Identifying opportunities for prevention of adverse outcomes following female genital fistula repair: protocol for a mixed-methods study in Uganda.

BACKGROUND: Female genital fistula is a traumatic debilitating injury, frequently caused by prolonged obstructed labor, affecting between 500,000-2 million women in lower-resource settings. Vesicovaginal fistula causes urinary incontinence, and other morbidity may occur during fistula development. Women with fistula are stigmatized, limit social and economic engagement, and experience psychiatric morbidity. Improved surgical access has reduced fistula consequences yet post-repair risks impacting quality of life and well-being include fistula repair breakdown or recurrence and ongoing or changing urine leakage or incontinence. Limited evidence on risk factors contributing to adverse outcomes hinders interventions to mitigate adverse events. This study aims to quantify these adverse risks and inform clinical and counseling interventions to optimize women's health and quality of life following fistula repair through: identifying predictors and characteristics of post-repair fistula breakdown and recurrence (Objective 1) and post-repair incontinence (Objective 2), and to identify feasible and acceptable intervention strategies (Objective 3). METHODS: This mixed-methods study incorporates a prospective cohort of women with successful vesicovaginal fistula repair at approximately 12 fistula repair centers in Uganda (Objectives 1-2) followed by qualitative inquiry among key stakeholders (Objective 3). Cohort participants will have a baseline visit at the time of surgery followed by data collection at 2 weeks, 6 weeks, 3 months and quarterly thereafter for 3 years. Primary predictors to be evaluated include patient-related factors, fistula-related factors, fistula repair-related factors, and post-repair behaviors and exposures, collected via structured questionnaire at all data collection points. Clinical exams will be conducted at baseline, 2 weeks post-surgery, and for outcome confirmation at symptom development. Primary outcomes are fistula repair breakdown or fistula recurrence and post-repair incontinence. In-depth interviews will be conducted with cohort participants (n ~ 40) and other key stakeholders (~ 40 including family, peers, community members and clinical/social service providers) to inform feasibility and acceptability of recommendations. DISCUSSION: Participant recruitment is underway. This study is expected to identify key predictors that can directly improve fistula repair and post-repair programs and women's outcomes, optimizing health and quality of life. Furthermore, our study will create a comprehensive longitudinal dataset capable of supporting broad inquiry into post-fistula repair health. Trial Registration ClinicalTrials.gov Identifier: NCT05437939.

Female genital fistula is a traumatic birth injury which occurs where access to emergency childbirth care is poor. It causes uncontrollable urine leakage and is associated with other physical and psychological symptoms. Due to the urine leakage and its odor, women with fistula are stigmatized which has mental health and economic consequences. Ensuring women's access to fistula surgery and ongoing wellbeing is important for limiting the impact of fistula. After fistula surgery, health risks such as fistula repair breakdown or recurrence or changes to urine leakage can happen, but studies during this time are limited. Our study seeks to measure these health risks and factors influencing these risks quantitatively, and work with patients, community members, and fistula care providers to come up with solutions. We will recruit up to 1000 participants into our study at the time of fistula surgery and follow them for three years. We will collect data on patient sociodemographic characteristics, clinical history, and behavior after fistula repair through patient survey and medical record review. If participants have changes in urine leakage, they will be asked to return to the fistula repair hospital for exam. We will interview about 80 individuals to obtain their ideas for feasible and acceptable intervention options. We expect that this study will help to understand risk factors for poor health following fistula repair and, eventually, improve women's health and quality of life after fistula.

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.

Community awareness about risk factors, presentation and prevention and obstetric fistula in Nabitovu village, Iganga district, Uganda.

BACKGROUND: Obstetric fistula is a worldwide problem that is devastating for women in developing countries. The cardinal cause of obstetric fistula is prolonged obstructed labour and delay in seeking emergency obstetric care. Awareness about obstetric fistula is still low in developing countries. The objective was to assess the awareness about risk factors of obstetric fistulae in rural communities of Nabitovu village, Iganga district, Eastern Uganda. METHODS: A qualitative study using focus group discussion for males and females aged 18-49 years, to explore and gain deeper understanding of their awareness of existence, causes, clinical presentation and preventive measures for obstetric fistula. Data was analyzed by thematic analysis. RESULTS: The majority of the women and a few men were aware about obstetric fistula, though many had misconceptions regarding its causes, clinical presentation and prevention. Some wrongly attributed fistula to misuse of family planning, having sex during the menstruation period, curses by relatives, sexually transmitted infections, rape and gender-based violence. However, others attributed the fistula to delays to access medical care, induced abortions, conception at an early age, utilization of traditional birth attendants at delivery, and some complications that could occur during surgical operations for difficult deliveries. CONCLUSION: Most of the community members interviewed were aware of the risk factors of obstetric fistula. Some respondents, predominantly men, had misconceptions/myths about risk factors of obstetric fistula as being caused by having sex during menstrual periods, poor usage of family planning, being a curse.

Overcoming phase 1 delays: the critical component of obstetric fistula prevention programs in resource-poor countries.

BACKGROUND: An obstetric fistula is a traumatic childbirth injury that occurs when labor is obstructed and delivery is delayed. Prolonged obstructed labor leads to the destruction of the tissues that normally separate the bladder from the vagina and creates a passageway (fistula) through which urine leaks continuously. Women with a fistula become social outcasts. Universal high-quality maternity care has eliminated the obstetric fistula in wealthy countries, but millions of women in resource-poor nations still experience prolonged labor and tens of thousands of new fistula sufferers are added to the millions of pre-existing cases each year. This article discusses fistula prevention in developing countries, focusing on the factors which delay treatment of prolonged labor. DISCUSSION: Obstetric fistulas can be prevented through contraception, avoiding obstructed labor, or improving outcomes for women who develop obstructed labor. Contraception is of little use to women who are already pregnant and there is no reliable screening test to predict obstruction in advance of labor. Improving the outcome of obstructed labor depends on prompt diagnosis and timely intervention (usually by cesarean section). Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. This time interval is often extended by delays in deciding to seek care, delays in arriving at a hospital, and delays in accessing treatment after arrival. Communities can reasonably demand that governments and healthcare institutions improve the second (transportation) and third (treatment) phases of delay. Initial delays in seeking hospital care are caused by failure to recognize that labor is prolonged, confusion concerning what should be done (often the result of competing therapeutic pathways), lack of women's agency, unfamiliarity with and fear of hospitals and the treatments they offer (especially surgery), and economic constraints on access to care. SUMMARY: Women in resource-poor countries will use institutional obstetric care when the services provided are valued more than the competing choices offered by a pluralistic medical system. The key to obstetric fistula prevention is competent obstetrical care delivered respectfully, promptly, and at affordable cost. The utilization of these services is driven largely by trust.

The fistula crisis in sub-Saharan Africa: an ongoing struggle in education and awareness.

This article examines the social and physical causes of obstetric fistulas, as well as resulting social and psychological consequences. Preventative strategies are addressed using Niger as a microcosm for this devastating condition that affects two million women worldwide.

Leaving no one behind: Is the achievement of the Sustainable Development Goals possible without securing the dignity, rights, and well-being of those who are "invisible"?

The persistence of obstetric fistula-a devastating childbirth injury occurring largely among poor, marginalized women and girls-constitutes a human rights violation and a public health crisis. The Sustainable Development Goals (SDGs) aim to "leave no one behind." Failing to eliminate fistula jeopardizes attainment of several of the SDGs. Member States of the United Nations adopted a UN Resolution on ending fistula in 2018, calling for an end to fistula within a decade. Building upon recommendations of the UN Secretary General's 2018 Report on Obstetric Fistula, the Resolution calls for significantly increased commitments and investments to end fistula. Crucial interventions for eliminating fistula include high-quality, equitable, accessible health systems; implementing costed national strategies for eliminating fistula; integrating fistula into national plans to achieve the SDGs; strengthening national fistula task forces; and significantly increased, sustained financial support. Fistula elimination necessitates protecting women's/girls' human rights and addressing social determinants that affect women's/girls' ability to "survive, thrive and transform," including social and economic inequities; gender-based violence; child marriage and early childbearing; and access to education. Enhanced awareness-raising and advocacy; improved research, data, monitoring and evaluation; holistic social reintegration and survivor empowerment; and community engagement are additional key strategies for realizing this ambitious goal.

Challenges in the field of obstetric fistula.

Thirteen years after the last supplement on obstetric fistula, the authors challenge the progress achieved. Citing the ongoing need for a standardized classification system, uniform surgical training and certification, evaluation, follow-up, and research, we emphasize the need for improved communication and coordination between government and nongovernment entities invested in ending obstetric fistula. Struck by the call by the United Nations to end obstetric fistula by 2030, we stress the need for increased and targeted funding of programs that are of the highest quality and impact.

Modelling allocation of resources in prevention and control of obstetric fistula in Ugandan women.

In spite of reliable and skilled healthcare resources, the prevalence rate of obstetric fistula in Uganda is high. The risk factors for obstetric fistula cut across due to high poverty rates and cultural barriers. The main objective of this study was to assess the impact of inability to access skilled healthcare at delivery and implications to the economy. The specific objective was to determine the best way of investment in getting women access to skilled healthcare before, during and after child birth. The question to be answered was whether it was more economical to invest in getting women access to skilled healthcare, or in expanding healthcare. The study was conducted using data from the Uganda Demographic Health Survey 2016. The data was from 18,506 women in the age group of 15-49 in 15 regions around the country. Results show that the highest investment in providing access to skilled healthcare is required when there are few skilled healthcare centres. On the other hand, if there is little investment in providing access to skilled healthcare during child birth, many skilled healthcare centres are required. Results show further that the minimum time taken to reduce fistula prevalence is attained when there are many women accessing skilled healthcare in the few equipped health centres. However, if there are many skilled healthcare centres but a few women treated for obstetric fistula, then it will take longer to reduce fistula prevalence. Fitting the model to data suggested that Uganda has a big backlog of women to treat for obstetric fistula as in all skilled healthcare centres, there were less women treated than expected. Although still under the expected figure, the benefit of these treatments for obstetric fistula is that for every one woman treated, 8 more would seek treatment for the condition. This would however cost the country a great deal in that the treatment funds would perhaps give more returns if diverted to outreach activities aimed to get women seek skilled healthcare during child birth.

Knowledge of obstetric fistula among prenatal clinic attendees and midwives in Mfantsiman municipality, Ghana.

OBJECTIVE: To determine obstetric fistula knowledge among prenatal attendees and midwives in Mfantsiman municipality, Ghana. METHODS: An analytical cross-sectional study was conducted among prenatal clinic attendees and midwives in Mfantsiman municipality from March to April, 2016. Women were selected by systematic sampling and consenting midwives were recruited. Respondents were interviewed using a pretested structured questionnaire. Data were analyzed using the χ2 test and Poisson regression with a robust error variance to generate relative risks (RRs) with 95% confidence intervals (CIs). P<0.05 was considered statistically significant. RESULTS: Altogether, 393 prenatal attendees and 45 midwives were studied. Mean age of attendees was 28.1 ± 7.1 years. About 29% of prenatal attendees knew of, 37.2% had poor knowledge of, and 56.6% had some misconceptions about obstetric fistula. Women who had attained some level of education (P trend=0.001), were employed (adjusted RR 4.92; 95% CI, 1.98-12.21), or had given birth before (P trend=0.01) were more likely to have heard of obstetric fistula. All midwives knew of obstetric fistula and its preventive measures; however, up to 73.3% had some misconceptions about it. CONCLUSION: Educating prenatal attendees and organizing regular refresher courses on obstetric fistula for midwives should be a priority in the municipality.

Aspects of psychosocial problems of patients with vesico-vaginal fistula.

Our objective was to evaluate psychosocial problems among patients presenting with vesico-vaginal fistula (VVF), and their close relatives. All patients presenting with VVF and their spouses or attendant close relatives were administered a structured questionnaire followed by an in-depth interview. A total of 20 patients and 10 attendant relatives were interviewed. The average age of patients was 24.7 years, range 16-38 years. A total of 11 patients (55%) had their first marriage between the ages of 15-20 years, with one nulliparous, unmarried patient, who acquired VVF following infertility treatment with herbs. Of the interviewed respondents, 19 affirmed that prolonged labour was the cause of VVF, while four patients developed VVF sequel to unsupervised vaginal birth after a previous caesarean section. Reported medical problems were dermatitis (20%), foul smell of urine (15%), recurrent UTI (10%), infertility (5%), amenorrhoea (5%), in that order. Socially, 45% felt ostracised and 50% were economically impoverished by job loss. The divorce rate was 25%, with one case of remarriage and childbirth with an unrepaired VVF. Some 56.6% respondents suggested hospital delivery was a preventive measure, while 33.3% felt avoidance of premarital sex and early marriage would prevent VVF. VVF is still a major social and reproductive health problem and most patients and relatives understand the place of difficult childbirth in VVF formation. The need to empower patients to timely access standard maternity and emergency obstetric care is recommended.

Vesicovaginal fistula: do the patients know the cause?

BACKGROUND: So much has been written on vesicovaginal fistula (VVF) but there is little on the patients' perspective of the condition. The objectives of this study were to determine the knowledge of patients who have developed VVF on the causes of the fistula and their attitude toward measures that would prevent future occurrence. METHODS: The questionnaire-based survey was conducted on VVF patients on admission from June to August 2003 at Maryam Abacha Women and Children Welfare Hospital, Sokoto, Nigeria. The case notes of the patients were reviewed after the interview to match the responses from the patients with those documented in the folders. Focus group discussions were held with the maternity staff to ascertain the content and quality of existing counseling. RESULTS: One hundred and thirty patients were studied out of which 121 (93%) had no formal education. Teenagers constituted 37%, while 57% were primiparae. Thirty-five (27%) patients were divorced or separated because of the VVF. There were seven cases of recurrence after a previous successful repair. Prolonged obstructed labor was the cause of the VVF in 110 (85%) patients and 77 (70%) correctly attributed their problem to the prolonged labor. The 33 patients who could not identify the prolonged obstructed labor as the cause either attributed their condition to God/destiny or to the operation that was done to relief the obstruction and therefore would not have hospital delivery in their subsequent pregnancies. From the focus group discussions, it was confirmed that pre and post-operative counseling were inadequate. CONCLUSION: Even though majority (70%) of the patients knew the cause of their fistula from the health talks, some (32%) would still not change from risky obstetric behavior. Mandatory provision of accurate and appropriate information and education to all VVF patients and their relatives or spouses by trained counselors should be ensured. Such information and education should emphasize the etiology and management of obstetric fistula in order to prevent a recurrence.

Research in Obstetric Fistula: Addressing Gaps and Unmet Needs.

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are "dry" tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.

The Role of Human Acellular Dermis in Preventing Fistulas After Bladder Neck Transection in the Exstrophy-epispadias Complex.

OBJECTIVE: To evaluate human acellular dermis (HAD) as an adjunct during bladder neck transection (BNT) by comparing surgical outcomes with other types of tissue interposition. METHODS: A prospectively maintained institutional database of exstrophy-epispadias complex (EEC) patients was reviewed for those who underwent a BNT with at least 6 months follow-up. The primary outcome was the occurrence of BNT-related fistulas. RESULTS: In total, 147 EEC patients underwent a BNT with a mean follow-up time of 6.9 years (range 0.52-23.35 years). There were 124 (84.4%) classic exstrophy patients, 22 (15.0%) cloacal exstrophy patients, and 1 (0.7%) penopubic epispadias patient. A total of 12 (8.2%) BNTs resulted in fistulization, including 4 vesicoperineal fistulas, 7 vesicourethral fistulas, and 1 vesicovaginal fistula. There were 5 (22.7%) fistulas in the cloacal exstrophy cohort and 7 (5.6%) fistulas in the classic bladder exstrophy cohort (P = .019). Using either HAD or native tissue flaps resulted in a lower fistulization rate than using no interposed layers (5.8% vs 20.8%; P = .039). Of those with HAD, the use of a fibrin sealant did not decrease fistulization rates when compared to HAD alone (6.5% vs 8.8%, P = .695). There was no statistical difference in surgical complications between the use of HAD and native flaps (8.6% vs 5%, P = .716). CONCLUSION: Use of soft tissue flaps and HAD is associated with decreased fistulization rates after BNT. HAD is a simple option and an effective adjunct that does not require harvesting of tissues in patients where a native flap is not feasible.

Obstetric fistula in rural Ethiopia.

OBJECTIVES: To determine the prevalence of obstetric fistula in rural Ethiopia and identify the circumstances and barriers to care that enhance development of obstetric fistula and its health and social consequences. DESIGN: A cross-sectional study. SETTING: The study was conducted in seven out of eleven administrative regions of Ethiopia by visiting randomly selected houses in rural areas and identifying women who have or had obstetric fistula and interviewing them. RESULTS: A total of 19,153 houses were visited. Untreated fistula prevalence was about 1.5 per 1000 amounting to approximately 26,819 women. Most of the patients were young women who delivered for the first time. Marriage took place early in life mostly through family arrangements or abduction. The median number of days in labour was three to eight. CONCLUSION: Promotive measures such as increasing age at marriage, and identification and treatment of patients should be intensified. There is a great need in improving accessibility and affordability of basic and emergency obstetric services for rural communities. Curving the situation in the long run requires dealing with the problem of poverty and improvement in the status of women.

Obstetric fistula and sociocultural practices in Hausa community of Northern Nigeria.

BACKGROUND: Obstetric Fistula is a childbirth injury that disproportionately affects women in sub-Saharan Africa. Although poverty plays an important role in perpetuating obstetric fistula, sociocultural practices has a significant influence on susceptibility to the condition. AIM: This paper aims to explore narratives in the literature on obstetric fistula in the context of Hausa ethno-lingual community of Northern Nigeria and the potential role of nurses and midwives in addressing obstetric fistula. DISCUSSION: Three major cultural practices predispose Hausa women to obstetric fistula: early marriages and early child bearing; unskilled birth attendance and female circumcision and sociocultural constraints to healthcare access for women during childbirth. There is a failure to implement the International rights of the girl child in Nigeria which makes early child marriage persist. The Hausa tradition constrains the decision making power of women for seeking health care during childbirth. In addition, there is a shortage of nurses and midwives to provide healthcare service to women during childbirth. CONCLUSION: To improve health access for women, there is a need to increase political commitment and budget for health human resource distribution to underserved areas in the Hausa community. There is also a need to advance power and voice of women to resist oppressive traditions and to provide them with empowerment opportunities to improve their social status. The practice of traditional birth attendants can be regulated and the primary health care services strengthened.

Vesicovaginal fistula: obstetric causes.

PURPOSE OF REVIEW: Obstetric fistula has a devastating impact on the lives of women in poor countries. Currently, there is an international campaign by the World Health Organisation, United Nations Population Fund and other bodies to address this problem. This article reviews recent literature and highlights the paucity of evidence-based data. RECENT FINDINGS: Articles on the pathophysiology, co-morbidities and sequelae including physical injury to 'multiorgan systems' and social consequences associated with obstetric fistula, are discussed. In particular, the devastating social, economic and psychological effects on the health and well-being, reintegration and rehabilitation are addressed. There is a need for prevalence and incidence studies to measure the extent of this problem. The creation of well-equipped fistula centres with multidisciplinary teams to evaluate patients should be the aim. Expert surgeons and optimal databases with personnel to do research will benefit patients. SUMMARY: Prevention should involve alleviation of poverty and improvement in education, maternity services and health. Research on issues such as persistent stress incontinence following fistula closure, management of reduced bladder capacity, best technique for fistula repair, role of vaginoplasty, role of early repair in selective obstetric fistula, future reproductive function, dermatological management, and social and cultural issues must be done to improve women's health.

Obstetric fistula in developing countries: a review article.

Obstetric fistula, one of the most devastating consequences of prolonged obstructed labour, is a historical issue in the developed world. However, it is still prevalent in resource poor countries like Ethiopia. The objective of this review article is to describe the epidemiology of obstetric fistula and its management, with specific emphasis on the experience of the Addis Ababa Fistula Hospital. Published and unpublished literature on obstetric fistula was reviewed, and expert opinions are used in augmentation. Most obstetric fistulas result from neglected obstructed labour, often affecting very poor, young, illiterate, rural women and girls. The women are often in labour for days, helped by unskilled family members. They deliver a stillborn child, become incontinent of urine and/or feces, and become outcast and divorced as a result. Surgical repair mends the lives of thousands of women, although not all injured cases have access to treatment. Although prevention should be the ultimate goal, the need for curative care services for the sufferers is shown to be significant.

Management of a case of primary vaginal cancer with irreducible massive uterine prolapse--a case report.

Primary cancer of the vagina constitutes 1-2% of all malignant genital tract tumors in women. As one of the most complicated therapeutic problems in gynecological oncology, this disease had been deemed to be untreatable until the end of 1930s. Presently, as a result of technological improvements in radiotherapy and radical surgery, more favorable prognoses are known to be achieved even in advanced cases. In the present case, a woman with vaginal cancer and Stage IV massive uterovaginal prolapsus, which could not be repositioned under general anesthesia, was repositioned by surgical intervention prior to radiotherapy to avoid any potential vesicovaginal fistula formation. The cervix was bilaterally suspended to the pectineal ligaments by polypropylene mesh.