A systematic review of the patient burden of Crohn's disease-related rectovaginal and anovaginal fistulas.

BACKGROUND: Crohn's disease (CD)-related rectovaginal fistulas (RVFs) and anovaginal fistulas (AVFs) are rare, debilitating conditions that present a substantial disease and treatment burden for women. This systematic literature review (SLR) assessed the burden of Crohn's-related RVF and AVF, summarizing evidence from observational studies and highlighting knowledge gaps. METHODS: This SLR identified articles in PubMed and Embase that provide data and insight into the patient experience and disease burden of Crohn's-related RVF and AVF. Two trained reviewers used pre-specified eligibility criteria to identify studies for inclusion and evaluate risk of bias using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for observational studies. RESULTS: Of the 582 records identified, 316 full-text articles were assessed, and 16 studies met a priori eligibility criteria and were included. Few epidemiology studies were identified, with one study estimating the prevalence of RVF to be 2.3% in females with Crohn's disease. Seven of 12 treatment pattern studies reported that patients had or required additional procedures before and/or after the intervention of interest, demonstrating a substantial treatment burden. Seven of 11 studies assessing clinical outcomes reported fistula healing rates between 50 and 75%, with varying estimates based on population and intervention. CONCLUSIONS: This SLR reports the high disease and treatment burden of Crohn's-related RVF and AVF and identifies multiple evidence gaps in this field. The literature lacks robust, generalizable data, and demonstrates a compelling need for substantial, novel research into these rare and debilitating sequelae of CD. Registration The PROSPERO registration number for the protocol for this systematic literature review is CRD42020177732.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda.

BACKGROUND: Obstetric fistula is a preventable and treatable condition predominately affecting women in low-income countries. Understanding the social context of obstetric fistula may lead to improved prevention and treatment. OBJECTIVES: This study investigated social experiences of women with obstetric fistula seeking treatment at Mulago Hospital in Kampala, Uganda. METHODS: A descriptive study was conducted among women seeking treatment for obstetric fistula during a surgical camp in July 2011 using a structured questionnaire. Descriptive statistics were computed regarding sociodemographics, obstetric history, and social experience. FINDINGS: Fifty-three women participated; 39 (73.58%) leaked urine only. Median age was 29 years (range: 17-58), and most were married or separated. About half (28, 47.9%) experienced a change in their relationship since acquiring obstetric fistula. More than half (27, 50.94%) acquired obstetric fistula during their first delivery, despite almost everyone (50, 94.3%) receiving antenatal care. The median years suffering from obstetric fistula was 1.25. Nearly every participant's social participation changed in at least one setting (51, 96.23%). Most women thought that a baby being too big or having kicked their bladder was the cause of obstetric fistula. Other participants thought health care providers caused the fistula (15, 32.61%; n = 46), with 8 specifying that the bladder was cut during the operation (cesarean section). Knowing someone with obstetric fistula was influential in pursuing treatment. The majority of participants planned to return to family (40, 78.43%; n = 51) and get pregnant after repair (35, 66.04%; n = 53). CONCLUSION: Study participants experienced substantial changes in their social lives as a result of obstetric fistula, and there were a variety of beliefs regarding the cause. The complex social context is an important component to understanding how to prevent and treat obstetric fistula. Further elucidation of these factors may bolster current efforts in prevention and holistic treatment.

Exploring the needs and challenges of women reintegrating after obstetric fistula repair in northern Ghana.

OBJECTIVE: to explore the cultural, social and economic needs and challenges of women in northern Ghana as they resume their day-to-day lives post obstetric fistula repair. DESIGN: a critical ethnographic approach. SETTING: a state run fistula treatment center in Tamale, northern Ghana, and 24 rural communities in northern Ghana. PARTICIPANTS: ninety-nine (N=99) participants were recruited using purposive, convenience and snowball sampling. The sample consisted of women (N=41) who had experienced an obstetric fistula repair and their family members (N=24). Health care providers (N=17) and stakeholders (N=17) who had specialised knowledge about reintegration programs at a community or national level were also included. FINDINGS: the needs and challenges of northern Ghanaian women post obstetric fistula repair were historically and culturally rooted. A woman's psychosocial acceptance back into her community post obstetric fistula was significant to her well-being but many women felt they had to 'prove' themselves worthy of acceptance and hid any signs of urinary incontinence post obstetric fistula repair. The cost of treatment compounded by a woman's inability to work while having the obstetric fistula exaggerated her economic needs. Skills training programs offered assistance but were often not suited to a woman's physical capability or geographic location. Many women who have experienced obstetric fistula along with women leaders have initiated obstetric fistula awareness campaigns in their communities with the aim of overcoming the challenges and improving the reintegration experiences of others who have had an obstetric fistula repair. CONCLUSION: developing understanding about the needs and challenges of women post obstetric fistula is an important step forward in creating social and political change in obstetric fistula care and reintegration. IMPLICATIONS FOR PRACTICE: Strategies to support women reintegrating to their communities post obstetric fistula repair include exploring alternative forms of skills training and income generation activities, creating innovative pre and post obstetric fistula health education and community awareness to reduce the perception of the condition as 'incurable', and promoting peer advocacy.

Sources of support for women experiencing obstetric fistula in northern Ghana: A focused ethnography.

OBJECTIVE: we explored how women in northern Ghana who have or have had obstetric fistula and those close to them perceive support. DESIGN: focused ethnography, that includes in-depth interviews, participant observation, and scrutiny of relevant records. SETTING: a fistula treatment centre in a regional urban centre and three remote villages located in northern Ghana. PARTICIPANTS: the sources of data included in-depth interview (n=14), non-participant observation and interaction, as well as scrutiny of relevant health records and documents. Participants for in-depth interviews and observation included women affected by obstetric fistula, their partners, parents, relatives, nurses and doctors. FINDINGS: presentation of obstetric fistula information, particularly by Non-Governmental Organisations was not in a format that was readily understandable for many women and their families. Food and other basic requirements for daily living were not necessarily available in the fistula treatment centre. Travelling for care was costly and frequently not easily accessed from their communities. Fistula repair surgery was available at unpredictable times and only for a few days every one to two months. CONCLUSIONS: women perceived support from spouses/partner, family members, and other relatives but much of this is limited to tangible support. Perceptions of support were particularly focused on access to information and finances. IMPLICATIONS FOR PRACTICE: the implementation of strategies to increase support for women living with obstetric fistula include improving access to fistula repair treatment, directing resources to create a dedicated specialist fistula centre located where most cases of OF occur and providing education to front-line workers. Strategies to prevent fistula as well as identify and support safe motherhood practices are needed for women affected by obstetric fistula.

Preventing obstetric fistulas in low-resource countries: insights from a Haddon matrix.

UNLABELLED: An obstetric fistula is classically regarded as an "accident of childbirth" in which prolonged obstructed labor leads to destruction of the vesicovaginal/rectovaginal septum with consequent loss of urinary and/or fecal control. Obstetric fistula is highly stigmatizing and afflicted women often become social outcasts. Although obstetric fistula has been eliminated from advanced industrialized nations, it remains a major public health problem in the world's poorest countries. Several million cases of obstetric fistula are currently thought to exist in sub-Saharan Africa and south Asia. Although techniques for the surgical repair of such injuries are well known, it is less clear which strategies effectively prevent fistulas, largely because of the complex interactions among medical, social, economic, and environmental factors present in those countries where fistulas are prevalent. This article uses the Haddon matrix, a standard tool for injury analysis, to examine the factors influencing obstetric fistula formation in low-resource countries. Construction of a Haddon matrix provides a "wide angle" overview of this tragic clinical problem. The resulting analysis suggests that the most effective short-term strategies for obstetric fistula prevention will involve enhanced surveillance of labor, improved access to emergency obstetric services (particularly cesarean delivery), competent medical care for women both during and after obstructed labor, and the development of specialist fistula centers to treat injured women where fistula prevalence is high. The long-term strategies to eradicate obstetric fistula must include universal access to emergency obstetric care, improved access to family planning services, increased education for girls and women, community economic development, and enhanced gender equity. Successful eradication of the obstetric fistula will require the mobilization of sufficient political will at both the international and individual country levels to ensure that adequate resources are devoted to this problem and that maternal health becomes a high priority on national political agendas. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After participating in this CME activity, physicians should be better able to apply the Haddon matrix, a tool commonly used for injury analysis, to the field of obstetrics and gynecology; analyze the problem of obstructed labor and obstetric fistula formation in low-resource countries using the Haddon matrix, and implement possible strategies for the prevention of obstetric fistulas and the mitigation of harm in cases of obstructed labor that arise from the use of the Haddon matrix.

Obstetric fistula in 14,928 Ethiopian women.

OBJECTIVES: Obstetric fistulas are severe sequelae of prolonged obstructed labor, a widespread but incompletely documented problem of low-income countries. Here, we characterize women with obstetric fistula, test the hypothesis that primi- and multipara represent different profiles and that fetal size is an important factor in developing fistula. DESIGN: Hospital registry statistics and questionnaire. POPULATION: A total of 14,928 Ethiopian women with obstetric fistula in 1974-2006 and 434 admitted in 2007-8. METHODS: Self-reported age, marital status, education, distance from home to health facility, parity, duration of labor, neonatal outcome and sex, lag time to treatment; measurement of weight, stature, extent of lesion and clinical assessment of continence before hospital discharge. OUTCOME MEASURES: Duration of labor, extent of pelvic injury and neonatal survival, cure rate. RESULTS: Primi- were more common than multiparous cases (56.8 vs. 43.2%). They were of similar age at marriage (17 years) and stature at hospital admission, but shorter than the population average (152.7 vs. 156.5 cm). Primipara had longer labor than multipara (50.5% > 3 days vs. 27%), larger uro-vaginal fistula, more stillbirths (95 vs. 88%), recto-vaginal fistula, vaginal scarring, persistent incontinence after repair and were more commonly divorced. Male fetuses were involved in 76.7% of obstructed deliveries but in only 44.6% of a previous uneventful delivery in multipara. Educational attainment positively influenced outcomes. CONCLUSIONS: Obstetric fistula is more commonly associated with primiparous than subsequent pregnancies. Primipara have a longer and more damaging labor. A causative role for cephalo-pelvic disproportion is supported by the observation that male fetuses are more commonly involved in obstructed labor.

Complications of loop ileostomy and ileostomy closure and their implications for extended enterostomal therapy: a prospective clinical study.

INTRODUCTION: Patients who have a temporary loop ileostomy have impaired quality of life. Complications associated with a loop ileostomy or ileostomy closure will impair patients' quality of life further and require extended enterostomal therapy. We performed a prospective audit of loop ileostomy to ascertain the nature of the workload that may be created with ileostomy-related complications. PATIENTS AND METHODS: One hundred and forty patients (67 males, 73 females, median age 50 years, range 5-90 years) who received a temporary loop ileostomy were analysed after completion of proformas on a prospective basis between 1999 and 2006. RESULTS: Operation was performed for rectal cancer 100 (71%), familial adenomatous polyposis 14 (10%), ulcerative colitis 21 (15%) and for trauma or Hirchsprung's disease 5 (3%). Complications of loop ileostomy were: retraction 1 (0.7%), ileostomy flux 11 (8%), stomal prolapse 1 (0.7%), parastomal hernia 1 (0.7%), paraileostomy abscess 4 (3%) and severe skin excoriation 9 (6%). The loop ileostomy was reversed in 117 (83%) at a median (range) of 13 weeks (1-60). Ileostomy closure-related complications were: small bowel fistula 1 (0.9%), small bowel obstruction 5 (4.3%) and a stitch sinus in 1 (0.9%). Five women developed recto-vaginal fistula (n=3; 2.6%), pouch-vaginal fistula (n=1; 0.9%) and pouch-anal fistula (n=1; 0.9%) that required extended enterostomal therapy, after loop ileostomy reversal. CONCLUSION: Nineteen percent of patients following creation of a loop ileostomy and 10.5% of patients after reversal of the ileostomy required extended enterostomal care by a specialized enterostomal therapist, which supported resumption of a normal life.

Women of the courtyard. A nurse's journey to treat obstetric fistulae in Niger.

Obstetric fistula is a devastating condition that results from prolonged or unassisted labor. It produces debilitating physical and emotional consequences caused by constant leaking of urine and/or feces. Because high-quality medical care is available throughout the developed world, unrepaired obstetric fistulae are virtually nonexistent in developed nations. However, the condition is rampant in many developing countries, including Niger, a nation in West Africa. This article explains what obstetric fistula is, why it is such a problem, and what nurses and other health care professionals can do to help improve the situation worldwide. It also tells the story of one nurse who went on a volunteer mission to treat obstetric fistulae in Niger, where she met a courtyard full of women she will never forget.