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.

HEAL Africa score to predict failure of surgical repair of obstetric urethro-vaginal fistula in the Democratic Republic of the Congo.

INTRODUCTION: Obstetric fistula (OF) repair surgery aims to restore the anatomical and functional integrity of the urinary tract, allowing affected women to regain their dignity and quality of life. However, in some cases, this surgical repair may fail. The objective of this study was to develop a predictive score to identify factors associated with the failure of surgical repair of obstetric urethro-vaginal fistula (FSROUVF) in the Democratic Republic of the Congo (DRC). METHODS: This is an analytical cross-sectional study of 358 patients with obstetric urethro-vaginal fistula (OUVF) who received surgical repair. We conducted bivariate and multivariate analyses. Score discrimination was assessed using the receiver operating characteristic (ROC) curve, C-index, and score calibration according to the Hosmer-Lemeshow test. RESULTS: Surgical repair of OUVF failed in 24.86% of cases (89/358). After logistic modelling, 6 criteria predicted FSROUVF: the use of intravaginal indigenous products (AOR = 3.59; 95% CI: 1.51-8.53), the presence of fibrosis (AOR = 6.37; 95% CI: 1.70-23.82), the presence of 2 or more fistulas in the same patient (AOR = 7.03; 95% CI: 3.14-15.72), the total urethral damage (AOR = 3.29; 95% CI: 1.36-7.95), the fistula size > 3 cm (AOR = 5.65; 95% CI: 2.12-15.01), and the postoperative infection (AOR = 351.10; 95% CI: 51.15-2409.81). A score of 0 to 14 was obtained, with a value ≤5 points indicating a low risk of FSROUVF, a value between 6 and 8 indicating a moderate risk, and a value ≥9 points corresponding to a high risk of FSROUVF. The area under the ROC curve of the score is 0.938 with a sensitivity of 60.67%, a specificity of 96.28%, a positive predictive value of 84.38%, and a negative predictive value of 88.10%. CONCLUSION: We report a FSROUVF rate in the DRC approaching a quarter of operative patients. Predictors of failure included fibrosis, presence of 2 or more fistulas, total urethral involvement, fistula size greater than 3 cm, postoperative infection, and use of intravaginal indigenous products. These factors are constitutive of the HEAL Africa score, which once validated, may have value in pre-operative counselling of patients. This study could be valuable for policy and strategies to address the problem of OUVF in the DRC and in resource limited settings more generally.

Obstetric vesico-uterine fistula in nine reference hospitals in the Democratic Republic of the Congo: epidemiological, clinical, and therapeutic aspects.

INTRODUCTION: With global cesarean section rates rising, there's concern about increase in obstetric vesico-uterine fistula (OVUF). Very little is known about this anatomoclinical entity of obstetric fistula in Africa in general and in DRC in particular. Our purpose was to describe the epidemiological, clinical, and therapeutic aspects of OVUF in the Democratic Republic of the Congo (DRC). METHODS: This was a descriptive cross-sectional study. Data were collected from patients who presented with OVUF across seven provinces of the DRC (North Kivu, Haut-Uélé, Kasai Central, Kwilu, Maniema, Nord-Ubangi and Sankuru) from January 2017 to December 2022. Study variables were epidemiological, clinical, and therapeutic features. RESULTS: Of 1,267 patients presenting with obstetric fistulas, 355 (28.0%) had OVUF. The mean age was 32.9 ± 11.6 years, 80.6% of patients (286/355) lived in rural areas, and the majority had a low level of education (40% no formal education, 30.1% primary school, 28.7% secondary school). In total, 64.8% of patients were primiparous (230/355) and in all (100%) cases, OVUF was caused iatrogenically during cesarean delivery. Majority (76.3%) of patients laboured for one day or less (mean duration 1.0 ± 0.5 days) before giving birth, and the fetus died in 58.3% of cases. In 35.8% of cases, the fistula had lasted more than 10 years (mean age 10.1 ± 10.0 years) before repair. A proportion of 88.2% (n = 313) of OVUF was isolated while 11.3% (n = 40) was associated with a uretero-vaginal fistula. In 82.8% (n = 294) of cases the OVUF was single. The average fistula size was 2.4 ± 1.0 cm (range: 0.5 and 5.5 cm) and 274 (77.2%) fistulas measured between 1.5 and 3 cm, with 14.9% (n = 53) of them larger than 3 cm. Fibrosis was present in 65.1% of cases, cervical involvement was absent in 97.7% and post-operative complications were absent in 94.4%. In all cases, the OVUF was surgically repaired abdominally with a success rate of 97.5% (346/355). CONCLUSION: The proportion of OVUF is relatively high in the DRC. Most affected patients were young, under-educated, primiparous women living in rural areas. Cesarean section was the sole identified cause of OVUF which was isolated, single, without fibrosis, in majority of cases. Abdominal repair of OVUF was very effective, with good results in almost all cases. Teaching young doctors working mainly in remote areas how to perform safe cesarean section is needed to reduce incidence of OVUF in DRC.

Determinants and predictive model of failure of surgical repair of obstetric vesico-vaginal fistula in the Democratic Republic of the Congo.

INTRODUCTION: Surgical repair of obstetric fistula aims to restore the anatomical and functional integrity of the urinary tract, enabling affected women to regain their dignity and quality of life. However, such repairs can end in a failure. The aim of this study is to develop a predictive score to identify factors influencing failure of surgical repair of obstetric vesico-vaginal fistula (FSROVVF) in the Democratic Republic of the Congo. METHODS: This was an analytical cross-sectional study of 318 women with obstetric vesico-vaginal fistula (OVVF) who had undergone surgical management. A bivariate and then a multivariate analysis were performed. Score discrimination was assessed using the ROC curve and C-index, and score calibration using the Hosmer-Lemeshow test. RESULTS: Surgical repair of OVVF was unsuccessful in 16.98% of cases (54/318). After logistic modeling, six criteria emerged as predictive factors for FSROVVF: the presence of fibrosis (AOR = 5.01; 95% CI:1.73-14.49), the presence of 2 or more fistulas (AOR = 9.04; 95% CI:3.01-27.13), the association of OVVF with another anatomoclinical entity of fistula (AOR = 3.16; 95% CI:1.09-9.13), the fistula size > 3 cm (AOR = 3.65; 95% CI:1.36-9.76), the peri-operative hemorrhage (AOR = 7.01; 95% CI:2.33-21.03), and the post-operative infection (AOR = 178.89; 95% CI:26.09-1226.64). A score ranging from 0 to 13 points was obtained, of which a value ≤ 5 points defines a low risk of FSROVVF, a value between 6 and 8 points defines a moderate risk and value ≥ 9 points corresponds to a high risk of FSROVVF. The area under the ROC curve of the score is 0.925 with a sensitivity of 61.11%, a specificity of 96.59%, a positive predictive value of 78.57% and a negative predictive value of 92.39%. CONCLUSION: This study demonstrated that the number of fistulas ≥ 2, fistula size > 3 cm, fibrosis, association of OVVF with other types of fistulas, peri-operative hemorrhage, and post-operative infection are factors predictive of FSROVVF. These six factors are key contributors to the score used to predict FSROVVF. Once validated, this score will inform and enable preoperative counseling regarding the prognosis and the chances of a successful outcome of surgical repair of OVVF.

Factors associated with surgical repair success of female genital fistula in the Democratic Republic of Congo: Experiences of the Fistula Care Plus Project, 2017-2019.

OBJECTIVE: We sought to document outcomes and factors associated with surgical success in hospitals supported by the Fistula Care Plus Project in the Democratic Republic of Congo (DRC), 2017-2019. METHODS: This was a retrospective cohort study analysing routine repair data on women with Female Genital Fistula. Univariate and multivariate analyses were conducted to determine factors associated with successful fistula repair. RESULTS: A total of 895 women were included in this study, with a mean age of 34 years (±13 years). The majority were married or in union (57.4%) and living in rural areas (82.0%), while nearly half were farmers (45.9%). The average duration living with fistula was 8 years (±7). Vesicovaginal (70.5%) and complex (59.8%) fistulas were the most common fistula types. Caesarean section (34.7%), obstructed labour (27.0%) and prolonged labour (23.0%) were the main aetiologies, with the causal deliveries resulting in stillbirth in 88% of cases. The vaginal route (74.9%) was the primary route for surgical repair. The median duration of bladder catheterization after surgery was 14 days (interquartile range [IQR] 7-21). Multivariate analysis revealed that Waaldijk type I fistula (adjusted odds ratio [aOR]:2.71, 95% confidence interval [CI]:1.36-5.40), no previous surgery (aOR:2.63, 95% CI:1.43-3.19), repair at Panzi Hospital (aOR: 2.71, 95% CI:1.36-5.40), and bladder catheterization for less than 10 days (aOR:13.94, 95% CI: 4.91-39.55) or 11-14 days (aOR: 6.07, 95% CI: 2.21-15.31) were associated with better repair outcomes. CONCLUSION: The Fistula Care Plus Project in the DRC recorded good fistula repair outcomes. However, further efforts are needed to promote adequate management of fistula cases.

Frequency and management of non-obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care Plus project.

OBJECTIVE: To describe the frequency, causes and post-repair outcomes of NOF in hospitals supported by the Fistula Care Plus (FC+) project in the Democratic Republic of Congo. METHODS: Retrospective cohort study from 1 January 2015 to 31 December 2017 in three FC + supported fistula repair sites. RESULTS: Of 1984 women treated for female genital fistula between 2015 and 2017 in the three FC + supported hospitals, 384 (19%) were considered to be non-obstetric fistula (NOF) cases. 49.3% were married/in a relationship at the time of treatment vs. 69% before the fistula, P < 0.001. Type III (n = 247; 64.3%) and type I (n = 121; 31.5%) fistulas according to Kees/Waaldijk classification were the most common. The main causes of NOF were medical procedure (n = 305; 79.4%); of these, caesarean section (n = 234; 76.7%) and hysterectomy (n = 54; 17.7%) were the most common. At hospital discharge, the fistula was closed and dry in 353 women (95.7%). CONCLUSION: Non-obstetric fistula, particularly due to iatrogenic causes, was relatively common in the DRC, calling for more prevention that includes improved quality of care in maternal health services.

OBJECTIF: Décrire la fréquence, les causes et les résultats post-réparation de la fistule non obstétricale (FNO) dans les hôpitaux soutenus par le projet Fistula Care Plus (FC+) en République Démocratique du Congo. MÉTHODES: Etude de cohorte rétrospective du 1er janvier 2015 au 31 décembre 2017 dans trois sites de réparation de fistules soutenus par FC+. RÉSULTATS: Sur 1984 femmes traitées pour une fistule génitale féminine entre 2015 et 2017 dans les trois hôpitaux soutenus par FC+, 384 (19%) étaient considérées comme des cas de FNO. 49,3% étaient mariées/en couple au moment du traitement contre 69% avant la fistule, p <0,001. Les fistules de type III (n = 247; 64,3%) et de type I (n = 121; 31,5%) selon la classification de Kees/Waaldijk étaient les plus courantes. Les principales causes de FNO étaient la procédure médicale (n = 305; 79,4%); parmi lesquelles les césariennes (n = 234; 76,7%) et l'hystérectomie (n = 54; 17,7%) étaient les plus courantes. A la sortie de l'hôpital, la fistule était fermée et sèche chez 353 femmes (95,7%). CONCLUSION: La FNO, en particulier due à des causes iatrogènes, était relativement courante en RDC, appelant à plus de prévention qui comprend l'amélioration de la qualité des soins dans les services de santé maternelle.

Late abdominal pregnancy in a post-conflict context: case of a mistaken acute abdomen - a case report.

BACKGROUND: Abdominal pregnancies have been reported in both high-income countries as well as low- and middle-income countries. They are frequently missed in routine antenatal care in resource-limited settings and delayed diagnosis is usually associated with poor fetal and maternal outcomes including death. This case report is among the first from eastern Democratic Republic of Congo (DRC), a post-conflict region. CASE PRESENTATION: In this case study, we present a 25 year-old primigravida patient referred to HEAL Africa hospital for management of an acute abdomen at 33-weeks gestation. Her chief complaint was severe abdominal pain associated with each fetal movement for a period of 1 week prior to admission. A diagnosis of peritonitis was made. Emergency laparotomy revealed a normal live 2 kg baby with placental implantation on the greater omentum and small intestine mesentery. The placenta was not removed. Both maternal and fetal outcomes were good. CONCLUSION: Abdominal pregnancy with a normal live fetus at such an advanced gestational age is rare. This case reminds clinicians that abdominal pregnancy remains a differential diagnosis for painful fetal movements.

Massive single visit cervical pre-cancer and cancer screening in eastern Democratic Republic of Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), practical and affordable strategies for cervical cancer screening are needed to detect and treat pre-cancerous and cancerous lesions in a timely fashion. This study presents the results of mass cervical cancer screenings in eastern DRC using a "screen and treat" approach. METHODS: In two mass cervical cancer screening campaigns, patients underwent a combination of visual inspection of the cervix with acetic acid, visual inspection of the cervix with Lugol iodine solution, and colposcopy with or without loop electrosurgical excision procedure. Cervical biopsy samples were taken for histology analysis. Marital status, age, history of abnormal bleeding, and number of pregnancies were recorded for each patient and association analyses were performed. RESULTS: Of the 644 women who received cervical pre-cancer and cancer screening, 48 had suspicious pre-cancer and cancer lesions that were biopsied (7.45%). On histology analysis cervical intraepithelial neoplasia (CIN) was identified in 15 (2.33%), squamous cell carcinoma (SCC) was identified in 6 (0.93%) and non-neoplastic cervicitis was identified in 11 (1.71%). Abnormal bleeding was significantly associated with CIN/SCC but no significant association was observed for prior pregnancy, patients' home region, or age. CONCLUSION: Forty-eight women with suspicious pre-cancerous or cancerous lesions were successfully identified using the "screen and treat" approach in eastern DRC, suggesting that this approach is feasible for reducing cervical cancer morbidity and mortality. However, community awareness would be necessary, providers would have to be properly trained, referral and follow up mechanisms would have to be put in place, and equipment / supplies would have to be secured if the "screen and treat" approach is to be successful on a wider scale. There is ongoing need for HPV vaccination in DRC as a primary prevention strategy against cervical cancer.

Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent.

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

Access to High Quality Surgical Repair Services is a Fundamental Right of Patients with Obstetric Fistulas: A Study on Quality of Life Data in the Democratic Republic of the Congo.

Purpose: The aim of this study was to assess quality of life (QoL) using the WHOQOL-BREF questionnaire among obstetric fistula (OF) patients before and after surgical repair of OF (SROF). Methods: A longitudinal cohort study was conducted between November 2022 and October 2023 in the Democratic Republic of the Congo (DRC) among OF patients to assess their QoL before and after SROF. A systematic sampling technique was used to recruit a total of 158 OF patients. The WHOQOL-BREF questionnaire assessed general health, life experience, as well as physical, social, psychological, and environmental domains. Results: The mean age among the 158 respondents was 33.51 ± 9.63 years, and 77.85% of them lived in rural areas. In terms of surgical outcomes, 80.38% had closure of the OF with regained continence, 5.7% had closure of the OF with persistent incontinence, and 13.9% had a failed surgical repair. Overall mean QoL scores were higher after OF surgical repair (3.83, standard deviation [SD]=0.89) in comparison to pre-operative (1.58, SD=0.63) (p<0.001). These QoL improvements included physical (mean score 66.32 post-surgery versus 28.37 before, p<0.001), social (mean score 64.92 post-surgery versus 27.90 before, p<0.001), psychological (mean score 68.09 post-surgery versus 21.28 before, p<0.001), environmental (mean score 48.41 post-surgery versus 16.91 before p<0.001), and general domains. Patients with a successful OF repair had a better QoL score than those with a closed fistula but ongoing incontinence or those for whom surgery failed to close the fistula. Conclusion: The present study showed that among OF patients, all QoL domains were impaired before surgical repair and significantly improved after surgery. Successful OF closure alleviates the consequences of OF and helps to restore patients' wellbeing. Our findings call for improved access to high-quality surgical repair services as a fundamental right for OF patients.

Integrating Client Tracker Tool Into Fistula Management: Experience From the Fistula Care Plus Project in the Democratic Republic of Congo, 2017 to 2019.

This study aimed to document the experience of integration and the contribution of the Client Tracker (CT) to female genital fistula (FGF) management and data quality in sites supported by the Fistula Care+ Project in the Democratic Republic of Congo (DRC), from 2017 to 2019. It was a parallel mixed methods study using routine quantitative data and qualitative data from in-depth interviews with the project staff. Quantitative findings indicated that CT forms were present in the medical records of 63% of patients; of these, 38% were completely filled out, and 29% were correctly filled out. Qualitative findings suggested that the level of use of CT in the management of FGF was associated with staff familiarity with the CT, staff understanding of concepts in the CT forms, and the CT-related additional workload. The CT has mainly contributed to improving data quality and reporting, quality of care, follow-up of fistula patients, and self-supervision of management activities. A possible simplification of the CT and/or harmonization of its content with existing routine forms, coupled with adequate continuous training of staff on record-keeping, would further contribute to maximizing CT effectiveness and sustainability.

Childbirth-Associated Fistula and Perineal Tears Repaired on Outreach Campaigns in Remote Democratic Republic of Congo.

PURPOSE: To describe the demographics and evaluate the repair of childbirth-associated injuries leading to incontinence in patients in remote Democratic Republic of Congo (DRC). PATIENTS AND METHODS: Four surgical outreach campaigns were organised between March 2018 and October 2019. These campaigns specifically targeted women with incontinence secondary to childbirth-associated injuries. Patients were recruited on a voluntary basis, and locations included Katako-kombe (Sankuru province), Wamba (Haut Uelé province), Karawa (North Ubangi province) and Kipaka (Maniema province). Necessary care was provided along with informal teaching with local healthcare professionals. RESULTS: A total of 481 patients,14-71 years old with a mean of 32 years of age, were included in this study. The average duration of incontinence associated with a childbirth injury was 6.8 years. Vesicovaginal fistulas (277/481; 57.6%) and perineal tears (148/481; 30.8%) were predominant, while the combination of vesicovaginal and rectovaginal fistulas were seen in only 5 (1.0%) patients. Vaginal delivery (259/481; 53.9%), caesarean section (120/481; 25.0%) and laparotomy (hysterectomy) (102/481; 21.2%) were identified as the causes of the fistulas treated during the surgical campaign. Vesicovaginal fistulas were more likely to require complex repairs, as compared to rectovaginal fistulas and perineal tears (P-value <0.0001). As well, vesicovaginal fistulas were less likely to result in successful resolution of the incontinence when compared to rectovaginal fistulas and perineal tears (P-value < 0.0001). CONCLUSION: Vesicovaginal fistulas are predominant among childbirth injuries encountered in remote DRC with poorly managed vaginal deliveries being the leading cause. Cure rate of fistulas and perineal tears is high during outreach campaigns; however, long-term follow-up is limited. There remains a need to train and mentor rural medical professionals in the DRC on adequate management of obstetric emergencies.

Obstetric vesico-vaginal fistulae seen in the Northern Democratic Republic of Congo: a descriptive study.

BACKGROUND: The Democratic Republic of Congo (DRC) is a developing country with poor obstetric indicators. Despite ongoing efforts to improve care, women continue to suffer multiple complications of child birth including vesico-vaginal fistulae (VVF). OBJECTIVE: To describe socio-demographic and clinical characteristics of VVF patients in Northern DRC. METHODS: Women presenting at two VVF mobile surgical campaign missions in the province of Equateur in Northern DRC in August 2012 and October 2013 were examined and treated for VVF. We collected socio-demographic data, including marital status, education, and accompaniment by husbands for treatment, as a proxy for marital support, and clinical data related to characteristics of VVF in patients, duration of illness, and the outcome of treatment surgery. RESULTS: Out of 163 VVF patients, 100 (61.3%) were less than 35 years old, 102 had no formal education ( 62.6%), and 100 were married ( 61.3%). The mean duration of illness before surgery was 8.4 years. Successful surgery rate for VVF was 87.1% (142/163). A majority of patients who were married, were accompanied to the hospital by their husbands for treatment (56/100; 56.00%). Association analysis revealed age was the only variable that maintained significant association with duration of illness after multivariate analysis (p-value <0.0001). Marital status was the only variable associated with surgical outcome (0.334, 95% CI 0.125- 0.847, p-value = 0.021). CONCLUSION: We found that most VVF patients were young adults, not educated, and married. Marital status and age may have important roles in outcome of VVF surgery and duration of illness, respectively.