Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020).

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences, such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a 2014 population-based survey suggest that 1% of reproductive-aged women have experienced fistula-like symptoms. In collaboration with key stakeholders, Fistula Foundation launched the Fistula Treatment Network (initially known as Action on Fistula) in 2014 to increase access to timely, quality fistula treatment and comprehensive post-operative care for women with fistula in Kenya. The integrated model built linkages between the community and the health system to support women through all parts of their treatment journey and to build capacity of healthcare providers and community leaders who care for these women. Fistula Foundation and its donors provided the program's funding. Seed funding, representing about 30% of the program budget, was provided by Astellas Pharma EMEA.Over the six-year period from 2014 to 2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center, trained eleven surgeons and 424 Community Health Volunteers, conducted extensive community outreach, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months.The Fistula Treatment Network facilitated collaboration across hospital and community actors to enhance long-term outcomes for women living with fistula. This model improved awareness and reduced stigma, increased access to surgery, strengthened the fistula workforce, and facilitated post-operative follow-up and reintegration support for women. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Reasons for delay in accessing free treatment of obstetric fistula in South-East Nigeria - A qualitative study.

Obstetric fistula continues to be a menace in Nigeria and other low- and middle-income countries. The national policy for its elimination makes surgical repair free in dedicated national centres. However, the majority of the clients present late for repair. The aim of the study was to explore the reasons for this delay in seeking treatment. It was a qualitative (exploratory) study carried out at the National Obstetric Fistula Centre (NOFIC), Abakaliki, Nigeria among obstetric fistula patients who presented for treatment with a duration of leakage of over six months. A consecutive sampling technique was used for patient recruitment. Data was collected from twenty patients using in-depth interviews. Thematic analysis of the responses and recurring patterns was done, with themes illustrated using the word cloud. The mean age of the participants was 37.1 years (range = 21-75 years) while the mean duration of leakage was 64.3 months (range = 8-564 months). Reasons for delay in accessing treatment of obstetric fistula were lack of awareness of the availability of free treatment in a specialized centre, delay in referral from index health care facilities, wrong information from health care workers, failed repairs at other health facilities, secondary delay due to transportation challenges, cultural beliefs and other issues peculiar to the patients. The commonest reason for the delay in accessing treatment for obstetric fistula is a lack of awareness on the part of patients, the public, and health workers. We recommend improved campaigns, advocacy, and community mobilization.

Unsettling the fistula narrative: cultural pathology, biomedical redemption, and inequities of health access in Niger and Ethiopia.

Obstetric fistula, a maternal childbirth injury that results in chronic incontinence, affects an estimated one million women in the global south. In the course of media and donor coverage on this condition, fistula sufferers have been branded as 'child brides' who, following the onset of their incontinence, become social pariahs and eventually find physical and social redemption through surgical repair. This narrative framing pits the violence of 'culture' against the potency of biomedical salvation. Based on over two years of ethnographic research at fistula repair centres in Niger and Ethiopia, this paper challenges this narrative and argues that most women with obstetric fistula remain embedded in social relations, receive continued familial support, and, unexpectedly, experience ambiguous surgical outcomes. This paper interrogates the existing logics of the fistula narrative that have had the unintended effects of obscuring global structural inequalities and diverting attention away from systemic health access reforms.

Management of genitourinary fistula.

PURPOSE OF REVIEW: To review current literature on the management of genitourinary fistulae, specifically, the techniques for diagnosis, timing to repair, surgical approach and recent advancements in surgical technique. RECENT FINDINGS: Recent advancement in minimally invasive surgery has prompted surgeons to perform fistula repairs with laparoscopic or robotic-assisted laparoscopic techniques. Whereas there is a role for transabdominal fistula closure, the majority of fistulae are still best approached via a transvaginal route. SUMMARY: Genitourinary fistulae from obstetric trauma have received increased attention and funding to treat and prevent this devastating condition in developing countries. Despite multiple classification systems, a standardized classification that accurately identifies predictors of successful repair is lacking. In industrialized nations, genitourinary fistulae are rare and are most frequently associated with pelvic surgery, pelvic radiation, cancer or trauma. Surgical techniques to repair these fistulae have shifted from transabdominal laparotomy to minimally invasive laparoscopic procedures. Vascularized tissue flaps can play an important role in successful closure of complex fistulae. Despite advancements in surgical technology, overarching principles of fistula closure remain. The majority of fistulae can be closed through a transvaginal approach, with a tension-free, watertight, multilayer closure.

Overlapping sphincteroplasty and posterior repair.

INTRODUCTION AND HYPOTHESIS: Knowledge of how to anatomically reconstruct extensive posterior-compartment defects is variable among gynecologists. The objective of this video is to demonstrate an effective technique of overlapping sphincteroplasty and posterior repair. METHODS: In this video, a scripted storyboard was constructed that outlines the key surgical steps of a comprehensive posterior compartment repair: (1) surgical incision that permits access to posterior compartment and perineal body, (2) dissection of the rectovaginal space up to the level of the cervix, (3) plication of the rectovaginal muscularis, (4) repair of internal and external anal sphincters, and (5) reconstruction of the perineal body. Using a combination of graphic illustrations and live video footage, tips on repair are highlighted. RESULTS: The goals at the end of repair are to: (1) have improved vaginal caliber, (2) increase rectal tone along the entire posterior vaginal wall, (3) have the posterior vaginal wall at a perpendicular plane to the perineal body, (4) reform the hymenal ring, and (5) not have an overly elongated perineal body. CONCLUSION: This video provides a step-by-step guide on how to perform an overlapping sphincteroplasty and posterior repair.

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.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group.

The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.

Pubic symphysis diastasis with urinary incontinence: collaborative surgical management.

Pubic symphysis diastasis during obstetric delivery occurs rarely. Symptoms usually respond to conservative management. A nulliparous 39-year-old delivered spontaneously with an audible pop noted. Pubic symphysis diastasis of 4.6 cm was diagnosed on pelvic X-ray. She developed severe pain with ambulation and stress urinary incontinence. After neither of these symptoms improved significantly in response to conservative management, the patient underwent open reduction internal fixation with plating of her pubic symphysis, and bladder neck sling placement using autologous rectus fascia. Postoperatively she experienced urinary retention, which resolved with continuous bladder drainage for 1 week. Both her urinary incontinence and pain resolved, and she had resumed normal activities 3 months following her surgery. Pubic symphysis diastasis is a rare obstetric complication with a paucity of literature to guide its management. A coordinated multidisciplinary approach to management is necessary when multiple organ systems are involved.

Abdominal disimpaction with lower uterine segment support as a novel technique to minimize fetal and maternal morbidities during cesarean section for obstructed labor: a case series.

Cesarean section for obstructed labor remains a difficult procedure that may be associated with serious fetal and maternal injuries. In this case series, we evaluated the use of abdominal disimpaction with lower segment support as a novel technique to minimize morbidities. Eight patients who underwent cesarean section for obstructed labor were recruited. Impacted fetal head was delivered using this technique and uterine extensions, bladder injury, vaginal injury, and intraoperative bleeding were reported. Maternal and neonatal outcomes were observed postoperatively. No major morbidities were reported. Accordingly, we consider this technique as a promising step to minimize complications during cesarean section for obstructed labor.

Pelvic angiomatosis: an unusual cause of recurrent obstructed labor: a case report and review of literature.

BACKGROUND: Pelvic angiomatosis is a very rare cause of obstructive labor. MATERIALS AND METHODS: A 26-year-old P2 L2 had two cesarean sections for recurrent obstructed labor due to a large pelvic mass. Investigations after the first cesarean section suggested a benign nature of the mass for which she was advised surgical resection, but she refused due to social reasons. Tumor had pelvic and extrapelvic part extending through obturator foramen into the right thigh. Resection of the pelvic part by abdominoperineal approach led to a profusely bleeding bed which was managed by ligation of bilateral internal iliac artery. Resection of extrapelvic part was attempted but it was abandoned due to hemodynamic instability of the patient. RESULTS: Patient is asymptomatic and is having a relatively static residual extrapelvic part of pelvic tumor for last 2 years. CONCLUSION: Pelvic angiomatosis is a very rare condition but should be considered and ruled out in case of a pelvic mass of uncertain origin. MRI plays an important role in the initial diagnosis, in surgical planning and in the follow-up in order to detect recurrences. Surgical resection should be as conservative as possible, balancing the need for complete surgical extirpation with the morbidity of the procedure.

Management and maternal outcome in morbidly adherent placenta.

BACKGROUND: Morbidly adherent placenta (MAP) with its variants is one of the most feared complications causing high morbidity and mortality in obstetrics. The objective of this study was to analyse different management options and maternal outcome in diagnosed cases of morbidly adherent placenta. METHODS: Descriptive case series was carried out in Obstetrics and Gynaecology Department, Combined Military Hospital, Rawalpindi and one private hospital from Jan 2008 to Dec 2010. During this period all cases of morbidly adherent placenta diagnosed by colour flow Doppler and MRI were analysed. Operative delivery was carried out in all patients. Three different surgical managements namely total abdominal hysterectomy with non separation of placenta, subtotal hysterectomy and trial haemostasis with uterine sparing surgery were carried out on when and where required basis. The outcome like total blood loss, blood transfused, Intensive unit care, postnatal complications including febrile morbidity, hospital stay and prolonged follow ups, were recorded. RESULTS: Total 32 cases of morbidly adherent placenta diagnosed by colour Doppler ultrasound/MRI (magnetic resonance imaging) were identified. In this study the frequency of morbidly adherent placenta found to be 1/274.8 deliveries and 1/122.6 caesarean sections. Initially total caesarean hysterectomy was performed in 16 patients, while subtotal hysterectomy in 9 and Trial haemostasis with uterine sparing in 7 cases out of which two cases underwent total hysterectomy due to massive postpartum haemorrhage same day. One case in subtotal hysterectomy for placenta percreta with bladder invasion had re-laparotomy for bladder fistula, while two for severe postpartum haemorrhage. Two needed ventilator support. Maternal morbidity was greater in subtotal hysterectomy and uterine sparing group. One patient died in this study. CONCLUSION: Antenatal diagnosis of morbidly adherent placenta followed by well-planned total abdominal hysterectomy with non-separation of placenta adapting multidisciplinary approach is the best surgical option to reduce maternal morbidity/mortality.

Lidocaine-prilocaine cream versus local infiltration anesthesia in pain relief during repair of perineal trauma after vaginal delivery: a systematic review and meta-analysis.

Background: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can be either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety.Objective: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anesthesia for pain control during perineal repair after vaginal delivery.Data sources: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma.Methods of study selection: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I2) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, the fixed effect meta-analysis was used when there was no significant heterogeneity.Results: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = .13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = .42). Regarding patient satisfaction, an overall analysis of three studies showed significant results favoring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = .0005). The pooled analysis of the outcome "duration of repair" showed the significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = .001).Conclusions: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.

Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial.

OBJECTIVE: To evaluate the repair techniques of continuous and interrupted methods for episiotomy or perineal tears. DESIGN: A randomised controlled trial. SETTING: The Hospital Universitario Principe de Asturias, a state hospital belonging to the community of Madrid. SAMPLE: Four hundred forty-five women who had undergone vaginal deliveries with episiotomies or second-grade tearing of the perineum between September 2005 and July 2007. METHODS: One group was repaired with continuous, nonlocking sutures involving the vagina, perineum, and subcutaneous tissues. The other group had continuous, locking sutures of the vagina, interrupted sutures in the perineal muscles, and interrupted transcutaneous sutures. The threads used for stitching were identical in both groups. MAIN OUTCOME MEASURES: The participants were questioned regarding the sensation of pain and the use of painkillers on the second and the tenth days, and 3 months postpartum. RESULTS: When comparing the group with continuous suture to the group with interrupted sutures, the differences included less repair time (1 minute; P= 0.017) and less suture material used (relative risk [RR], 3.2, 95% CI: 2.6-4.0). The comparison of pain on the second and tenth days, and 3 months postpartum were not statistically different between the two techniques (RR, 1.08, 95% CI: 0.74-1.57; RR, 0.96, 95% CI: 0.59-1.55; and RR, 0.68, 95% CI: 0.19-2.46, respectively). CONCLUSIONS: Although we did not demonstrate that one technique was better than the other in the incidence of pain in the short or long term, we showed that episiotomy and perineal tear repairs with continuous suturing were quicker and used less suture material without an increase in complication than interrupted suturing.

Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial.

OBJECTIVE: To evaluate two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation. DESIGN: A randomised controlled trial testing a pragmatic set-up of brief training of clinicians. SETTING: Delivery ward at a Danish district hospital with approximately 1600 annual deliveries. POPULATION: Primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia or the vagina, perineal lacerations of first or second degree or mediolateral episiotomies. METHODS: The trial was set up to evaluate the effect of a brief 2-hour hands-on training in the use of ear acupuncture. All midwives (n = 36) in the department had previous experience in using acupuncture for obstetric pain relief. Pain and wound healing were evaluated using validated scores. Data collection was performed by research assistants blinded towards treatment allocation. Randomisation was computer assisted. A total of 207 women were randomised to receive ear acupuncture (105) and local anaesthetics (102), respectively. MAIN OUTCOME MEASURES: The primary outcome was pain during surgical repair. Secondary outcomes were wound healing at 24-48 hours and 14 days postpartum, participant satisfaction, revision of wound or dyspareunia reported 6 months postpartum. RESULTS: Pain during surgical repair was more frequently reported by participants allocated to ear acupuncture compared with participants receiving local anaesthetics (89 versus 54%, P < 0.01). Pain intensity during surgical repair was also reported higher (Visual Analogue Scale score 3.5 versus 1.5, P < 0.01). The ear acupuncture group received more additional pain relief during repair (53 versus 19%, P < 0.01). No difference was observed in wound healing at 24-48 hours or 14 days postpartum. Revision of wounds was rare, and no difference occurred in this trial. Comparable proportions of participants reported dyspareunia at 6 months. Patient satisfaction with the allocated pain-relief method was lower in the ear acupuncture group (69 versus 91%, P < 0.01) and fewer women would recommend the method to a friend (74 versus 91%, P < 0.01). CONCLUSIONS: Ear acupuncture as used in this trial was less effective for pain relief compared with a local anaesthetic. No difference was observed in wound healing, need for revision of wound or dyspareunia. Patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.

[Obstetric hysterectomy in a patient with uterine myoma of uterus duplex--case report]. / Histerektomia poloznicza u pacjentki z miesniakiem macicy podwójnej--opis przypadku.

A case of a 43-year-old multipara in 36th week of pregnancy with a duplicate uterus and uterine myoma with 15 centimeters diameter has been presented in the article. The aim of the study was to present her obstetric history, course of pregnancy and delivery mode.

The natural caesarean: a woman-centred technique.

Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a 'natural' approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide.

Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial.

OBJECTIVE: To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. DESIGN: Randomised controlled trial. SETTING: University hospital in Sweden. POPULATION: A total of 165 women diagnosed with a third- to fourth-degree perineal tear. METHODS: The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. MAIN OUTCOME MEASURES: Anal incontinence measured by the validated Pescatori incontinence score. RESULTS: A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. CONCLUSION: Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.