Epidemiological, anatomoclinical, and therapeutic profile of obstetric fistula in the Democratic Republic of the Congo: About 1267 patients.

OBJECTIVE: Our aim is to describe the epidemiological, anatomoclinical and therapeutic profile of obstetric fistula (OF) in the Democratic Republic of the Congo (DRC). METHODOLOGY: This was a descriptive retrospective study that collected 1416 obstetric fistulas in 1267 patients in seven provinces of the DRC, treated between January 2017 and December 2022. The variables studied were epidemiological, anatomoclinical and therapeutic. RESULTS: The mean age of patients at the time of surgical repair was 33.2 years (range: 15 and 77 years) and 32.8% of patients were aged between 20 and 29 years. The mean age of the fistula at repair was 10 years (range: 3.5 months and 56 years). At the time of fistula, 61.7% of patients had delivered vaginally and 28.7% by caesarean section and 8.2% of patients had a haemostasis hysterectomy. Labour lasted at least 3 days in 47.3% of these patients for the fistula birth. Deliveries took place either at home (27.4%) or in a health facility (72.6%); 83.6% of newborns resulting from these births had died. Taken as a whole, urogenital fistulas are more common than genito-digestive fistulas. Urethro-vaginal (26.2%) and vesico-uterine (24.7%) anatomoclinical entities were predominant among urogenital fistulas. A total of 1416 fistulas were surgically repaired in 1267 patients. These repairs were successful for 1226 (86.6%) fistulas. The main surgical route used was transvaginal (68.8%). CONCLUSION: In the DRC, obstetric fistula is common in young adult women. It often results from vaginal delivery, after prolonged labour. Fistula births often result in the death of newborns. Uro-genital obstetric fistulas are the most frequent with predominance of urethro-vaginal and vesico-uterine anatomoclinical entities. Fistulas remain untreated for a long time. Mostly done transvaginally, surgical repair gives a good result.

Novel use of the rectus abdominus muscle flap for vaginal reconstruction in complex obstetric fistula repair: A case series.

OBJECTIVE: Globally, obstetric fistula is a tragic outcome following obstructed labour. Failure of complex repair and post-operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominus flap at the time of fistula repair. DESIGN: Retrospective case series. SETTING: Malawi, Fistula Care Centre. METHODS: Patients were followed for 3 months after discharge to determine continence and healing. RESULTS: Five of six patients were continent at 3 months and one was lost to follow-up by dry at a one month post-operative phone call. There were no major complications. CONCLUSIONS: The rectus abdominus flap may be a useful adjunct to repair of complex obstetric fistula.

Development and Pilot Test of a Multi-Component Intervention to Support Women's Recovery from Female Genital Fistula.

INTRODUCTION AND HYPOTHESIS: We evaluated a pilot multi-component reintegration intervention to improve women's physical and psychosocial quality of life after genital fistula surgery. METHODS: Twelve women undergoing fistula repair at Mulago Specialized Women and Neonatal Hospital (Kampala, Uganda) anticipated in a 2-week multi-component intervention including health education, psychosocial therapy, physiotherapy, and economic investment. We assessed feasibility through recruitment, retention, and adherence, acceptability through intervention satisfaction, and preliminary effectiveness through reintegration, mental health, physical health, and economic status. We collected quantitative data at enrollment, 6 weeks, 3 months, and 6 months. We conducted in-depth interviews with six participants. Quantitative data are presented descriptively, and qualitative data analyzed thematically. RESULTS: Participants had a median age of 34.5 years (25.5-38.0), 50% were married/partnered, 42% were separated, 50$ had completed less than primary education, and 67% were unemployed. Mean number of sessions received was 12 for health education (range 5-15), 8 for counseling (range 8-9), and 6 for physiotherapy (range 4-8). Feasibility was demonstrated by study acceptance among all those eligible (100%); comfort with study measures, data collection frequency and approach; and procedural fidelity. Acceptability was high; all participants reported being very satisfied with the intervention and each of the components. Participant narratives echoed quantitative findings and contributed nuanced perspectives to understanding approach and content. CONCLUSIONS: Our results suggest that the intervention and associated research were both feasible and acceptable, and suggested certain modifications to the intervention protocol to reduce participant burden. Further research to determine the effectiveness of the intervention above and beyond surgery alone with regard to the health and well-being of women with fistulas is warranted.

Journey for a cure: Illness narratives of obstetric fistula survivors in North Central Nigeria.

Obstetric fistula is a life transforming event resulting in embodied biographical disruption. Survivors suffer myriad long-term physical and emotional consequences. This paper is an account of a narrative inquiry, conducted with 15 fistula survivors in North-central, Nigeria, who described how their identities had been transformed by their condition. A narrative therapeutic approach, using Frank's 'chaos, restitution and quest' typology, was used to map their recovery narratives. 'Chaos', described by Frank as the opposite of restitution, dominated, with women losing hope of recovery. Women's shift towards 'restitution' began with treatment, but inadequate health-care access often delayed this process. In their quest narratives, women's life and identify changes enabled them to derive meaning from their experience of obstetric fistula within the context of their own lives. The findings highlight socio-structural factors raising the risk of obstetric fistula, which in turn causes biographical disruption and hampers sufferers' treatment and recovery. Rehabilitation should include income-generating skills to bring succour to survivors, particularly those whose incontinence persists after repairs.

Childbearing after treatment for obstetric fistula: perspectives from survivors in Malawi.

Women who suffer from an obstetric fistula endure more than just physical pain. Their ability or desire to bear children may also be affected due to physical damage to their reproductive organs. In addition, they may suffer from emotional trauma which is likely to affect their decision to have children. The aim of this study therefore was to explore in more detail the perspectives of obstetric fistula survivors about childbearing after treatment for their condition. This qualitative study was conducted at a non-governmental organisation in the Central Region of Malawi. Data was collected using in-depth interviews from 18 women who had suffered from an obstetric fistula. The study revealed that many women either had no further desire for children or were unable to bear children. Fear of dying and resulting pain from the fistula surgery deter women from wanting further pregnancies. However, there was still strong emphasis placed on childbearing, especially for the younger women who desired children as a means of maintaining their marriages. The risk of further pregnancies and mitigation strategies for reducing obstetric fistulas, should be fully communicated to women. Those who become infertile as a result of obstetric fistula may also require appropriate counselling.

Health seeking behaviour associated with obstetric fistula care in Guinea: An analysis of the 2018 Demographic and Health survey.

This study aimed to analyze factors associated with obstetric fistula care-seeking behavior in Guinea, based on data from the 2018 Demographic and Health Survey. Women aged 15-49 years who reported having obstetric fistula constituted the study population, statistical analysis was using Stata 16.0 software. Multivariate logistic regression was used to identify the factors associated with fistula care-seeking behavior. Among women with obstetric fistula, 78.9% sought care; 21.1% of those who sought care underwent repair. Factors associated with care-seeking behavior were being divorced (AOR =8.08; 95% CI:1.56-41.84), having a job (AOR =3.23; 95% CI: 1.11-9.44), being a member of a poor household (AOR =6.49; 95% CI:1.21-34.82) and whose fistula had appeared 6 days or more after the occurrence of the causal circumstance (AOR =3.63 95% CI: 1.28-10.28). This study suggests that the foundations on which fistula prevention and treatment programs are built should be reviewed, taking into account the factors highlighted by this study.

Cette étude visait à analyser les facteurs associés aux comportements de recherche de soins pour la fistule obstétricale en Guinée, partant des données de l'enquête démographique et de santé de 2018. Les femmes âgées de 15 à 49 ans ayant déclaré avoir une fistule obstétricale ont constitué la population d'étude, l'analyse statistique a été réalisée à l'aide du logiciel Stata 16.0. La régression logistique multivariée a été utilisée pour identifier les facteurs associés aux comportements de recherche de soins pour la fistule. Parmi les femmes atteintes de fistule obstétricale, 78,9 % ont eu recours à des soins ; 21,1 % de celles qui ont recouru ont subi une réparation. Les facteurs associés aux comportements de recherche de soins étaient le fait d'être divorcée (ORA=8.08 ; 95% IC :1.56-41.84), d'avoir un travail (ORA =3.23 ; 95% IC : 1.11-9.44), d'être membre d'un ménage pauvre (ORA =6.49 ; 95% IC :1.21-34.82) et dont la fistule était apparue 6 jours ou plus après la survenue de la circonstance causale (ORA =3.63 95% IC : 1.28-10.28). Cette étude suggère de revoir les bases sur lesquelles les programmes de prévention et de traitement de la fistule sont construits, tout en prenant en compte les facteurs mis en évidence par cette étude.

Predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center, Northern Ethiopia.

BACKGROUND: Obstetric fistula is a medical condition that involves an opening between vagina and bladder or vagina and rectum. From 2010 to 2013, on average, around 2000 women each year had surgery for obstetric fistula in Ethiopia. The success and failure rate of obstetric fistula repair varies from center to center and is determined by many factors. Thus, this study aimed to assess the predictors and outcomes of surgical repair of obstetric fistula at Mekelle Hamlin Fistula Center (MHFC). METHODS: A retrospective reviewed medical records of 328 patients with obstetric fistula were carried out at MHFC. Multivariable logistics regression analysis was conducted, a significant association was declared when the p-value was less than 0.05, and the strength of the association was determined by computing the odds ratio at 95% CI. The analysis was done using SPSS version 24. RESULTS: Obstetrics fistula patients who had formal education were 13% more likely to be successfully repaired than obstetrics fistula patients who had no formal education. Additionally, obstetrics fistula patients who had a live birth were 32.325 (exp (ß) = 32.325) times more likely to have had a successful repair than those who had a stillbirth. CONCLUSION: Fistula closure was achieved in 89.3% of cases. The success rate for VVF (vesico-vaginal fistula) and RVF (recto-vaginal fistula) surgical repair was 86.9% and 100% respectively, which is higher than the WHO target. Body mass index between 18.5-24.9 kg/m2, formal education, antibiotic use, live birth, large fistula size, and home and cesarean delivery were predictors of successful closure of obstetric fistula.

Predictors of outcomes in patients with repeat surgery for obstetric fistula: a retrospective review.

INTRODUCTION AND HYPOTHESIS: Predictors of surgical outcomes in patients with an obstetric fistula who have been operated before should be identified in order to guide surgical strategy and optimize counseling of the patient. METHODS: This retrospective study is aimed at identifying predictors of outcomes for repeat surgery in 346 patients who had been operated on before for an obstetrics fistula at the Fistula Care Center (FCC) in Lilongwe, Malawi. Repeat cases were only undertaken by advanced and expert surgeons. The primary outcome was successful anatomical closure, based on a negative postoperative dye test. The secondary outcomes involved urinary continence, based on a patient-reported questionnaire and an objective 1-h pad weight test. Logistic regression models were used to test the predictors for statistical significance. RESULTS: Successful fistula closure was achieved in 288 (83%) patients and continence was achieved in 185 (64%) patients after the first repeat attempt at the FCC. Lack of urethral involvement (Goh classification: proximity to the urethra) was shown to be a good predictor of the outcomes: fistula closure and subjective and objective continence. CONCLUSIONS: Absence of urethral involvement is an independent predictor for successful outcomes in repeat surgery for obstetric fistulas. Even in the hands of an expert surgeon, the risk of another failure in achieving anatomical closure or subjective or objective continence is between 4 and 5 times higher than when the urethra is not involved.

Etiology and factors associated with urogenital fistula among women who have undergone cesarean section: a cross-sectional study.

BACKGROUND: The prevalence and impact of fistulas are more common in developing countries with limited access to emergency obstetric care. As a result, women in these settings often experience adverse psychosocial factors. The purpose of this study was to describe the characteristics of Congolese women who developed urogenital fistula following Cesarean sections (CS) to determine the characteristics associated with two etiologies: (1) prolonged obstructed labor; and (2) a complication of CS following obstructed labor. METHODS: We performed a cross-sectional study on abstracted data from all patients with urogenital fistula following CS who received care during a surgical campaign in a remote area of the Democratic Republic of the Congo (DRC). Descriptive analyses characterized patients with fistula related to obstructed labor versus CS. Univariate and multivariate logistic regression models identified factors associated with obstetric fistula after cesarean delivery following obstructed labor. Variables were included in the logistic regression models based upon biological plausibility. RESULTS: Among 125 patients, urogenital fistula etiology was attributed to obstructed labor in 77 (62%) and complications following CS in 48 (38%). Women with a fistula, attributed to obstructed labor, developed the fistula at a younger age (p = .04) and had a lower parity (p = .02). Attempted delivery before arriving at the hospital was associated with an increased risk of obstetric fistula after cesarean delivery following obstructed labor (p < .01). CONCLUSION: CS are commonly performed on women who arrive at the hospital following prolonged obstructed labor and fetal demise, and account for almost 40% of urogenital fistula. Obstetric providers should assess maternal status upon arrival to prevent unnecessary CS and identify women at risk of developing a fistula.

The psycho-social impact of obstetric fistula and available support for women residing in Nigeria: a systematic review.

BACKGROUND: Obstetric fistula continues to affect the social and mental wellbeing of women living in Nigeria giving rise to poor maternal health outcome. While the World Health Organisation (WHO) has recommended the introduction of psycho-social interventions in the management of obstetric fistula women, psycho-social support for women living with obstetric fistula in Nigeria, are limited. This systematic review aimed to synthesise the psycho-social impact of obstetric fistula on women living in Nigeria as well as the available psycho-social support for these affected women. METHODS: Following a keyword strategy, Medline, CINAHL, Google scholar, ScienceDirect, Cochrane library, PsychINFO, AMED, British Nursing database, Pubmed central, TRIP database, UK Pubmed central, socINDEX, Annual reviews, ISI Web of Science, Academic search complete, Credo reference, Sage premier and Scopus databases were searched alongside hand searching of articles. The inclusion criteria were set as articles published between 2000 and 2020, on the psychosocial consequences of obstetric fistula in Nigeria. The Critical Appraisal Skills Program (CASP) tool was used to appraise the quality of the included studies. The data was extracted and then analysed using narrative synthesis. RESULTS: 620 relevant citations were identified, and 8 studies were included. Women with obstetric fistula, living in Nigeria were found to be ostracised, abandoned by families and friends, stigmatised and discriminated against, which led to depression, loneliness, loss of self-esteem, self-worth and identity. Psycho-social interventions for women who experienced obstetric fistula are not widely available. CONCLUSION: There is a need for the introduction of more rehabilitation and reintegration programs across the country. The psychosocial effect of obstetric fistula is significant and should be considered when developing interventions. Further, more research is needed to evaluate the sustainability of psychosocial interventions in Nigeria.

Women's experiences of care after stillbirth and obstetric fistula: A phenomenological study in Kenya.

BACKGROUND: Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low- and middle-income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula. AIM: To explore the lived experiences of women following stillbirth and fistula. METHODS: Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach. RESULTS: Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'. CONCLUSION: The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow-up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences. PATIENT OR PUBLIC CONTRIBUTION: A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant-facing materials and confirmation of findings.

Factors associated with obstetric fistula among reproductive age women in Ethiopia: a community based case control study.

BACKGROUND: Obstetric fistula is a major public health concerns in Ethiopia. It is the most devastating cause of all maternal morbidities. METHOD: Data from the 2016 Ethiopian Demographic Health Survey (EDHS) was analyzed. A community-based unmatched case control study was conducted. Seventy cases and 210 non cases were selected using random number table. Data were analyzed by using STATA statistical software version 14. Multivariable logistic regression model was applied to determine the factors associated with fistula. RESULTS: The majority of fistula cases were from rural residences. The multivariable statistical model showed that rural residence (Adjusted OR (AOR) = 5, 95% CI 4.26, 7.52), age at first marriage (AOR = 3.3, 95% CI 2.83, 4.60), poorest wealth index (AOR = 3.3, 95% CI 2.24, 5.01) and decision making for contraceptive use by husband alone (AOR = 1.3, 95% CI 1.124, 1.67) were factors significantly associated with obstetric fistula. CONCLUSION: Age at first marriage, rural residence, poorest wealth index and decision making for contraceptive use by husband alone were significantly associated factors for obstetric fistula. Intervening on these factors will reduce the magnitude of obstetrics fistula. In this context there is in-need to improve on avoiding early marriage through awareness creation to the community and developing legal framework by the policymakers. Furthermore, information about the joint decision making to use contraceptives should be disseminated though mass-media and interpersonal channels.

Globally, 2­3 million women are affected by obstetric fistula. It is common in developing nations, mainly in sub-Saharan Africa and Southeast Asia where suitable, timely care and treatment are hard to find. This devastating condition adversely affects women's physical and mental health. There is little research conducted in relation to the experiences of women living with leakage of urine and/or feces in Ethiopia. Therefore, this study provides a better understanding on obstetric fistula and its associated factors.The present study used the recent Ethiopia Demographic Health Survey (EDHS) 2016, to determine the associated factors of obstetric fistula among reproductive age group women (15­49 years) in Ethiopia.In this study rural residence, poorest wealth index, age at first marriage less than 18 years, and decision making for contraceptive use by husband alone were the associated factors of obstetric fistula. Intervening on these factors will reduce the magnitude of obstetrics fistula. In this context there is in-need to improve on avoiding early marriage through awareness creation to the community and developing legal framework by the policymakers. Furthermore, information about the joint decision making to use contraceptives should be disseminated though mass-media and interpersonal channels. Comprehensive intervention strategies should be customized at different government hierarchies to combat and reduce obstetric fistula.

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.

Female urinary incontinence in sub-Saharan Africa.

Urinary incontinence (UI) is highly prevalent amongst women around the world. In this review article we explore UI, its consequences and treatment in sub-Saharan Africa, providing specific examples from Uganda and Malawi. In sub-Saharan Africa the prevalence of UI is difficult to assess because of the wide variation in reporting resulting from patients hiding their condition due to the associated stigma in many communities. Whilst much of the literature from low- or low-middle-income countries focuses on UI from pelvic floor fistula, recent evidence demonstrates that non-fistulous stress, urgency and mixed UI are highly prevalent in sub-Saharan Africa. Incontinence secondary to vesico-vaginal fistula can be related to obstetric causes, mainly obstructed labour. The risk factors for non-fistulous incontinence are similar to those identified in high-income countries, including high parity, vaginal and assisted delivery, gestational age, constipation, obesity, chronic cough and ageing. Urinary incontinence has significant social and emotional consequences, with a high proportion of women in African countries reporting relationship problems, depression and suicidal ideation. There is poor understanding of the perceived aetiology of incontinence in sub-Saharan Africa, which may, in part, act as a barrier for women to seek medical advice. Innovative solutions have been found to manage the large number of obstetric fistulas that are prevalent across Africa, but a lack of capacity in specialists trained to treat women with UI means that more doctors, medical officers and better resource prioritization will be required to help the, as yet unquantified, number of women with non-fistulous leakage. Better patient peri-natal education may reduce the incidence of fistula still further, especially if the stigma felt by women with incontinence is overcome and they are encouraged to seek treatment.

Follow-up of obstetric fistula repair using Singapore fasciocutaneous flap and/or gracilis muscle flap.

AIMS: To report on the follow-up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both. METHODS: This cross-sectional study reports on the follow-up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self-reported continence grade. Secondary outcomes were urinary incontinence based on a 1-h pad-weight test, quality of life based on the Incontinence Quality of Life (I-QOL) questionnaire, surgical complications, and the indication for additional surgery after repair. RESULTS: Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1-h pad weight test improved between surgery and follow-up. QOL scores based on the I-QOL were low but patients indicated moderate to great improvement in quality of life. Twenty-two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow-up. CONCLUSION: The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow-up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort.

Anatomical and functional outcomes of non-obstetric urogenital fistula repair.

INTRODUCTION AND HYPOTHESIS: Studies on non-obstetric urogenital fistulas (NOUGFs) provide limited information on predictive outcome factors. This study was aimed at specifying and analyzing the risk factors for long-term anatomical and functional results. METHODS: A cross-sectional study of surgical repair for non-obstetric urogenital fistula was performed. From 2012 to 2020, a total of 479 patients with urogenital fistulas were treated in two tertiary centers. Patients with isolated ureteral fistulas and rectal injuries were excluded. For evaluation of the long-term results, patients with vesicovaginal and urethrovaginal fistulas with at least 12 months of follow-up were identified and contacted by phone and/or examined in the clinic. The anatomical outcome was assessed by resolution of symptoms and/or clinical examination. The Urinary Distress Inventory (UDI-6) was used for the functional outcomes. RESULTS: Overall, 425 patients were studied (mean age was 49.8; BMI 27.5; mean fistula size 1.4 cm, mean follow-up was 12 months). Vesicovaginal fistula affected 73% of patients. Hysterectomy without radiation was the most common etiology (66.3%), followed by hysterectomy with subsequent radiation (16%) and pelvic radiotherapy (12.2%). The transvaginal approach was used in 54.4%, abdominal in 12.4%, transvesical in 22.4%, and a combined approach in 10.8%. The successful closure rate was 92.9% for primary cases, 71.6% for secondary cases, and 66.7% for radiation fistulas. A high risk for relapse was found for NOUGFs with ureteral involvement (RR 2.5; 95% CI 1.3-4.5; p = 0.003), radiation fistulas (RR 2.1; 95% CI 1.3-3.5, p = 0.003); and combined radiation and hysterectomy cases (RR 2.9; 95% CI 1.8-4.6; p = 0.0001). In multifactorial analysis, fistula size >3.0 cm, pelvic radiation, and previous vaginal surgeries were associated with a higher risk for failure or lower urinary symptoms. CONCLUSIONS: Factors for successful NOUGF closure are fistula size less than 3.0 cm, absence of pelvic radiation, and previous vaginal surgeries.

A retrospective review of genital fistula occurrence in nine African countries.

BACKGROUND: Female genital fistulas are abnormal communications that lead to urinary and/or fecal incontinence. This analysis compares the characteristics of women with fistulas to understand how countries differ from one another in the circumstances of genital fistula development. METHODS: This retrospective records review evaluated demographics and circumstances of fistula development for 6,787 women who sought fistula treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. RESULTS: Most women developed fistula during childbirth, whether vaginal (3,234/6,787, 47.6%) or by cesarean section (3,262/6,787, 48.1%). Others had fistulas attributable to gynecological surgery (215/6,787, 3.2%) or rare causes (76/6,787, 1.1%). Somalia, South Sudan, and Ethiopia had comparatively high proportions following vaginal birth and birth at home, where access to care was extremely difficult. Fistulas with live births were most common in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia, indicating more easily accessible care. CONCLUSIONS: Characteristics of women who develop genital fistula point to geographic differences in obstetric care. Access to care remains a clear challenge in South Sudan, Somalia, and Ethiopia. Higher proportions of fistula after cesarean birth and gynecological surgery in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia signal potential progress in obstetric fistula prevention while compelling attention to surgical safety and quality of care.

Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review.

BACKGROUND: Genito-urinary fistulas may occur as complications of obstetric surgery. Location and circumstances can indicate iatrogenic origin as opposed to pressure necrosis following prolonged, obstructed labor. METHODS: This retrospective review focuses on 787 women with iatrogenic genito-urinary fistulas among 2942 women who developed fistulas after cesarean birth between 1994 and 2017. They are a subset of 5469 women who sought obstetric fistula repair between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. We compared genito-urinary fistula classifications following vaginal birth to classifications following cesarean birth. We assessed whether and how the proportion of iatrogenic genito-urinary fistula was changing over time among women with fistula, comparing women with iatrogenic fistulas to women with fistulas attributable to pressure necrosis. We used mixed effects logistic regression to model the rise in iatrogenic fistula among births resulting in fistula and specifically among cesarean births resulting in fistula. RESULTS: Over one-quarter of women with fistula following cesarean birth (26.8%, 787/2942) had an injury caused by surgery rather than pressure necrosis due to prolonged, obstructed labor. Controlling for age, parity, and previous abdominal surgery, the odds of iatrogenic origin nearly doubled over time among all births resulting in fistula (aOR 1.94; 95% CI 1.48-2.54) and rose by 37% among cesarean births resulting in fistula (aOR 1.37; 95% CI 1.02-1.83). In Kenya and Rwanda the rise of iatrogenic injury outpaced the increasing frequency of cesarean birth. CONCLUSIONS: Despite the strong association between obstetric fistula and prolonged, obstructed labor, more than a quarter of women with fistula after cesarean birth had injuries due to surgical complications rather than pressure necrosis. Risks of iatrogenic fistula during cesarean birth reinforce the importance of appropriate labor management and cesarean decision-making. Rising numbers of iatrogenic fistulas signal a quality crisis in emergency obstetric care. Unaddressed, the impact of this problem will grow as cesarean births become more common.

Sub-Saharan African women's views and experiences of risk factors for obstetric fistula: a qualitative systematic review.

BACKGROUND: Obstetric fistula used as synonymous with VVF in this study, is an abnormal communication/hole between the urinary tract and the genital tract or the gastrointestinal tract and the genital tract, resulting from prolonged obstructed labour. VVF may cause sufferers to experience chronic urinary/faecal incontinence, and the stigma of continuing foul odour. VVF is primarily caused by prolonged obstructed labour, which is brought about by a range of causes. Recently, it has been proposed that women's groups and fistula survivors should suggest interventions to reduce or prevent the incidence of obstetric fistula. OBJECTIVE: The objective of this review was to synthesise what is reported about women's views and experiences of the risk factors underlying the causes of VVF. METHODS: A systematic approach outlined in the Joanna Briggs Institute Manual for Evidence synthesis was followed for this review, articles published since the last 11 years from 2011 to 2021 were selected against several criteria and critically appraised using JBI Critical Appraisal Checklist for qualitative studies. RESULTS: Nine studies were retained for inclusion in this review and the data were then synthesised into five themes: (1) Cultural beliefs and practices impeding safe childbirth, (2) Lack of woman's autonomy in choices of place to birth safely, (3) Lack of accessibility and social support to safe childbirth, (4) Inexperienced birth attendants and, (5) Delayed emergency maternal care (childbirth). CONCLUSIONS: This review highlights the complexity of risk factors predisposing women to the known causes of VVF. It also illuminates the absence of women's voices in the identification of solutions to these risks. Women are most directly affected by VVF. Therefore, their knowledge, views, and experiences should be considered in the development and implementation of strategies to address the issue. Exploring women's views on this issue would enable the identification of gaps in maternity care provision, which would be of interest to community and health service leaders as well as policymakers in Sub-Saharan Africa.

Knowledge of obstetric fistula and its associated factors among women of reproductive age in Northwestern Ethiopia: a community-based cross-sectional study.

BACKGROUND: Obstetric fistula has been a major maternal health challenges in low and middle-income countries, especially in Ethiopia, due to high child marriage and poor access to healthcare. Obstetric fistula is common among teenage mothers that results in a vast social, economic and cultural sequel. In Ethiopia, there is a paucity of research evidence on women's knowledge about obstetric fistula. Therefore, this study aimed to assess women's knowledge about obstetric fistula and its associated factors at Banja District, Northwestern Ethiopia. METHODS: A community-based cross-sectional study design was conducted from 1st -21th July 2021. Systematic sampling method was used to recruit 784 women in the reproductive age from six rural and one urban sub-districts. Two days of training was given to research assistants regarding the objective of the study, inclusion and exclusion criteria, checking completeness and ways of protecting confidentiality. Data were collected using face-to-face interview method. Collected data were entered into EpiData and exported into SPSS version 24 for cleaning and analysis. Descriptive statistics, binary and multivariable logistic regression analysis were performed to identify associated factors. Adjusted odds ratio (AOR) at 95% CI with p < 0.05 was used to declare significant association with women's knowledge of obstetric fistula. RESULTS: A total of 773 women gave a complete response with response rate of 98.6% (773/784). One-third (36.4%; 95%CI: 32.9-39.7%) had good knowledge about obstetric fistula. Women who had completed primary education (AOR:3.47, 95%CI:2.01-5.98), secondary and above (AOR:3.30, 95%CI:1.88-5.80), being a student (AOR: 6.78, 95%CI:3.88-11.86), get counseling about obstetric fistula (AOR:6.22, 95%CI: 3.78-10.24), participated in pregnant women's discussion forum (AOR:3.36, 95%CI: 1.99-5.66), had antenatal care follow-up (AOR: 2.40, 95% CI: 1.39-4.13), being an urban resident (AOR: 3.19, 95% CI: 1.33-7.66), and having access to Television/Radio (AOR:1.68, 95%CI:1.10-2.60) were significantly associated with women's good knowledge about obstetric fistula. CONCLUSION: Women's knowledge about obstetric fistula is unacceptably low. Therefore, concerned stakeholders should enhance awareness creation programs, strengthen antenatal care, counselling and women's discussion forum that could substantially optimize women's knowledge about obstetric fistula and its risk factors of obstetric fistula.