Risk factors for early and late failures following repair of urogenital fistulas.

INTRODUCTION AND HYPOTHESIS: In Sub-Saharan Africa, obstetric fistulas are a health crisis of extensive proportions. Although risk factors for failure are described, little data exist regarding differences in risk factors for early and late recurrences. METHODS: A retrospective cohort study was conducted to evaluate risk factors for fistula recurrence. Inclusion criteria included women who underwent repair of urogenital fistula at a Fistula Hospital in Uganda between 2013 and 2019. Our primary objective was to determine the incidence of both early and late failures and to identify and compare risk factors for each. Logistic regression was used to calculate crude odds ratios (ORs) and 95% confidence intervals (CIs) representing the association between each risk factor for early and late failures. Covariates significantly associated with early or late failure in univariate analyses were included in multivariate logistic regression models. RESULTS: A total of 541 patients were included. The incidence of early failure was 10.9%. Risk factors for early failure included stillbirth (aOR = 3.71, 95% CI: 1.38-9.96), fistula larger than 3 cm, (aOR = 3.12 95% CI: 1.40-6.93), presence of foot drop (aOR = 4.74, 95% CI:1.88-11.97), and perioperative blood transfusion (aOR = 3.10, 95% CI: 1.11-8.66). Risk factors for late failures included stillbirth (aOR = 4.63, 95% CI:1.04-20.51), and previous fistula repairs (aOR = 3.13, 95% CI:1.30-7.56). CONCLUSION: Both early and late failures can occur and risk factors for each may be different. Identifying patients at risk for late failures is important for improved counseling and highlights the importance of developing risk-reducing strategies to improve patient outcomes after discharge.

Improving non-technical skills (teamwork) in post-partum haemorrhage: A grouped randomised trial.

OBJECTIVE: To determine the effect of a decision support technology on teamwork and associated non-technical (NTS) and technical skills when teams manage post-partum haemorrhage (PPH) in the simulated environment. METHODS: Multidisciplinary (MDT) maternity teams were taught how to manage post partum haemorrhage. They were randomised to the intervention: using a decision support mobile digital platform or a control group. Each team managed a post-partum simulation, which was recorded and reviewed by assessors. Primary outcome measures to assess teams NTS were the validated Global Assessment of Obstetric Team Performance (GAOTP) and Clinical Teamwork Scale (CTS). Secondary outcome measures were the 'friends and family test', technical skills, and the System Usability Scale (SUS). Sample size estimation was calculated by using 80% power 5% significance two tailed test (p1=85% p2=40%) n=34. RESULTS: 38 teams from August 2014-February 2016, were recruited, technical issues with failure of recording equipment meant 4 teams were excluded from teamwork analysis (1 intervention 3 control). Teamwork improved across all domains with the intervention (using a decision support mobile digital platform) p <0.01. CTS improved between 6.7-16.8% (average 14.2%) and GAOTP between 8.6-17.1% (average 13.5%) for all domains. Using the control group as baseline, the intervention improved teamwork by 25% using CTS and 22% using GAOTP. Fewer technical skills were missed with the intervention (p<0.01). There was no statistical difference in the time technical skills were achieved. Assessors were more likely to recommend intervention teams 87.5% (77/88) than control teams 63.6% (56/88) p<0.01 to their friends or family. The SUS was 'Good' (69) becoming excellently 'Usable' (81.6) over the study period. CONCLUSION: We report a decision support system, which improved NTS when managing PPH. Lack of teamwork is often cited as the cause of failures in care and we report a usable technology that assists with and improves teamwork during an emergency.

MedNav - helping midwives manage neonatal resuscitation in resource poor settings.

We set out to understand whether MedNav, a digital decision support tool, improves the quality of neonatal resuscitation practice in resource poor settings. A 6-month long trial in Uganda showed that adherence to good practice increased from a mean of 46% without MedNav to 94% with MedNav. The mean system usability score was self-assessed at 84.5%. While the younger midwifery team liked MedNav, it was unpopular with senior members of staff who felt that staff should not rely on support tools even if they improved -clinical practice. Next steps include a larger scale study -looking at neonatal survival outcomes and greater attention to the -barriers that need to be overcome in order to enhance -acceptance and adoption.

Delivery room logbook - fact or fiction?

The delivery room logbook entries of Gimbie Adventist Hospital for a period of one month were monitored and compared with the actual number of births recorded on a separate worksheet for that period. The implications of the missing data were reviewed. This data was compared to a previous audit of the same design. Eighty per cent of births were recorded during this one month period which reflected an improvement from 72% reported in a previous study. Underreporting resulted in discrepencies when calculating the number of births and signal functions such as caesarean section rates, blood transfusion, administration of parenteral anticonvulsants and removal of retained products. In turn, these discrepencies impact the calculation of process indicators of safe motherhood projects. The reliability of the delivery room logbook as the sole source of information to create health policy and to monitor and evaluate health programs is questionable.

A case series of bleeding due to Leech infestation from the Gimbie region, Ethiopia.

We present a case series of patients who presented to Gimbie Adventist Hospital (GAH), Western Wollege, Ethiopia. GAH is located in the town of Gimbie in the Western Wollega province of Ethiopia, about 450 km west of Addis Ababa. Gimbie zone is 9 degrees north of the equator at 2000 m. There are 'area' wells, which supply only a minority of the population. The patients presented with bleeding of unknown aetiology and supportive care was the initial management. Leech infestation was found to be the cause of the bleeding. In Western Ethiopia in a patient presenting with bleeding of unknown aetiology, leech infestation is an important differential diagnosis.