Time to recovery from obstetric fistula and determinants in Gondar university teaching and referral hospital, northwest Ethiopia

Risk factors for failed fistula closure in Addis Ababa at fistula centre, central Ethiopia

Background

Obstetric Fistula leads to fecal and urine incontinence in women and girls. Surgical repair is the cornerstone of care. Failure to repair an obstetric fistula exposes women not only to repeated surgery but also to ongoing incontinence and its sequela, depression, and social exclusion. Which impacts the nation's health intervention programs and socioeconomic burden.

Objective

To determine factors associated with failed fistula closure in women who underwent Fistula Closure at the Hamlin Fistula Center in Addis Ababa, central Ethiopia, between February 10, 2018, and December 28, 2020.

Methods

Women who underwent Fistula Closure between February 10, 2018, and December 28, 2020 were included in a case-control study that was conducted between May and June 2021. In total, 417 study participants (139 cases and 280 controls) were selected using a systematic random sampling technique. Two professional midwife data collectors and one BSC nurse for the supervisory assessment of women's medical cards utilized a structured questionnaire to collect data. SPSS version 25 was used to enter, clean, and analyze the data. During data analysis, bivariate and multivariate regression models were used. A p-value of less than 0.05 indicates a significant correlation.

Results

Forty-nine patients (35.3%) and 133 controls (47.8%) who were older than 26 years were at repair while they were (14-19 years old). The factors that contributed to failure of fistula closure included age at repair (14-19 years old) [AOR = 2.1, 95% CI (0.94-4.89)], prior fistula attempts (9.6, rural residence [AOR = 2.69, 95% CI (1.36-5.35)], height <150 cm [AOR = 1.80, 95% CI (0.99-3.59)], labor duration longer than 2 days [AOR = 1.89, 95% CI (0.99-3.59)], delivery by cesarean section [AOR = 1.88, 95% CI (1.04-3.89)], damaged urethra [AOR = 2.02, 95% CI (1.04-3.89)], diameter of fistula >3 cm, mild vaginal scar [AOR = 3.20, 95% CI (1.24-8.29)], moderate and severe vaginal scar [AOR = 5.49, 95% CI (1.92-15.75)], and completion of ANC [AOR = 0.20 (0.11, 0.38)].

Conclusion and recommendation

Age at the time of repair, Residence, Height, duration of labor, mode of delivery, completion of ANC, damaged urethra, fistula diameter >3 cm, previous fistula attempts, and vaginal scar are factors related to failure of fistula closure. By focusing on these areas, we can significantly improve the outcomes for patients undergoing fistula repair and lower the likelihood of failed closures in the future. Community-based health education regarding obstetric fistula and the importance of seeing a doctor as soon as possible during labor to lower the risk of obstructed delivery, boost antenatal care completion, and shorten the length of labor are all necessary to prevent failed fistula closure in comparable patients in the future.

Treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries: A scoping review

BACKGROUND

Obstetrical fistula is an abnormal opening between the reproductive tract and lower urinary and/or gastrointestinal tract resulting from obstetrical complications, affecting nearly two million women worldwide. It imposes physical, economic, social, and mental consequences on the affected women. Treatment outcomes vary and, mostly, surgical treatment results in improved quality of life and successful subsequent pregnancy for survivors.

OBJECTIVES

The review aimed to chart and examine the treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries.

SEARCH STRATEGY

This is a scoping review study to identify treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries. The search was conducted from databases (PUBMED, Embase, CINAHL, Scopus, and Web of Science), and gray literature (Google Scholar, Google, and conference proceedings).

SELECTION CRITERIA

The eligibility criteria were constructed using a participant, concept, and context framework and included study types of primary research, reviews, and reports. Studies without full text and in languages other than English were excluded.

DATA COLLECTION AND ANALYSIS

The relevant characteristics of the included studies were extracted on an Excel spreadsheet and analyzed to chart treatment outcomes.

MAIN FINDINGS

The review examined the full text of 57 studies on the treatment outcomes of obstetrical fistula. The findings were grouped into two themes: early and late outcomes. The early outcomes included incontinence, surgical-site infection, urine retention, hemorrhage, and retained catheter. The late outcomes included fistula recurrence, residual incontinence, quality of life, reproductive issues, mental health, family and social support, and financial status.

CONCLUSION

The treatment outcomes of obstetrical fistula can be grouped into short-term and long-term outcomes. Although this review found adequate studies for the analysis, most study designs were poor. Stronger studies are recommended in the future to guide policy and decision-making. We would like to suggest that researchers conduct systematic reviews and meta-analyses independently for short-term and long-term outcomes.

A systematic review and meta-analysis on the recovery time of obstetric fistula in Ethiopia, 2023

INTRODUCTION

Obstetric fistula is a birth injury that causes the vagina to open abnormally. As a result, women may experience urinary leakage, which can lead to isolation, depression, and a lower quality of life. Due to the scarcity of evidence regarding the average recovery time for obstetric fistula in Ethiopia, Therefore, this study aimed to assess the recovery time for women with obstetric fistula in Ethiopia.

METHODS

Between September and 8 November 2023, published studies were searched using online databases including PubMed, Hinari, Epistemonikos, and Google Scholar. The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Study quality was assessed using Egger's test and a visual inspection of funnel plot symmetry. Statistical analysis was performed using STATA version 17 software. A random-effects model was employed for analysis, and the Cochrane Q-test and I² statistics were used to assess heterogeneity among studies.

RESULT

A total of six studies were included in this analysis. The minimum and maximum median survival times were 2.67 and 5.19 weeks, respectively. The pooled median recovery time was 4.05 weeks (95% CI: 2.92, 5.18) based on the random effects model. Heterogeneity among the included studies assessed by the I² statistic was 97.72% (p = 0.000). The p-value for Egger's regression test (0.017) was significant, indicating evidence of publication bias.

CONCLUSION

The findings reveal a pooled median recovery time of 4.05 weeks, with considerable heterogeneity. Although these figures provide valuable insights, the presence of publication bias was evidenced by the asymmetric funnel plot and significant Egger's test. Efforts to address publication bias are essential to improve future meta- the reliability of the surveys has increased.

REGISTRATION

The protocol for this systematic review was pre-registered on the International Prospective Register of Systematic Reviews (Registration Number: CRD42023270497).

Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Obstetric fistula is a serious and debilitating problem resulting from tissue necrosis on the reproductive and urinary and/or lower gastrointestinal tract organs due to prolonged labor. Primary studies of the treatment of obstetric fistulae report significantly variable treatment outcomes following surgical repair. However, no systematic review and meta-analysis has yet estimated the pooled proportion and identified the determinants of successful obstetric fistula surgical repair.

OBJECTIVE

To estimate the proportion and identify the determinants of successful surgical repair of obstetric fistulae in low- and middle-income countries.

METHODS

The protocol was developed and registered at the International Prospective Register of Systematic Reviews (ID CRD42022323630). Searches of PubMed, Embase, CINAHL, Scopus databases, and gray literature sources were performed. All the accessed studies were selected with Covidence, and the quality of the studies was examined. Finally, the data were extracted using Excel and analyzed with R software.

RESULTS

This review included 79 studies out of 9337 following the screening process. The analysis reveals that 77.85% (95%CI: 75.14%; 80.56%) of surgical repairs in low and middle-income countries are successful. Women who attain primary education and above, are married, and have alive neonatal outcomes are more likely to have successful repair outcomes. In contrast, women with female genital mutilation, primiparity, a large fistula size, a fistula classification of II and above, urethral damage, vaginal scarring, a circumferential defect, multiple fistulae, prior repair and postoperative complications are less likely to have successful repair outcomes.

CONCLUSION

The proportion of successful surgical repairs of obstetric fistula in low and middle-income countries remains suboptimal. Hence, stakeholders and policymakers must design and implement policies promoting women's education. In addition, fistula care providers need to reach and manage obstetric fistula cases early before complications, like vaginal fibrosis, occur.

Successful surgical closure and continence rate of obstetric fistula in Africa: systematic review and meta-analysis

Background

A female genital fistula is an abnormal connection between a woman's reproductive tract and her urinary tract or rectum. While numerous studies have aimed to determine the success rate of obstetric fistula closure in different health settings, there remains a significant scarcity of data on closure success rates and incontinence rates for various types of fistulas at the regional and sub-regional levels. The success rate reflects the continent's healthcare setup in regard to the World Health Organization standards. Thus, this study aims to determine the success of surgical closure and the continence rate of obstetric fistula in Africa.

Methods

This systematic review and meta-analysis review includes studies conducted up to February 2023. Search engines like EMBBASE, Medline, Google, PubMed, Google Scholar, African Journals Online, and ScienceDirect databases were utilized to find articles. The Joanna Briggs Institute critical evaluation checklist was used to evaluate the quality of our review, which was conducted in accordance with PRISMA criteria. Heterogeneity was indicated by a p-value for I2 statistics of less than 0.05. Publication bias was assessed using the Egger regression asymmetry test. Data were entered into Microsoft Excel and analyzed using STATA 16.

Result

This review includes 85 studies. A total of 24 countries from East, West, Central, North, and Southern African sub-regions were included. The overall pooled estimated rate of successful obstetric fistula closure is 86.15 (95% CI: 83.88-88.42). Moreover, the pooled estimated rate of successfully closed vesico-vaginal fistulas but with ongoing or residual incontinence (wet) was revealed as 13.41% (95% CI: 11.15-15.68). The pooled estimated rate of successfully closed rectovaginal fistulas and combined VVF and RVF are 91.06% (95% CI: 86.08-96.03) and 62.21% (95% CI: 48.94-75.49), respectively.

Conclusions

The rate of successful obstetric fistula closure in Africa is 86.15, which is higher than the WHO target. However, the surgical closure rate of a combined VVF and RVF is 62.2%, which is significantly lower than the WHO target.

Effect of vaginal scarring on the recovery of surgical repair of obstetric fistula in Northern Ethiopia

OBJECTIVE

To determine the effect of vaginal scarring on the recovery from surgical repair of obstetric fistula in Northern Ethiopia from 2015 to 2020.

METHODS

A hospital-based retrospective cohort study was conducted among 224 women who had obstetric fistula repair surgery in Northern Ethiopia from March 1 to March 31, 2020. Cox proportional hazards regression model was used to determine the adjusted predictors of recovery for each main baseline predictor variable, using 95% confidence interval (CI) and P < 0.05 to declare statistical significance.

RESULTS

The overall recovery rate was 57 of 1000 women (43 of 1000 and 73 of 1000 for women with and without vaginal scar, respectively), with an overall median time to recovery from obstetric fistula repair surgery of 15 days. Vaginal scarring (adjusted hazard ratio [aHR], 1.58 [95% CI, 1.13-2.21]), age of the patient (aHR, 4.05 [95% CI, 1.56-10.5]), mode of delivery (aHR, 2.14 [95% CI, 1.31-3.49]), place of delivery (aHR, 1.91 [95% CI, 1.17-3.12]), prior repair (aHR, 1.90 [95% CI, 1.08-3.35]), and duration of catheterization (aHR, 12.91 [95% CI, 7.21-23.13]) were independent predictors of recovery.

CONCLUSIONS

In the present study, we found that women who had no vaginal scar, age older than 30 years, facility and spontaneous vaginal delivery, first attempt repair, and shorter duration of catheterization had a shorter recover time.

Survival Modeling on the Determinants of Time to Recovery from Obstetric Fistula: The Case of Mekelle Hamlin Fistula Center, Ethiopia

BACKGROUND

An obstetric fistula is an abnormal opening between the vagina, rectum, and/or bladder. Obstetric fistula has a devastating impact on women's physical, social, and psychological health. Despite the numerous health consequences in developing countries, including Ethiopia, there have been few studies on the determinants of time to recovery from obstetric fistula. Therefore, this study is aimed at addressing the gap.

METHODS

A retrospective cohort study was employed to include 328 randomly selected records of women admitted for obstetric fistula treatment at Mekelle Hamlin Fistula Center from January 2015 to 2020. Data collected from the medical records was coded and entered into SPSS software version 20 and exported to STATA 10 and R statistical software for data cleaning and data analysis. The Kaplan-Meier and log-rank tests were computed to explore the data. The log-logistic inverse Gaussian shared frailty model was employed using a 95% CI, and variables with a p value < 0.05 were declared as determinants of recovery time.

RESULTS

Of 328 fistula patients, 293 (89.33%) were physically cured. The Kaplan-Meier result showed that the overall mean and median survival time of time to recovery from obstetric fistula patients at Mekelle Hamlin Fistula Center is 42 and 33 days, respectively. In a log-logistic inverse Gaussian shared frailty model analysis, extensive fistula size (AHR : 1.282; 95% CI = 1.175-1.388), secondary and above education level (AHR : 0.830; 95% CI = 0.693-0.967), rural residence (AHR : 1.357; 95% CI = 1.236-1.479), and physiotherapy use (AHR : 0.801, 95% CI = 0662-0.940, 95% CI = 1.175-1.388) were statistically significant predictors of recovery from obstetrics fistula.

CONCLUSION

Rural place of residence, home delivery, and large and extensive size of the fistula prolong the timing of healing from the obstetric fistula. However, having tall height, physiotherapy treatment, secondary and above-educated women, and RVF type of fistula has a short time of healing for obstetric fistula in Mekelle Hamlin Fistula Center. Therefore, we recommend that health professionals promote institutional delivery and physiotherapy, shorten the duration of catheterization, and manage urine incontinence. In addition, we recommend that the regional health bureau promotes female education and pregnancy after 18 years. The survival probability of patients with obstetric fistulas is better predicted by the log-logistic inverse Gaussian shared frailty model. Therefore, it would be good for future researchers to take this model into account.

Awareness of obstetric fistula and its associated factors among reproductive-age women in Ethiopia: a multilevel analysis of Ethiopian Demographic and Health Survey data: a cross-sectional study

OBJECTIVE

This study aimed to determine the magnitude and associated factors of obstetric fistula (OF) awareness among reproductive-age women in Ethiopia.

METHODS

This community-based cross-sectional study was conducted among 15 683 reproductive-aged women in Ethiopia. Following the presentation of a case vignette, women's OF awareness was measured by asking if they had ever heard of OF. A multilevel multivariable logistic regression analysis was employed. A 95% CI and p<0.05 were used to declare statistical significance.

RESULT

The magnitude of women's awareness of OF was 38% (95% CI 0.37 to 0.39). Individual level variables including being in the age group of 20-25 (adjusted OR, AOR 1.17; 95% CI 1.02 to 1.35), 26-30 (AOR 1.50; 95% CI 1.27 to 1.76) and >30 (AOR 1.76; 95% CI 1.50 to 2.07), being Muslim (AOR 0.83; 95% CI 0.73 to 0.94), having primary (AOR 1.70; 95% CI 1.53 to 1.89), secondary (AOR 3.43; 95% CI 2.95 to 3.99) and tertiary education (AOR 5.88; 95% CI 4.66 to 7.42), history of pregnancy termination (AOR 1.31; 95% CI 1.13 to 1.51), media exposure (AOR 1.33; 95% CI 1.2 to 1.49), internet use (AOR 2.25; 95% CI 1.84 to 2.75), medium (AOR 1.17; 95% CI 1.02 to 1.34) and rich house hold wealth (AOR 1.50; 95% CI 1.31 to 1.72) and community level factors including high community media exposure (AOR 1.30; 95% CI 1.05 to 1.61), high community antenatal care rate (AOR 1.66; 95% CI 1.37 to 2.02) and low health facility distance problem (AOR 1.49; 95% CI 1.23 to 1.81) were significantly associated with women's awareness of OF.

CONCLUSIONS AND RECOMMENDATIONS

The magnitude of women's awareness of OF was very low in Ethiopia. Awareness of OF was influenced by sociodemographic, economic, obstetric and community-related factors. Thus, tailored public health education is required at the national level to enhance women's awareness of OF.

Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India

BACKGROUND

The study was conducted to estimate the prevalence and risk factors of obstetric fistula in the rural area of the south eastern community of India and the training of community health workers for its prevention.

METHODS

A population-based cross-sectional analytical study was conducted in the south eastern rural community of India. A total of 3939 women were included in the study and Probability proportional to size sampling was used in the study. Frequency distribution and logistic regression were computed to analyse the data using STATA version 11.2.

RESULTS

Out of 3939 participants interviewed, 23.7% women reported obstetric fistula symptoms whereas after clinical diagnosis and speculum examination the obstetric morbidity pattern was: Obstetric fistula 0.3%, stress urinary incontinence 20.0%, pelvic inflammatory diseases 1.2%, uterine prolapse 1.4% and urinary tract infection 3.8%. The awareness level of the rural women regarding the obstetric fistula was assessed by a structured knowledge questionnaire and found to be very poor, hence community based fistula training was implemented among community health workers as a health system based strategy for its prevention. Obstetric fistula found to be more prevalent among women of poor educational level, low socioeconomic status, less no of antenatal visits, delay in accessing the emergency obstetric care and prolonged labour (p ≤ 0.05).

CONCLUSION

Finding of the study indicated that the prevalence and risk of developing obstetric fistula was associated with less number of antenatal visits, prolonged labour, delay in timely intervention, delay in accessing emergency obstetric care and more number of movements from home to the delivery place. Finally, our study suggests that emphasis needs to be placed on training of community health workers to facilitate early screening for identification and referral of women with obstetric fistula.