Impact of a double catastrophe, war and COVID-19, on health service utilization of a tertiary care hospital in Tigray: an interrupted time-series study

BACKGROUND

In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.

METHODS

An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.

RESULTS

There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].

CONCLUSIONS

The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

"Menstruation is a Fearful Thing": A Qualitative Exploration of Menstrual Experiences and Sources of Information About Menstruation Among Adolescent Schoolgirls

Background

Although menstruation is a biological phenomenon, it is still subjected to secrecy, shame, and negativity. Schoolgirls lack access to appropriate sources of information about menstruation. Little is known about the content of the information provided to schoolgirls concerning menstruation in northern Ethiopia. This study explored schoolgirls' experiences and the content of information they receive concerning menstrual hygiene management in Tigray.

Methods

A qualitative design was implemented. Focus group discussions and in-depth interviews were conducted using the local language among 79 schoolgirls who had experienced menarche. Data were audio-recorded, transcribed, translated, and imported into ATLAS.ti-7.5.18 computer software for analysis. Data were coded and analyzed using a thematic analysis.

Results

Five themes have emerged from the analysis: 1) there is an indistinct and haphazard source of menstrual information; 2) menstruation is perceived as "a natural gift"; 3) menstruation is also considered fearful and embarrassing; 4) negative community perceptions of menstruation lead to menstrual restrictions, and 5) lack of privacy for dealing with menstrual issues as well as the scarcity of menstrual hygiene management materials is an on going problem. Schoolgirls have indistinct and haphazard sources of information concerning menstrual hygiene management, obtaining it from teachers, mothers, sisters, and friends, but the information they receive is shrouded in secrecy and often is factually incorrect. Menstruation is commonly linked to notions of sexuality, shame, and the approach of marriageability.

Conclusion

The information that schoolgirls in rural Tigray receive about menstrual hygiene management is inaccurate, insufficient, and encumbered with social taboos. Thus, schoolgirls do not have an adequate understanding of the physiology of menstruation and do not receive adequate emotional support at menarche, leaving them with feelings of embarrassment and anxiety. There should be efforts to implement programs that change community perceptions about menstruation.

Infectious Complications of Abortion

This article reviews the infectious complications of abortion (both spontaneous and induced) and the management of this condition. The key points are: (1) Making abortion illegal does not reduce its incidence or prevalence; rather, it only makes abortions unsafe, increasing the likelihood of infectious complications. (2) Timely recognition of developing sepsis in the pregnant patient is critical. This requires constant vigilance and a high index of suspicion. (3) Rapid intravenous administration of broad-spectrum antibiotics targeted to the likely intrauterine source of infection as soon as sepsis is diagnosed is critical to prevent severe sepsis, septic shock, and multisystem organ failure. (4) The mainstay of treatment is prompt evacuation of any residual products of conception from within the uterine cavity under broad-spectrum antibiotic cover targeting the likely intrauterine source of infection. (5) Prompt engagement of specialists in both critical care and obstetrics-gynecology is necessary to optimize outcomes in patients with septic abortion.

Characterizing persistent urinary incontinence after successful fistula closure: the Uganda experience

BACKGROUND

Obstetric fistula is a devastating childbirth injury. Despite successful closure of the fistula, 16% to 55% of women suffer from persistent urinary incontinence after surgery.

OBJECTIVE

This study assessed the type and severity of persistent incontinence after successful fistula closure and its impact on the quality of life of Ugandan women post-fistula treatment.

STUDY DESIGN

This cross-sectional study enrolled women with a history of obstetric fistula repair who continued to have persistent urinary incontinence (cases, N=36) and women without incontinence (controls, N=52) after successful fistula closure. Data were collected in central and eastern Uganda between 2017 and 2019. All the participants completed a semistructured questionnaire. Cases underwent a clinical evaluation and a 2-hour pad test and completed a series of incontinence questionnaires, including two novel tools designed to assess the severity of incontinence in low-literacy populations.

RESULTS

Cases were more likely to have acquired a fistula during their first delivery (63% vs 37%, P=.02), were younger when they developed a fistula (20.3±5.8 vs 24.8±7.5 years old, P=.003), and were more likely to have had >2 fistula surgeries (67% vs 2%, P≤.001). Cases reported a much higher rate of planned home birth for their index pregnancy compared to controls (44% vs 11%), though only 14% of cases and 12% of controls actually delivered at home. Cases reported higher rates of pain with intercourse (36% vs 18%, P=.05), but recent sexual activity status (intercourse within the previous six months) was not significantly different between the groups (47% vs 62%, P=.18). Among cases, 67% reported stress incontinence, 47% reported urgency incontinence, and 47% reported mixed incontinence. The cough stress test was successfully done with 92% of the cases, and of these, almost all (97%) had a positive cough stress test. More than half (53%) rated their incontinence as "very severe," which was consistent with objective findings. The 24-hour voiding diary indicated both high urinary frequency (average 14) and very frequent leakage episodes (average 20). Two-hour pad-tests indicated that 86% of cases had >4 g change in pad weight within 2 hours. Women with more severe incontinence reported a more negative impact on their quality of life. The mean score of the International Consultation on Incontinence Questionnaire-Quality of Life was 62.77±12.76 (range, 28-76, median=67), with a higher score indicating a greater impact on the quality of life. There was also a high mental health burden, with both cases and controls reporting high rates of suicidal ideation at any point since developing fistula (36% vs 31%, P=.67).

CONCLUSION

Women with obstetric fistulas continue to suffer from severe persistent urinary incontinence even after successful fistula closure. Both stress and urgency incontinence are highly prevalent in this population. Worsening severity of incontinence is associated with a greater negative impact on the quality of life.

The Sims position and the Sims vaginal speculum, re-examined

INTRODUCTION AND HYPOTHESIS

American gynecologist J. Marion Sims (1813-1883) is known for developing the first consistently successful operation for the repair of vesico-vaginal fistula, for inventing the Sims vaginal speculum, and for popularizing the left lateral decubitus position for gynecological examination and treatment.

METHODS AND RESULTS

This article reviews the history of the Sims vaginal speculum, charting its evolution from a bent pewter spoon to the lever speculum and finally to its now-familiar form as the two-bladed Sims speculum.

CONCLUSION

The article also reviews the origins of the Sims position, correcting popular misconceptions concerning both the position and the speculum and advocating for greater familiarity with the use of both of these valuable tools by practicing clinicians.

Girls' attendance at school after a menstrual hygiene intervention in northern Ethiopia

OBJECTIVE

To evaluate the effect on school attendance of a menstrual hygiene intervention that distributes educational booklets to school children and menstrual hygiene kits to schoolgirls in northern Ethiopia.

METHODS

Attendance was tracked for 8839 students in grades 7-12 during the 2015-2016 academic year when the intervention was implemented. Negative binomial regression was used to test whether student sex predicted post-intervention school absences when controlling for grade-level and pre-intervention absences. Similar attendance data were analyzed for 3569 students in grades 7, 9, and 11 for the 2014-2015 academic year as a historical comparison.

RESULTS

Over 12 211 educational booklets were distributed to students and 5991 menstrual hygiene kits were distributed to schoolgirls. After the intervention, girls had 24% fewer school absences than boys. Sex was not a predictor of absences during a similar time-period in the prior school year.

CONCLUSION

This is one of the first large studies to show a positive relationship between a menstrual hygiene intervention and girls' school attendance. These positive results suggest such interventions should be expanded to other schools in northern Ethiopia. Future research should explore whether similar interventions can also decrease the rate at which girls drop out of school around menarche.

Henry van Roonhuyse and the first repair of a vesico-vaginal fistula (~1676)

INTRODUCTION AND HYPOTHESIS

Obstetric vesico-vaginal fistula is a traumatic complication of prolonged obstructed labor in which pressure necrosis from the impacted fetal head destroys portions of the vesico-vaginal septum, resulting in continuous and uncontrollable urinary incontinence. Ancient evidence suggests that fistula cases have probably been occurring since the development of rotational delivery mechanics in anatomically modern humans hundreds of thousands of years ago. It is likely that attempts to repair such injuries also have a long history. The early history of vesico-vaginal fistula surgery was investigated to determine the earliest credible report of successful cure of this condition.

METHODS

Historical review of vesico-vaginal fistula surgery was undertaken, focusing on the work of Henry Van Roonhuyse, a seventeenth century Dutch surgeon living in Amsterdam.

RESULTS

Van Roonhuyse's clinical treatise entitled Medico-Chirurgical Observations (1676) was reviewed in detail and is described in this article. His technique for vesico-vaginal fistula repair included six essential steps that are still recognizable today: (1) use of the lithotomy position; (2) exposure of the fistula with a speculum; (3) sharp paring of the fistula edge prior to attempted closure; (4) careful approximation of the denuded edges of the fistula; (5) dressing of the wound with absorbent vaginal packing; (6) immobilization of the patient in bed until the repair has healed.

CONCLUSIONS

Henry Van Roonhuyse is the most credible candidate presently known for having successfully repaired a vesico-vaginal fistula in the pre-modern era.

Reintegration needs of young women following genitourinary fistula surgery in Uganda

INTRODUCTION AND HYPOTHESIS

Genitourinary fistulas (usually arising following prolonged obstructed labor) are particularly devastating for women in low-income counties. Surgical repair is often difficult and delayed. While much attention has been devoted to technical surgical issues, the challenges of returning to normal personal, family, and community life after surgical treatment have received less scrutiny from researchers. We surveyed young Ugandan women recovering from genitourinary fistula surgery to assess their social reintegration needs following surgery.

METHODS

A cross-sectional survey of 61 young women aged 14-24 years was carried out 6 months postoperatively. Interviews were carried out in local languages using a standardized, interviewer-administered, semistructured questionnaire. Data were entered using EpiData and analyzed using SPSS.

RESULTS

Ongoing reintegration needs fell into interrelated medical, economic, and psychosocial domains. Although >90% of fistulas were closed successfully, more than half of women had medical comorbidities requiring ongoing treatment. Physical limitations, such as foot drop and pelvic muscle dysfunction impacted their ability to work and resume their marital relationships. Anxieties about living arrangements, income, physical strength, future fertility, spouse/partner fidelity and support, and possible economic exploitation were common. Sexual dysfunction after surgery-including dyspareunia, loss of libido, fear of intercourse, and anxieties about the outcome of future pregnancies-negatively impacted women's relationships and self-esteem.

CONCLUSIONS

Young women recovering from genitourinary fistula surgery require individualized assessment of their social reintegration needs. Postoperative social reintegration services must be strengthened to do this effectively.

Tending the 'monthly flower:' a qualitative study of menstrual beliefs in Tigray, Ethiopia

Background

Menstruation is a universal aspect of human female reproductive life. Management of menstrual flow presents hygiene challenges to girls and women in low-income countries, especially when they first start their periods. As part of a project to improve menstrual hygiene management in the Tigray Region of Ethiopia, we explored the local understanding of menstruation through focus-group discussions and individual interviews.

Methods

A detailed ethnographic survey of menstrual beliefs was carried out through 40 focus group discussions, 64 in-depth key informant interviews, and 16 individual case histories in the Tigray Region of northern Ethiopia. A total of 240 individuals participated in six types of focus groups (pre-menarchal girls, menstruating adolescents, married women of reproductive age, post-menopausal women, adolescent males, and married men). In-depth interviews were also carried out with 80 individuals, including Orthodox Christian priests, imams from the Muslim community, principals of primary and secondary schools, teachers and nurses, as well as menstruating schoolgirls and women. Audio data were transcribed and translated, then broken down into discrete codes using Atlas Ti software (version 7.5.4, Atlas.ti Scientific Software Development Mnbh, Berlin) and further grouped into related families and sub-families based on their content. The results were then synthesized to produce a cohesive narrative concerning menstruation in Tigray.

Results

Recurrent themes identified by participants included descriptions of the biology of menstruation (which were sometimes fanciful); the general unpreparedness of girls for menarche; cultural restrictions imposed by menstruation on females (particularly the stigma of ritual uncleanliness in both Christian and Muslim religious traditions); the prevalence and challenges of unmet menstrual hygiene needs at schools (including lack of access to sanitary pads and the absence of acceptable toilet/washing facilities); and the stigma and shame associated with menstrual hygiene accidents in public.

Conclusions

Changes in the educational system in northern Ethiopia are required to improve student understanding of the biology of menstruation, to foster gender equity, to overcome the barriers to school attendance presented by poor menstrual hygiene management, and to create a society that is more understanding and more accepting of menstruation.

Gurya cutting and female genital fistulas in Niger: ten cases

INTRODUCTION AND HYPOTHESIS

The objective was to determine the contribution of female genital cutting to genital fistula formation in Niger from the case records of a specialist fistula hospital.

METHODS

A retrospective review was undertaken of the records of 360 patients seen at the Danja Fistula Center, Danja, Niger, between March 2014 and September 2016. Pertinent clinical and socio-demographic data were abstracted from the cases identified.

RESULTS

A total of 10 fistulas resulting from gurya cutting was obtained: 9 cases of urethral loss and 1 rectovaginal fistula. In none of the cases was genital cutting performed for obstructed labor or as part of ritual coming-of-age ceremonies, but all cutting procedures were considered "therapeutic" within the local cultural context as treatment for dyspareunia, lack of interest in or unwillingness to engage in sexual intercourse, or female behavior that was deemed to be culturally inappropriate by the male spouse, parents, or in-laws. Clinical cure (fistula closed and the patient continent) was obtained in all 10 cases, although 3 women required more than one operation.

CONCLUSIONS

Gurya cutting is an uncommon, but preventable, cause of genital fistulas in Niger. The socio-cultural context which gives rise to gurya cutting is explored in some detail.

Obstetric fistula in Niger: 6-month postoperative follow-up of 384 patients from the Danja Fistula Center

INTRODUCTION AND HYPOTHESIS

The impoverished West African country of Niger has high rates of obstetric fistula. We report a 6-month postoperative follow-up of 384 patients from the Danja Fistula Center and assess factors associated with operative success or failure.

METHODS

The medical records of 384 women who had completed a 6-month follow-up after fistula surgery were reviewed. Cases were categorized as "easy," "of intermediate complexity," or "difficult" based on a preoperative points system. Data were analyzed using simple chi-squared statistics and logistic regression.

RESULTS

The patients were predominantly of Hausa ethnicity (73%), married young (average 15.9 years), had teenage first pregnancies (average first delivery 16.9 years), and experienced prolonged labor (average 2.3 days) with poor outcomes (89% stillbirth rate). The average parity was four. Patients commonly developed their fistula during their first delivery (43.5%), but over half sustained a fistula during a subsequent delivery (56.5%). Prior fistula surgery elsewhere (average 1.75 operations) was common. The overall surgical success ("closed and dry") was 54%. When the 134 primary operations were analyzed separately, the overall success rate was 80%. Increasing success was seen with decreasing surgical difficulty: 92% success for "easy" cases, 68% for "intermediate" cases, and 57% success for "difficult" cases. Success decreased with increasing numbers of previous attempts at surgical repair.

CONCLUSIONS

These data provide further evidence that clinical outcomes are better when primary fistula repair is performed by expert surgeons in specialist centers with the support of trained fistula nurses.

A case-control study of the risk factors for obstetric fistula in Tigray, Ethiopia

INTRODUCTION AND HYPOTHESIS

We tested the null hypothesis that there were no differences between patients with obstetric fistula and parous controls without fistula.

METHODS

A unmatched case-control study was carried out comparing 75 women with a history of obstetric fistula with 150 parous controls with no history of fistula. Height and weight were measured for each participant, along with basic socio-demographic and obstetric information. Descriptive statistics were calculated and differences between the groups were analyzed using Student's t test, Mann-Whitney U test where appropriate, and Chi-squared or Fisher's exact test, along with backward stepwise logistic regression analyses to detect predictors of obstetric fistula. Associations with a p value <0.05 were considered significant.

RESULTS

Patients with fistulas married earlier and delivered their first pregnancies earlier than controls. They had significantly less education, a higher prevalence of divorce/separation, and lived in more impoverished circumstances than controls. Fistula patients had worse reproductive histories, with greater numbers of stillbirths/abortions and higher rates of assisted vaginal delivery and cesarean section. The final logistic regression model found four significant risk factors for developing an obstetric fistula: age at marriage (OR 1.23), history of assisted vaginal delivery (OR 3.44), lack of adequate antenatal care (OR 4.43), and a labor lasting longer than 1 day (OR 14.84).

CONCLUSIONS

Our data indicate that obstetric fistula results from the lack of access to effective obstetrical services when labor is prolonged. Rural poverty and lack of adequate transportation infrastructure are probably important co-factors in inhibiting access to needed care.

A community-based study of menstrual beliefs in Tigray, Ethiopia

OBJECTIVE

To investigate knowledge and beliefs about menstruation in the Tigray Region of Ethiopia.

METHODS

Between May 5 and May 25, 2015, a cross-sectional survey using semi-structured questionnaires was undertaken in 10 subdistricts (5 urban, 5 rural) in the Tigray Region of northern Ethiopia by trained data collectors (native speakers of the local languages). Individuals in randomly selected households who were aged 10years or older and who were willing to participate were asked various questions regarding the nature and management of menstruation. Interviews were recorded, and handwritten field notes were taken during the interview process. Data were compiled, transcribed, translated into English, categorized, and analyzed thematically.

RESULTS

Overall, 428 household members (349 female, 79 male) were interviewed. Reproductive anatomy and biology of menstrual regulation were poorly understood by the respondents. The belief that menstruating girls should not attend school was voiced by 17 (21.5%) male and 37 (10.6%) female respondents. Satisfactory management of menstrual hygiene was acknowledged to be a problem, and many respondents complained about the high cost of commercially produced, disposable menstrual pads.

CONCLUSION

Improved education on menstruation and better access to low-cost, reusable menstrual hygiene supplies would be worthwhile in the Tigray Region of Ethiopia.

Uterine rupture in Mekelle, northern Ethiopia, between 2009 and 2013

OBJECTIVE

To review cases of uterine rupture at a center in northern Ethiopia.

METHODS

In a retrospective chart review, data were assessed for cases of symptomatic uterine rupture treated at Ayder Referral Hospital in Mekelle between January 1, 2009, and December 31, 2013.

RESULTS

In the 5-year study period, there were 5185 deliveries and 47 cases of uterine rupture, giving a rate of one case per 110 deliveries. All patients underwent laparotomy for suspected uterine rupture. Mean parity was 3.6 (range 0-8). The most common predisposing factors were cephalopelvic disproportion (35 [74%] patients), previous cesarean delivery (5 [11%)], and fetal malpresentation (4 [9%]). Hysterectomy was undertaken for 35 (74%) patients; the other 12 (26%) were treated conservatively by simple repair of the rupture. There were 44 (95%) stillbirths and 1 (2%) maternal death.

CONCLUSION

Uterine rupture remains an important clinical problem in northern Ethiopia. Changes in the cultural preference for home delivery, better transport and referral systems, and improved obstetric training and hospital management of laboring women are needed.

Validation of a culturally compliant voiding platform for urodynamics in African vesicovaginal fistula patients

INTRODUCTION AND HYPOTHESIS

Most patients in regions where obstetric vesicovaginal fistulas (VVF) are endemic void using a squatting posture. Additionally, many patients continue to have lower urinary tract symptoms (LUTS) following fistula closure. We designed and validated a prototype platform that allows urodynamic studies to be performed in a squatting position and conducted a pilot study to assess uroflowmetry in this patient population.

METHODS

Sixteen patients with persistent LUTS following fistula surgery were recruited. Posture measurements were taken in each patient's natural voiding posture on the ground and were then repeated using the platform. Nine patients with persistent urinary incontinence also underwent uroflowmetry. The data were compared with normal values in different nomograms. Paired t tests were used to determine significant differences in posture. One-way ANOVA was used to determine statistical significance between flow rate values.

RESULTS

Only the heel-to-heel distance (H-H) measure of posture was significantly increased on the platform compared with on the ground. The mean corrected Qmax was 0.89 ± 0.46. Flow rate values were significantly lower than mean normal flow rates obtained from the nomograms. In general, the patients' uroflowmetry patterns were similar to those indicative of impaired detrusor function.

CONCLUSION

A platform for conducting urodynamic studies in a squatting posture was successfully validated in the VVF patient population. The finding of increased H-H on the platform is expected, since the patient must accommodate a large funnel for urine collection. The pilot data suggest that patients with persistent urinary incontinence following VVF closure may also have significant voiding dysfunction.

Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries

BACKGROUND

An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor.

DISCUSSION

Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women's agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care.

SUMMARY

Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

Ethical concerns regarding operations by volunteer surgeons on vulnerable patient groups: the case of women with obstetric fistulas

By their very nature, overseas medical missions (and even domestic medical charities such as "free clinics") are designed to serve "vulnerable populations." If these groups were capable of protecting their own interests, they would not need the help of medical volunteers: their medical needs would be met through existing government health programs or by utilizing their own resources. Medical volunteerism thus seems like an unfettered good: a charitable activity provided by well-meaning doctors and nurses who want to give of their time, skills, and resources to help those who would not otherwise be able to take care of their medical needs. In this article, I argue that if medical volunteerism is to be "good," however, it must always meet certain basic ethical requirements. These requirements may be (and perhaps often are) overlooked in the rush to organize and carry out short-term medical missions. I illustrate my point with special reference to short-term medical missions designed to provide surgical repair of obstetric vesico-vaginal fistula, a condition in which the tissues that normally separate the bladder from the vagina are destroyed by obstetric trauma, leading to continuous and unremitting incontinence in the affected woman.

Ethical issues in vesico-vaginal fistula care and research

The plight of women in poor nonindustrialized countries who have incurred catastrophic childbirth injuries, such as vesico-vaginal and recto-vaginal fistulas, from prolonged obstructed labor is receiving increased attention from the world medical community. While the good intentions that have prompted this greater concern are not in doubt, intentions by themselves are insufficient guarantees of ethical conduct in programs developed to repair these injuries. Clinical proposals put forward to deal with the problem of fistula must undergo critical analysis to insure that basic ethical requirements are met. This article emphasizes the vulnerability to exploitation of women with obstetric fistulas and reviews the basic principles of medical ethics relevant to fistula care.

Where should obstetric vesico-vaginal fistulas be repaired: at the district general hospital or a specialized fistula center?

Expanded surgical capacities are required to treat obstetric fistulas. Achieving a balance between relative ease of access to services and use of the appropriate clinical setting is difficult. This article asks, "Are obstetric fistulas best repaired locally, at the district hospital where more women would have greater access, or is it necessary to provide these services at a tertiary referral or fistula center, where specialized surgical procedures can be conducted? Each possibility has advantages and disadvantages. The author concludes that 3 critical factors are necessary to provide safe and effective fistula repair services: adequate, long-term funding to cover the costs of all aspects of the care; the presence of a surgeon who is a "fistula champion"; and adequate operating theatre time and supplies. Without external funding, these prerequisites are almost impossible to meet at rural district hospitals.

The High Cost of Free Lunch

Most physicians deny their professional integrity can be "bought" by something as trivial as a cup of coffee or a free lunch. In this paper, we review the social science literature arguing that "gifting" physicians in this way is, in fact, a highly successful method of boosting drug sales. Unlike ordinary consumer goods, the sale of prescription drugs does not take place directly between the producer and the consumer; rather, prescription drug sales are mediated by the physician who writes the script for the medication. Pharmaceutical sales practices are geared toward influencing physician drug recognition so that, when prescriptions are written, their drug is the first one that comes to mind. Even small gifts produce in their recipients a disproportionately powerful willingness to reciprocate in some manner. The simple act of providing food has been shown to make any message more palatable and more likely to be favorably received. We argue that physician prescribing habits should be based upon careful consideration of what medication is really in the patient's best clinical interests, not on who most recently provided the doctor with a free lunch.

Did J. Marion Sims deliberately addict his first fistula patients to opium?

American surgeon J. Marion Sims (1813-83) is regarded by many modern authors as a controversial figure because he carried out a series of experimental surgeries on enslaved African American women between 1846 and 1849 in an attempt to cure them of vesicovaginal fistulas, which they had all developed as a result of prolonged obstructed labor. He operated on one woman, Anarcha Westcott, thirty times before he successfully closed her fistula. Sims performed these fistula repair operations without benefit of anesthesia but gave these women substantial doses of opium afterwards. Several modern writers have alleged that Sims did this in order to addict them to the drug and thereby to enhance his control over them. This article examines the controversy surrounding Sims' use of postoperative opium in these enslaved surgical patients. The evidence suggests that although these women were probably tolerant to the doses of opium that he used, there is no evidence that he deliberately tried to addict them to this drug. Sims' use of postoperative opium appears to have been well supported by the therapeutic practices of his day, and the regimen that he used was enthusiastically supported by many contemporary surgeons.

What motivates women to take part in clinical and basic science endometriosis research?

BACKGROUND

The objective of this study was to identify factors motivating women to take part in endometriosis research and to determine if these factors differ for women participating in clinical versus basic science studies.

METHODS

A consecutive series of 24 women volunteering for participation in endometriosis-related research were asked to indicate, in their own words, why they chose to volunteer. In addition, the women were asked to rate, on a scale of 0 to 10, sixteen potentially motivating factors. The information was gathered in the form of an anonymous self-administered questionnaire.

RESULTS

Strong motivating factors (mean score > 8) included potential benefit to other women's health, improvement to one's own condition, and participation in scientific advancement. Weak motivating factors (mean score < 3) included financial compensation, making one's doctor happy, and use of 'natural' products. No difference was detected between clinical and basic science study participants.

CONCLUSION

This study is the first study to specifically investigate the factors that motivate women to take part in endometriosis research. Understanding why women choose to take part in such research is important to the integrity of the informed consent process. The factors most strongly motivating women to participate in endometriosis research related to improving personal or public health; the weakest, to financial compensation and pleasing the doctor.

Vesicovaginal Fistula Formation After Cervical Cerclage Mimicking Premature Rupture of Membranes

BACKGROUND

Women with a history of pregnancy loss in the second trimester are often diagnosed with cervical insufficiency and are treated with cervical cerclage. We present an unusual complication of this procedure that mimicked preterm rupture of membranes.

CASE

A 38-year-old woman with a history of cervical conization, loss of a triplet pregnancy at 22 weeks, and one early spontaneous abortion underwent cervical cerclage placement during her third pregnancy. She developed an intermittent vesicovaginal fistula 2 weeks after the procedure that mimicked preterm premature rupture of membranes. Only after the urine loss became heavy and continuous 10 weeks later was the diagnosis of vesicovaginal fistula made.

CONCLUSION

Obstetricians should recognize that cerclage placement may result in unusual urinary tract injury.

Obstetric vesicovaginal fistula as an international public-health problem

Vesicovaginal fistula is a devastating injury in which an abnormal opening forms between a woman's bladder and vagina, resulting in urinary incontinence. This condition is rare in developed countries, but in developing countries it is a common complication of childbirth resulting from prolonged obstructed labour. Estimates suggest that at least 3 million women in poor countries have unrepaired vesicovaginal fistulas, and that 30 000-130 000 new cases develop each year in Africa alone. The general public and the world medical community remain largely unaware of this problem. In this article I review the pathophysiology of vesicovaginal fistula in obstructed labour and describe the effect of this condition on the lives of women in developing countries. Policy recommendations to combat this problem include enhancing public awareness, raising the priority of women's reproductive health for developing countries and aid agencies, expanding access to emergency obstetric services, and creation of fistula repair centres.

Humanitarian ventures or 'fistula tourism?': the ethical perils of pelvic surgery in the developing world

The vesico-vaginal fistula from prolonged obstructed labor has become a rarity in the industrialized West but still continues to afflict millions of women in impoverished Third World countries. As awareness of this problem has grown more widespread, increasing numbers of American and European surgeons are volunteering to go on short-term medical mission trips to perform fistula repair operations in African and Asian countries. Although motivated by genuine humanitarian concerns, such projects may serve to promote 'fistula tourism' rather than significant improvements in the medical infrastructure of the countries where these problems exist. This article raises practical and ethical questions that ought to be asked about 'fistula trips' of this kind, and suggests strategies to help insure that unintended harm does not result from such projects. The importance of accurate data collection, thoughtful study design, critical ethical oversight, logistical and financial support systems, and the importance of nurturing local capacity are stressed. The most critical elements in the development of successful programs for treating obstetric vesico-vaginal fistulas are a commitment to developing holistic approaches that meet the multifaceted needs of the fistula victim and identifying and supporting a 'fistula champion' who can provide passionate advocacy for these women at the local level to sustain the momentum necessary to make long-term success a reality for such programs.

Refusals by pharmacists to dispense emergency contraception: a critique

Over the past several months, numerous instances have been reported in the United States media of pharmacists refusing to fill prescriptions written for emergency postcoital contraceptives. These pharmacists have asserted a "professional right of conscience" not to participate in what they interpret as an immoral act. In this commentary, we examine this assertion and conclude that it is not justifiable, for the following reasons: 1) postcoital contraception does not interfere with an implanted pregnancy and, therefore, does not cause an abortion; 2) because pharmacists do not control the therapeutic decision to prescribe medication but only exercise supervisory control over its dispensation, they do not possess the "professional right" to refuse to fill a legitimate prescription; 3) even if one were to grant pharmacists the "professional right" not to dispense prescriptions based on their own personal values and opinions, pharmacists "at the counter" lack the fundamental prerequisites necessary for making clinically sound ethical decisions, that is, they do not have access to the patient's complete medical background or the patient's own ethical preferences, have not discussed relevant quality-of-life issues with the patient, and do not understand the context in which the patient's clinical problem is occurring. We conclude that a policy that allows pharmacists to dispense or not dispense medications to patients on the basis of their personal values and opinions is inimical to the public welfare and should not be permitted.

The medical ethics of Dr J Marion Sims: a fresh look at the historical record

Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between 1845 and 1849. Numerous modern authors have attacked Sims's medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. This article reviews these allegations using primary historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims's modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. Although enslaved African American women certainly represented a "vulnerable population" in the 19th century American South, the evidence suggests that Sims's original patients were willing participants in his surgical attempts to cure their affliction-a condition for which no other viable therapy existed at that time.

Regarding zygotes as persons: implications for public policy

In this paper, we examine the notion put forward by certain groups (largely as a consequence of their opposition to elective abortion) that the immediate post-fertilization cellular entity - the zygote - is a person and should be given full moral status. Because the zygote has none of the inherent characteristics necessary to be regarded as a person in the traditional philosophical sense (e.g., John Locke or Immanuel Kant), some advocates of this position attempt to advance their case with arguments based on the genetic potential of the human zygote to develop into a person. We argue that this position represents a flawed use of human genetics and ignores the extraordinarily inefficient and wasteful nature of human reproduction. We then explore the public policy consequences that would follow from granting the zygote full moral status. We conclude that the logical consequences of granting the zygote full moral status would require a revolutionary restructuring of many basic social institutions, especially the health care system. The social, political, and economic changes that would be required if the zygote is enshrined as a person in law constitute a convincing reductio ad absurdum that demonstrates the danger in taking this position seriously.

Dr. George Hayward (1791–1863): a forgotten pioneer of reconstructive pelvic surgery

American surgeon George Hayward (1798-1863) has become lost to the historical memory of practicing urologists and urogynecologists, yet he deserves to be remembered for his important contributions to the advancement of pelvic surgery. In addition to being an observant commentator on the surgical practice of his day, he performed the first major operation carried out under ether anesthesia and he was the originator of the "flap-splitting" operation for the repair of vesico-vaginal fistula commonly, but erroneously, attributed to Lawson Tait. This article reviews George Hayward's career and professional accomplishments with the hope of restoring his well-deserved prominence as a pioneer of reconstructive pelvic surgery.

The obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria

OBJECTIVE

The purpose of this study was to describe the characteristics of women with obstetric vesicovaginal fistulas at a hospital in north central Nigeria.

STUDY DESIGN

A retrospective record review was conducted of all women who were seen with vesicovaginal fistulas at Evangel Hospital in Jos, Plateau State, Nigeria, between January 1992 and June 1999.

RESULTS

A total of 932 fistula cases were identified, of which 899 cases (96.5%) were associated temporally with labor and delivery. The "typical patient" was small and short (44 kg and <150 cm); had been married early (15.5 years) but was now divorced or separated; was uneducated, poor, and from a rural area; had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus.

CONCLUSION

Obstetric vesicovaginal fistula is extremely common in north central Nigeria. A complex interaction that involves multiple biologic and socioeconomic factors appears to predispose young women to this devastating childbirth injury.

Ethical issues arising from the performance of pelvic examinations by medical students on anesthetized patients

Anesthetized women are frequently examined by medical students before gynecologic surgery is performed. We argue that the key element in determining the appropriateness of such examinations is whether there is benefit to the patient as a result. Because every member of a surgical team needs a clear understanding of the nature, goals, and technical steps to be used in carrying out any operation, it is appropriate for a medical student to examine those patients in whose surgery he or she is going to participate as an active member of the surgical team. However, if pelvic examinations are carried out "solely for educational purposes" by students who are not actual members of the operating team, such actions are not appropriate unless specific permission has been obtained from the patient by the surgeon in charge of the case.

The treatment of urinary incontinence in 1814

A selection from a little-known medical treatise of the early 19th century is presented which describes the condition of urinary stress incontinence and its treatment by means of pessaries, mechanical occlusive devices and electrical stimulation therapy. The author provides a foreshadowing of therapies that would come into more common use 150 years later.