, CINAHL), Web of Science; and websites of international organizations such as Women's Dignity Project and EngenderHealth. Keywords, Inclusion and exclusion criteria were defined and 25 articles published between 2004 to January 2015 were identified.

METHODS

An integrative review of 25 articles was carried out.

RESULTS

Three broad themes were identified: Challenges of living with fistula; treatment and care experiences; and reintegration experiences of women after fistula repair.

CONCLUSIONS

Living with a fistula presents multidimensional consequences affecting women, families and communities. Accessing treatment is difficult and there are no standardised treatment packages. Surgical repairs were variable in their success rate. Some authors claim women resume normal lives irrespective of their continence status, whilst others claim they face discrimination despite being continent thereby hindering reintegration. Quality of life is diminished for those remaining incontinent. Post repair psychosocial support services are beneficial for reintegration, but research on programme benefits is limited. Therefore further research is required to support its benefits; and for policy development to meet care provision for women with fistula.

RELEVANCE TO CLINICAL PRACTICE

The review provides insights into avenues of improving care provision and delivery by health professionals and policy makers. It also exposes areas that need further research for quality care provision.

Bladder stones in vesicovaginal fistula: is concurrent repair an option? Experience with 87 patients

INTRODUCTION AND HYPOTHESIS

The objective was to assess the outcomes of a one-stage approach to bladder stones in the setting of a vesicovaginal fistula, performing fistula repair concurrently with stone extraction.

METHODS

Retrospective review of urogenital fistula surgeries at Evangel VVF Center in Jos, Nigeria, between December 2003 and April 2014, identified 87 women with bladder stones accompanying their fistulas and 2,979 repaired without stones. Concurrent stone extraction and fistula repair were performed in 51 patients. Outcomes were compared with respect to fistula size, classification, and fibrosis.

RESULTS

Women presenting with bladder stones were older and had larger fistulas than those without stones (P < 0.001). Additionally, their fistulas were more often classifiable as large and less often as high (P = 0.02), and were more fibrotic (P = 0.003). Twenty-six (51 %) patients with concurrent repair successfully became dry. Comparing results by classification, concurrent repair of high fistulas with stones was very likely to be successful (OR 8.8, 95% CI 1.0-78.2), whereas low fistulas were not (OR 0.2, 95% CI 0.02-0.7). Outcomes were similar to those of patients without stones, except for low fistulas, which were 5 times more likely to fail (P = 0.04).

CONCLUSION

Concurrent closure of vesicovaginal fistula at the time of bladder stone extraction is possible and, in many respects, preferable to a staged approach, particularly among high or midvaginal fistulas.

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya

INTRODUCTION AND HYPOTHESIS

More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears.

METHODS

Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya.

RESULTS

One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33 %) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95 %) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51 %) women with OF symptoms ultimately had true OF confirmed at operation.

CONCLUSION

These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Development of an intervention to improve mental health for obstetric fistula patients in Tanzania

Obstetric fistula is a debilitating childbirth injury that has been associated with high rates of psychological distress. Global efforts have helped to link women to surgical repair, but thus far no evidence-based interventions exist to address the psychological needs of these women during the hospital stay. In this paper, we describe the development of a psychological intervention for women in Tanzania who are receiving surgical care for an obstetric fistula. The intervention was developed based on theories of cognitive behavioral therapy and coping models. Content and delivery were informed by qualitative data collection with a range of stakeholders including women with fistula, and input from a study advisory board. The resulting intervention was six individual sessions, delivered by a trained community health nurse. The session topics were (1) recounting the fistula story; (2) creating a new story about the fistula; (3) loss, grief and shame; (4) specific strategies for coping; (5) social relationships; and (6) planning for the future. A trial run of the intervention revealed that the intervention could be delivered with fidelity and was acceptable to patients. A future randomized control trial will evaluate the efficacy of this intervention to address the mental health symptoms of this population.

Rehabilitation experiences after obstetric fistula repair: systematic review of qualitative studies

OBJECTIVES

To synthesise evidence on women's experiences surrounding rehabilitation and reintegration after obstetric fistula repair in sub-Saharan Africa and explore recommendations from women and health service providers.

METHOD

Systematic literature review of qualitative studies surrounding rehabilitation experiences of women in sub-Saharan Africa who have undergone obstetric fistula repair. Using a pre-defined search strategy, seven databases, relevant source publications and grey literature were searched for primary qualitative studies. Data from ten studies were collected, and thematic analysis based on the framework approach was used to analyse the findings.

RESULTS

The most important rehabilitating factor for women was fulfilment of social roles. Health service perspectives were more frequent than women's perspectives. Counselling and health education were the most common recommendations from both perspectives.

CONCLUSION

Little qualitative evidence is available on rehabilitation after obstetric fistula repair in sub-Saharan Africa. Counselling services and community health education are priorities. Further research should emphasise women's perspectives to better inform interventions aimed at addressing the physical and social consequences of obstetric fistula.

A qualitative study of the experience of obstetric fistula survivors in Addis Ababa, Ethiopia

Research on obstetric fistula has paid limited attention to the lived experiences of survivors. This qualitative study explored the evolution of survivors' perceptions of their social relationships and health since developing this obstetric complication. In-depth interviews were conducted with eight survivors who were selected based on purposive and snowball sampling techniques. Thematic categorization and content analysis was used to analyze the data. The resultant themes included participants' understanding of factors predisposing to fistula, challenges they encounter, their coping responses, and the meaning of their experiences. First, the participants had a common understanding of the factors that predisposed them to obstetric fistula. They mentioned poor knowledge about pregnancy, early marriage, cultural practices, and a delay in or lack of access to emergency obstetric care. Second, the participants suffered from powerlessness experienced during their childhood and married lives. They also faced prolonged obstructed labor, physical injury, emotional breakdown, depression, erosion of social capital, and loss of healthy years. Third, to control their negative emotions, participants reported isolating themselves, having suicidal thoughts, positive interpretation about the future, and avoidance. To obtain relief from their disease, the women used their family support, sold their properties, and oriented to reality. Fourth, the participants were struggling to keep going, to accept their changed reality, and to change their perspectives on life. In conclusion, obstetric fistula has significant physical, psychosocial, and emotional consequences. The study participants were not passive victims but rather active survivors of these challenges. Adequate support was not provided by their formal or informal support systems. To prevent and manage obstetric fistula successfully, there should be family-based interventions that improve access to and provision of emergency obstetric care. These initiatives should also ensure men's participation, women's empowerment, and the utilization of community-based institutions.

Community-based screening for obstetric fistula in Nigeria: a novel approach

BACKGROUND

Obstetric fistula continues to have devastating effects on the physical, social, and economic lives of thousands of women in many low-resource settings. Governments require credible estimates of the backlog of existing cases requiring care to effectively plan for the treatment of fistula cases. Our study aims to quantify the backlog of obstetric fistula cases within two states via community-based screenings and to assess the questions in the Demographic Health Survey (DHS) fistula module.

METHODS

The screening sites, all lower level health facilities, were selected based on their geographic coverage, prior relationships with the communities and availability of fistula surgery facilities in the state. This cross-sectional study included women who presented for fistula screenings at study facilities based on their perceived fistula-like symptoms. Research assistants administered the pre-screening questionnaire. Nurse-midwives then conducted a medical exam. Univariate and bivariate analyses are presented.

RESULTS

A total of 268 women attended the screenings. Based on the pre-screening interview, the backlog of fistula cases reported was 75 (28% of women screened). The backlog identified after the medical exam was 26 fistula cases (29.5% of women screened) in Kebbi State sites and 12 cases in Cross River State sites (6.7%). Verification assessment showed that the DHS questionnaire had 92% sensitivity, 83% specificity with 47% positive predictive value and 98% negative predictive value for identifying women afflicted by fistula among women who came for the screenings.

CONCLUSIONS

This methodology, involving effective, locally appropriate messaging and community outreach followed up with medical examination by nurse-midwives at lower level facilities, is challenging, but represents a promising approach to identify the backlog of women needing surgery and to link them with surgical facilities.

New hope: community-based misoprostol use to prevent postpartum haemorrhage

The wide gap in maternal mortality ratios worldwide indicates major inequities in the levels of risk women face during pregnancy. Two priority strategies have emerged among safe motherhood advocates: increasing the quality of emergency obstetric care facilities and deploying skilled birth attendants. The training of traditional birth attendants, a strategy employed in the 1970s and 1980s, is no longer considered a best practice. However, inadequate access to emergency obstetric care and skilled birth attendants means women living in remote areas continue to die in large numbers from preventable maternal causes. This paper outlines an intervention to address the leading direct cause of maternal mortality, postpartum haemorrhage. The potential for saving maternal lives might increase if community-based birth attendants, women themselves, or other community members could be trained to use misoprostol to prevent postpartum haemorrhage. The growing body of evidence regarding the safety and efficacy of misoprostol for this indication raises the question: if achievement of the fifth Millennium Development Goal is truly a priority, why can policy makers and women's health advocates not see that misoprostol distribution at the community level might have life-saving benefits that outweigh risks?

Waiting for attention and care: birthing accounts of women in rural Tanzania who developed obstetric fistula as an outcome of labour

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Avoidable maternal deaths: three ways to help now

The current paper examines the realities of women delivering in resource-poor settings, and recommends cost-effective, scalable strategies for making these deliveries safer. Ninety-five percent of maternal deaths occur in poor settings, and the largest proportion of these deaths are women who deliver at home, far away from health care facilities, and without financial access to skilled providers. This situation will improve only when policymakers and programme planners refocus their attention on service delivery and financing interventions, with the potential to reach the largest portion of women living in places where mortality is the highest. We suggest three feasible interventions that can potentially minimise both demand and supply side problems of safe delivery: (1) misoprostol to treat postpartum haemorrhage, an easy to use and heat stable technology to reduce the leading cause of maternal deaths; (2) alternative providers, such as clinical officers, trained to offer emergency obstetric care services; (3) financing safe delivery through vouchers or other mechanisms that can be implemented in poor settings and made attractive to the donor community through output-based assistance (OBA).

New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003?

In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.

Genitourinary fistula experience in Sierra Leone: review of 505 cases

PURPOSE

We reviewed cases of genitourinary fistula resulting from birth trauma in Sierra Leone to determine factors predictive of successful operative repair.

MATERIALS AND METHODS

A total of 505 operative repairs of genitourinary fistula were completed at 2 centers in Sierra Leone from 2004 to 2006. Statistical analysis of patient demographics, fistula characteristics, outcomes and surgical complications was performed.

RESULTS

Primary repairs, defined as the first repair, accounted for 68% of repairs in the population with 92% classified as vesicovaginal fistula alone. Only 56% of women were deemed to have an intact urethra at presentation and 68% were diagnosed with moderate or severe fibrosis surrounding the fistula. On univariate analysis parameters that demonstrated significant differences with primary operative success were patient age at fistula occurrence (p = 0.0192), index pregnancy (p = 0.0061), location (p <0.0001), surface area (p <0.0001), urethral status (p <0.0001) and fibrosis (p <0.0001). On multivariate analysis the fistula parameter that correlated with successful repair was the extent of fibrosis (severe fibrosis OR 3.7).

CONCLUSIONS

Genitourinary fistula as a result of prolonged obstructed labor is a cause of considerable morbidity in sub-Saharan Africa, including Sierra Leone. The most profound factor correlating with a positive operative outcome was the extent of fibrosis surrounding the fistula. These data are important to help predict the likelihood of successful repair and assist in selecting women for the appropriate surgical procedure.

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.