Obstetric fistula policy in Nigeria: a critical discourse analysis.

BACKGROUND: In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing. METHODS: A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice. RESULTS: The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development." CONCLUSION: This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

Barriers and facilitators to preventive interventions for the development of obstetric fistulas among women in sub-Saharan Africa: a systematic review.

BACKGROUND: Obstetric fistula is a debilitating childbearing injury that results from poorly managed obstructed labour, leading to the development of holes between the vagina and bladder and/or rectum. Effects of this injury are long-lasting, as women become incontinent and are often marginalised from their communities. Despite continuous occurrence of this injury in lower-income countries, it is preventable, as evidenced in high-income countries. This systematic review aims to identify and understand barriers and facilitators to interventions aimed at the prevention of obstetric fistulas in sub-Saharan African women. METHODS: Electronic databases and grey literature were searched. We included studies written in English that discussed interventions to prevent obstetric fistulas implemented in sub-Saharan Africa, and their associated barriers and facilitators. Quality of the studies was assessed, and data including: country of implementation, preventive interventions, and barriers and facilitators to the interventions were extracted. They were then categorised based on the Three Phase Delay Model. RESULTS: Our search yielded 537 studies, of which 18 were included from sub-Saharan countries including Ethiopia, Nigeria, and Zambia. The most noted barrier to prevention addressed the first phase of delay: the decision to seek care, particularly lack of awareness of the dangers of unsupervised labours. The most noted facilitator addressed the decision to seek care and the quality of care received at a facility, through partnerships between health facilities and governments, and other organisations that provided both financial and resource support. CONCLUSION: Despite being categorised by the three phases of the delay model, barriers and facilitators were found to play a role in multiple phases. The topic of obstetric fistula needs to be researched more extensively, particularly the effectiveness of preventive interventions.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder.

Standard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome. This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula. In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

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.

Ureterovaginal fistula after insertion of a McDonald suture: Case report and review of published reports.

Complications associated with cerclage that are commonly described in the existing published reports include injuries to the cervix or bladder, premature rupture of membranes, chorioamnionitis and bleeding. We report an unusual complication of a ureterovaginal fistula formation after the insertion of a McDonald suture.

Vaginal repair of ureterovaginal fistula may be suitable for selected cases.

Ureterovaginal fistula (UVF) is an uncommon but devastating complication of gynecologic surgery. Management includes ureteral stenting for 6-8 weeks. For stent failure, ureteroneocystostomy (UNC) through an open, laparoscopic, or robotic abdominal approach is the classic alternative. Originally pioneered for repair of vesicovaginal fistulas (VVF), the use of the vaginal approach in UVF is scarcely reported in the literature. We report the successful repair of UVF performed exclusively through the vaginal approach in two women after robotic hysterectomy. In select clinical scenarios, this approach may be applied, as it provides a minimally invasive option for managing UVF after failure of ureteral stenting.

Why give birth in health facility? Users' and providers' accounts of poor quality of birth care in Tanzania.

BACKGROUND: In Tanzania, half of all pregnant women access a health facility for delivery. The proportion receiving skilled care at birth is even lower. In order to reduce maternal mortality and morbidity, the government has set out to increase health facility deliveries by skilled care. The aim of this study was to describe the weaknesses in the provision of acceptable and adequate quality care through the accounts of women who have suffered obstetric fistula, nurse-midwives at both BEmOC and CEmOC health facilities and local community members. METHODS: Semi-structured interviews involving 16 women affected by obstetric fistula and five nurse-midwives at maternity wards at both BEmOC and CEmOC health facilities, and Focus Group Discussions with husbands and community members were conducted between October 2008 and February 2010 at Comprehensive Community Based Rehabilitation in Tanzania and Temeke hospitals in Dar es Salaam, and Mpwapwa district in Dodoma region. RESULTS: Health care users and health providers experienced poor quality caring and working environments in the health facilities. Women in labour lacked support, experienced neglect, as well as physical and verbal abuse. Nurse-midwives lacked supportive supervision, supplies and also seemed to lack motivation. CONCLUSIONS: There was a consensus among women who have suffered serious birth injuries and nurse midwives staffing both BEmOC and CEmOC maternity wards that the quality of care offered to women in birth was inadequate. While the birth accounts of women pointed to failure of care, the nurses described a situation of disempowerment. The bad birth care experiences of women undermine the reputation of the health care system, lower community expectations of facility birth, and sustain high rates of home deliveries. The only way to increase the rate of skilled attendance at birth in the current Tanzanian context is to make facility birth a safer alternative than home birth. The findings from this study indicate that there is a long way to go.

The challenge of pouch-vaginal fistulas: a systematic review.

Pouch-vaginal fistulae affect 6% of women after ileal pouch-anal anastomosis. Such fistulae significantly impact on the patient's quality of life and present a technical challenge to the surgeon. Although several operative approaches have been described, results from a number of case series are variable and associated with significant rates of failure. As a result, there remains a lack of consensus in the literature with regard to the management of this troublesome problem. The purpose of this article is to review the results of surgical intervention and to provide a clinical algorithm that gives a structured approach to the management of pouch-vaginal fistulae.

Fallopian tube prolapse presenting as a peritoneovaginal fistula.

INTRODUCTION: Peritoneovaginal fistula is an extremely rare cause of persistent vaginal leakage following a hysterectomy. Likewise, fallopian tube prolapse is an uncommon but known complication of hysterectomy. Fallopian tube prolapse resulting in peritoneal leakage has yet to be reported in the literature. CLINICAL CASE: A 27-year-old female presented with a two year history of continuous leakage per vagina. The leakage started shortly after an abdominal hysterectomy. Examination noted clear fluid emanating from a vaginal lesion located at the level of the vaginal cuff. An extensive workup ruled out vesicovaginal and ureterovaginal fistula. Surgical exploration noted that the lesion was a prolapsed fallopian tube, which was resected vaginally. DISCUSSION: This is the first reported case of peritoneovaginal fistula associated with a prolapsed fallopian tube. CONCLUSION: Vaginal resection of the fallopian tube remnant and reclosure of the vaginal cuff results in cure of the leakage.

Guidelines for the evaluation and treatment of recurrent urinary incontinence following pelvic floor surgery.

OBJECTIVE: To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery. OPTIONS: Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions. OUTCOMES: These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms. EVIDENCE: Published opinions of experts, and evidence from clinical trials where available. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). RECOMMENDATIONS: 1. Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management. (II-3B) 2. Conservative management options should be used as the first line of therapy. (III-C) 3. Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-2B) 4. Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling). (II-3B) 5. In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape. (I-B) 6. Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization. (III-C) 7. Overactive bladder should be treated using medical and/or behavioural therapy. (II-2B) 8. Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used. (III-C) 9. Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis. (III-C) 10. Fistulae should be managed by an experienced physician. (III-C).

Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls.

The study aims to evaluate the efficacy of transpubic access using a pedicle flap from the labia minora for urethral reconstruction in young girls with urethrovaginal fistula secondary to pelvic fracture. Between January 2011 and January 2016, 4 cases of traumatic urethrovaginal fistula in young girls were treated using a pedicle flap from the labia minora. The mean follow-up was 27 months. All patients voided well and achieved normal urinary control. One patient had recurrent urethrovaginal fistula. The remaining 3 patients required no additional treatment. A labia minora skin flap for urethral reconstruction in young girls with urethrovaginal fistula secondary to pelvic fractures is a reliable technique.

Eliminating obstetric fistula: progress in partnerships.

Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003.

[Ureterovaginal fistula after caesarean: Diagnosis and management in a resource-constrained hospital in Togo]. / La fistule urétérovaginale après césariennes : diagnostic et traitement dans un hôpital à ressources limitées au Togo.

The purpose of this study is to describe a simple, non-expensive, accessible and effective technique of ureterovaginal fistula diagnosis, and to assess the results of surgical management in a resource-constrained hospital. During a campaign of obstetric fistulas repair, we diagnosed ureterovaginal fistulas by vaginal exam with the blue methylene test associated to abdominal ultrasonography, two simple and non-expensive explorations which permitted to identify ureterovaginal fistula and to do differential diagnosis with vesicovaginal fistula. The management was surgery, by ureterovesical reimplantation. Four ureterovaginal fistulas have been diagnosed in 32 women presented with obstetrical fistula. The mean age of those fistulas was 4.85 years; it was located on the left ureter in three cases, on the right in one case. The ureteral lesion was consecutive to a caesarean section in all patients and sited on the pelvic segment of ureter. In three patients, diagnosis was performed by the negativity of the blue test and unilateral dilation of ureter and kidney while the discovery was done during the treatment of vesicovaginal and rectovaginal fistulas associated in the last patient. After effects of surgery were simple, characterized by disappearance of urine leakage and dilation of ureter kidney. In resources-constrained context, techniques such as blue test and ultrasonography are enough to perform diagnosis of ureterovaginal fistula. Ureterovesical reimplantation is an effective therapeutic method for diagnosing ureterovaginal fistula.

[Ureterovaginal fistulae]. / Fistole ureterovaginali.

Ureterovaginal fistulae are pathological communications between the ureter and the vagina; it commonly occur as a rare but serious sequela of unrecognized distal ureteral injuries during pelvic operations. Patients may present symptoms as leakage of urine from the vagina, flank pain and fever; in some cases it could be possible also the loss of renal function. The purpose of this study is to review the articles from 1991 to 2014 to evaluate the most correct diagnostic procedures and endourological and surgical techniques used in the management of ureterovaginal fistula. Nowadays computered tomography and retrograde pielography are the most commonly diagnostic modalities used to identify fistulous tract and to describe its anatomical position. The major of ureterovaginal fistulae can be successfully managed by conservative methods. Modern endourological treatment will result in resolution of a ureterovaginal fistula if retrograde or anterograde passage of a suitable internal stent is feasible. When stenting failed or in complicated cases, ureteral reimplantation is necessary. Ureteroneocystostomy, psoas hitch and Boari flap are three different possible surgical techniques used to realized an ureteral reimplantation. Both open and mini invasive (laparoscopy and robot assisted) surgical approach have proved successful.

The use of the Rectus abdominis muscle to suspend the bladder in the treatment of uretero-vaginal fistulae.

This study evaluates a new and simpler technique for suspending the bladder during uretero-neocystostomy, using the posterior surface of the Rectus abdominis muscle rather than an vesico-psoas hitch. The technique was employed in six consecutive patients who presented with ureteric injuries following hysterectomy or caesarean section. Each patient was fully evaluated preoperatively, and the results of surgery evaluated after three months in five out of six women. All the patients were Zulu women who had sustained injuries to the lower five centimetres of a ureter at hysterectomy or caesarean section. This study was conducted in the obstetric and gynaecological unit of Eshowe Hospital, a 460 bed sub-regional hospital in northern KwaZulu Natal. The technique described in this paper proved to be easy to perform. Every patient was continent following surgery. All those who returned for follow up had normal drainage of the affected ureter. We conclude that this is a useful alternative to vesico-psoas hitch for suspending the bladder during uretero-neocystostomy.

Laparoscopic treatment of post-hysterectomy colovaginal fistula in diverticular disease. Case report.

Colonic diverticular disease is a benign condition typical of the Western world, but it is not rare for even the 1st episode of diverticulitis to carry potentially fatal complications. The evolution of a peridiverticular process generally poses problems for medical treatment and exposes patients to repeated episodes of diverticulitis, making surgical treatment necessary in approximately 30% of symptomatic patients. One of the most worrying complications of diverticulosis is internal fistula. The most common types of fistula are colovesical and colovaginal, against which the uterus can act as an important protective factor. The symptoms and the clinical and instrumental management of patients with diverticular fistulas are much the same as for patients with episodes of acute diverticulitis. Staging of the disease (according to Hinchey) should be done promptly so that the necessary action can be taken prior to surgery, implementing total parenteral nutrition (TPN), nasogastric aspiration and broad-spectrum antibiotic treatment. The best surgical approach to adopt in patients with diverticulitis complicated by fistula is still not entirely clear, though the 3-step strategy is currently tending to be abandoned due to its high morbidity and mortality rates. There is a widespread conviction, however, that the 2-step strategy (Hartmann, or resection with protective stomy) and the 1-step alternative should be reserved, respectively, for patients in Hinchey stages 3, 4 and 1, 2 with a situation of attenuated local inflammation. The 1-step approach seems to be safe and effective. This report describes a case of colovaginal fistula in a patient with colonic diverticulosis who had recently undergone hysterectomy, but who, unlike such cases in the past, was treated in a single step using a laparoscopic technique.

[Peritoneovaginal fistula after vaginal hysterectomy]. / Fistule péritonéo-vaginale après hystérectomie vaginale.

Peritoneovaginal fistula is a rare complication of hysterectomy. A patient with pelvic pain and vaginal discharge due to peritoneovaginal fistula, 6 months after hysterectomy, is presented. The laparoscopic approach with an intravaginal blue-test, provided the evidence of the peritoneovaginal fistula. The transvaginal approach offered a surgical closure of the fistula and a resolution of the symptoms. In addition, we have reviewed the literature, the symptoms, the differential diagnosis and the management of this problem.

[Laparoscopically created stomas]. / Estomas por laparoscopia.

PURPOSE: The aim of this paper is to present the results obtained in five cases with a stoma created by the laparoscopic approach. PATIENTS AND METHOD: Analysis of five patients who required a stoma as treatment for their diseases or as a complementary management of another medical problem from March 1999 to May 1999. There were three women and two men. Mean age was 43 years (range 20-59 years). Two women had a rectovaginal fistula secondary to radiation proctitis, another woman presented an infected sacral wound, one man suffered a sphincteric lesion that required sphincteroplasty, and the other man had Fournier's gangrene. Surgical technique included the use of two ports, one at the umbilicus for the camera and the other at the site previously chosen for the stoma. RESULTS: Mean surgical time was 30 min (range 20-40 min), transoperative bleeding was meaningless; all stomas began to function during the first 24 h after the procedure. One patient began oral intake on the first day, three patients on the second day, and one patient was intubated in the intensive care unit and for this reason was unable to eat. All stomas achieved the objective sought and there were no complications related to the procedure. CONCLUSIONS: Stoma creation by the laparoscopic approach may offer advantages over the open-surgery technique.