Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country.

In Africa, about 33 000 cases of obstetric fistula occur each year. Women with fistula experience debilitating incontinence of urine and/or faeces and are often socially ostracized. Worldwide, Uganda ranks third among countries with the highest burden of obstetric fistula. Obstetric fistula repair competes for scarce resources with other healthcare interventions in resource-limited settings, even though it is surgically efficacious. There is limited documentation of its cost-effectiveness in the most affected settings. We therefore sought to assess the cost-effectiveness of surgical intervention for obstetric fistula in Uganda so as to provide appropriate data for policy-makers to prioritize fistula repair and reduce women's suffering in similarly burdened countries. We built a decision-analytic model from the perspective of Uganda's National Health System to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery vs a competing strategy of no surgery for Ugandan women with fistula. Long-term disability outcomes were assessed based on a lifetime Markov state-transition cohort and effectiveness of surgery. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula and mortality rates among the general population in Uganda were based on published sources. The cost of providing fistula repair surgery in Uganda was estimated at $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the lifetime disability burden from 8.53 DALYs to 1.51 DALYs, yielding a cost per DALY averted of $54. The results were robust to variations in model inputs in one-way and probabilistic sensitivity analyses. Surgery for obstetric fistula appears highly cost-effective in Uganda. In similar low-income countries, governments and non-governmental organizations need to prioritize training and strengthening surgical capacity to increase access to fistula surgical care, which would be an important step towards achieving universal health coverage.

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.

[Obstetric urogenital fistula (OUGF): cost analysis at the Niamey National Hospital (Niger)]. / Fistule urogénitale d'origine obstétricale (Fugo) : coût de la prise en charge à l'hôpital national de Niamey (Niger).

BACKGROUND: A program to eliminate obstetric urogenital fistula (OUGF) was set up on February 19, 2004 in Niger. Though the consultations were free of charge, there was a cost involved, which constitutes the objective of this study. METHOD: The data were obtained from a documentary study completed by discussions with the principal management participants and interviews targeting the women suffering from OUGF attending the national hospital of Niamey during the surgery sessions of April and November 2006. Cost assessment included all resources devoted to activities involved in the program: hospital stay, hygiene education, medical and surgical treatment, social rehabilitation interventions (preparation for revenue generating activities and return to residence). Data analysis was performed with Excel and Epi2000 software. Average cost per item and patient was determined. RESULTS: The cost of the stay at the National hospital of Niamey was 96,445 francs CFA divided between transportation (4,688), room and board (21,572), assistance bonus (3,708) and indirect costs (66,477). The hygiene education cost 194,140 francs CFA: 30,150 for human resources, 143,965 for material resources and 20,025 for operational costs. The medical and surgery treatment had a cost of 144,009 francs CFA divided between consultations (15,000), complementary explorations (44,900), surgical operation (50,000) and consumables (34,109). The preparation for revenue generating activities had a cost of 118,244 francs CFA including training for clothes dying (22,084), soap manufacture (46,160) and the financial supportive grant (50,000). The return to the community cost 295,000 francs CFA, included room and board (2,500), human resources (65,000) and material resources (227,500). Altogether, the cost of the OUGF program came up to 742,018 francs CFA for our sample (76% of women with revenue generating activity), and was assessed at a maximum of 781,362 francs CFA if none of the woman had a revenue generating activity, and a minimum of 729,594 francs CFA if all of them did. CONCLUSION: Without the free consultations, the high cost of the OUGF program at the national hospital of Niamey would be inaccessible to Nigerian women owing to poverty and ignorance. Because of this observation, a long-term program is warranted for the treatment of overt cases and the reduction of prevalence, to enable Nigerian women to contribute to the development activities of their country.

Social implications of obstetric fistula: an integrative review.

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub-Saharan Africa.

Simple fistulas: diagnosis and management in low-resource settings--a descriptive report.

Obstetric fistulas occur in developing countries because of the scarcity or complete absence of obstetric services. The magnitude of the problem is unknown but thought to be sizeable. This article describes a basic approach to the care of women with fistulas in a low-resource rural hospital in northern Ghana, where the results were similar to those obtained at better-equipped centers. The facility includes an outpatient clinic for history taking and clinical examinations, and a laboratory for hemoglobin concentration assessment, sickling test, blood grouping, and cross-matching when necessary. Anesthesia consists of a spinal anesthesia given by the surgeon and monitored by a nurse while the surgeon scrubs up before repairing the fistula. Surgery is performed with the patient in exaggerated lithotomy position, and a bed sheet used as a sling prevents her from falling backwards. The patients are kept at the hospital for 14 days postoperatively for continuous bladder drainage.