Fistula in War-Torn Tigray: A Call to Action.

Fistula is roaring in the ongoing war on Tigray. The potential risk factors for fistula in the conflict zone include obstructed labour due to limited or absent maternal care services, a correlation between malnutrition-stunted growth and birth difficulties and trauma, and sexually transmitted infections (STIs) due to conflict-related sexual violence. As a call to action to mitigate the unimaginable suffering that women and girls are facing in the region, concerted international effort is needed to provide treatment, rehabilitation, and re-integration; secure peace and stability; rebuild the health-care system; and ensure perpetrators are held accountable.

Surgical Management of Pelvic Organ Prolapse in Ethiopian Women: What Is the Preferred Approach?

OBJECTIVES: The aim of this study was to determine the most effective approach to surgical repair of pelvic organ prolapse for Ethiopian women and to characterize this population. METHODS: This is a prospective cohort study of women presenting for prolapse repair. Demographics and assessments of prolapse were obtained preoperatively. Information surrounding the surgical encounter was collected. The same anatomic and symptomatic measures were ascertained postoperatively. Information regarding surgical complications was collected. RESULTS: Two hundred thirty-three women with stage III or IV prolapse underwent surgical prolapse repair between March 2015 and November 2017. Seventy-eight of these women participated with a median length of follow-up of 255 days. All of the sacrocolpopexy patients (n = 21) and 56 of 57 vaginal repair patients had follow-up anatomic data. Anatomic failure as defined by Pelvic Organ Prolapse-Quantification (Ba, C, or Bp > 0) occurred in 0% (0/21) of sacrocolpopexy patients and 34% (19/56) of vaginal repair patients (P = 0.005). Symptomatic failure, as defined by self-reported recurrence of vaginal bulge, occurred in 0% (0/21) of sacrocolpopexy patients and 23% (13/56) of vaginal repair patients (P = 0.015). A global assessment of improvement (worse, same, or improved) revealed that 100% (21/21) of sacrocolpopexy patients reported improvement, whereas 91% (50/55) of vaginal repair patients reported improvement, 7% (4/55) reported being the same, and 2% (1/55) reported being worse. There were 2 intraoperative complications and 3 postoperative complications. There were no cases of mesh erosion. CONCLUSIONS: Although both vaginal and abdominal routes of prolapse surgery seem to be safe, an abdominal approach with mesh augmentation may be the preferred surgical repair in Ethiopian women.

Capacity building in female pelvic medicine and reconstructive surgery: Global Health Partnership beyond fistula care in Ethiopia.

OBJECTIVE: Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it. METHODS: Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia. RESULTS: This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum. CONCLUSION: We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

A case-control study of the risk factors for obstetric fistula in Tigray, Ethiopia.

INTRODUCTION AND HYPOTHESIS: We tested the null hypothesis that there were no differences between patients with obstetric fistula and parous controls without fistula. METHODS: A unmatched case-control study was carried out comparing 75 women with a history of obstetric fistula with 150 parous controls with no history of fistula. Height and weight were measured for each participant, along with basic socio-demographic and obstetric information. Descriptive statistics were calculated and differences between the groups were analyzed using Student's t test, Mann-Whitney U test where appropriate, and Chi-squared or Fisher's exact test, along with backward stepwise logistic regression analyses to detect predictors of obstetric fistula. Associations with a p value <0.05 were considered significant. RESULTS: Patients with fistulas married earlier and delivered their first pregnancies earlier than controls. They had significantly less education, a higher prevalence of divorce/separation, and lived in more impoverished circumstances than controls. Fistula patients had worse reproductive histories, with greater numbers of stillbirths/abortions and higher rates of assisted vaginal delivery and cesarean section. The final logistic regression model found four significant risk factors for developing an obstetric fistula: age at marriage (OR 1.23), history of assisted vaginal delivery (OR 3.44), lack of adequate antenatal care (OR 4.43), and a labor lasting longer than 1 day (OR 14.84). CONCLUSIONS: Our data indicate that obstetric fistula results from the lack of access to effective obstetrical services when labor is prolonged. Rural poverty and lack of adequate transportation infrastructure are probably important co-factors in inhibiting access to needed care.