Genito-urinary fistula patients at Bugando Medical Centre.

BACKGROUND: Information was collected on 1500 obstetric fistula patients attending Bugando Medical Centre (BMC) in Mwanza, Tanzania. OBJECTIVES: To identify high risk populations of fistula patients treated from 1998-2006. DESIGN: A prospective description study of 1294 patients treated for urine and faecal incontinence at BMC. SETTING: Obstetrics and Gynaecological ward at Bugando Medical Centre. INTERVENTIONS: A total of 1294 patients underwent surgical treatment of incontinence. MAIN OUTCOME MEASURES: Of the 1294 surgical repairs, 84% of the patients were cured, 12% had stress incontinence and 4% failed. CONCLUSIONS: The study shows that low education and poverty were the key factors in the development of fistula. Most obstetric fistulae can be cured, particularly during the first attempt by those properly trained in the skills. Prevention of genital fistula requires raising the education and social status of women including poverty reduction strategies, improving the quality of antenatal care. Increased access to Caesarean section is also needed for prevention of genitourinary fistulas.

Successful management of vesicovaginal fistulae at St. Gaspar Hospital, Itigi, Singida, Tanzania: a preliminary report.

Twenty five patients with vesicovaginal fistulae were managed at St. Gaspar Hospital, Itigi, Tanzania between February 1993 and March 1994. Most of them, 92% were repaired vaginally routinely using the Martius labial flap and 8% were repaired transabdominally because the fistulae were inaccessible vaginally as they were vesicouterine or vesicocervical fistulae. The success rate was 96% after the first operative attempt.

PIP: Since there are no specialized fistula centers in Tanzania, fistulae are usually repaired in national referral hospitals where other surgical conditions are managed. Only a few small hospitals attempt the repair, forcing women from remote rural areas to travel long distances in search of treatment. St. Gaspar Hospital, in Itigi, however, is a small, rural facility which has offered the routine management of vesicovaginal fistulae (VVF) since February 1993. 25 patients with various sized VVF were managed at the hospital between February 1993 and March 1994. All patients had their fistulae confirmed by vaginal examination using a Sim's speculum. The VVF resulted in 96% of cases from prolonged or difficult labor, with the most common form of VVF being the very large fistulae, among 28%, followed by the big juxta-cervical fistulae, among 24%. Twelve patients were aged 15-24 years, while the remainder were aged 25-40. 92% were repaired vaginally routinely using the Martius labial flap. The remaining 8% were repaired transabdominally given the inaccessibility of vesicouterine or vesicocervical fistulae via the vagina. All patients were administered postoperative prophylactic antibiotics for five days and had indwelling catheters for 14 days. They were then discharged home one or two days after removal of the catheter with advice that they should abstain from sexual intercourse for three months, avoid pregnancy for one year, and deliver by cesarean section should they become pregnant. An outcome was considered successful when the patient left the hospital dry and remained so upon the follow-up visit 6-8 weeks later; the success rate was 96% after the first operative attempt.

Pregnancy intervals: their determinants and foetal outcome at the KCMC, Moshi, Tanzania.

A total of 566 multigravidae who delivered at the Kilimanjaro Christian Medical Centre (KCMC), Moshi, between 15th May and 30th July, 1989, were interviewed to determine the pregnancy intervals, their determinants as well as foetal outcome. 62.1% of the study group had pregnancy intervals longer than 2 years. The factors which appeared to influence pregnancy interval in this study included maternal age, period of breastfeeding, postpartum amenorrhoea, postpartum coital abstinence, contraception and outcome of the preceding pregnancy. Other factors such as maternal education, occupation, marital status, pregnancy order, and religion, did not appear to have any effect on the pregnancy intervals. The pregnancy interval did not seem to affect the outcome of the index pregnancy. It is recommended that those factors with a positive impact on pregnancy interval be promoted as widely as possible in Tanzania, so as to contribute toward the control of population growth, as well as the overall maternal and child health, and national economy.

PIP: Between May 15 and July 30, 1989, in northern Tanzania, two obstetricians interviewed 566 multigravida women, 17-48 years old, who delivered at the Kilimanjaro Christian Medical Centre in Moshi to examine the determinants of birth intervals and their effect on fetal outcome. The pregnancy interval between the last and index pregnancies was greater than 2 years in 62.1% of cases. Older women tended to have a longer pregnancy interval than younger women (p .05). As the length of breast feeding increased so did the pregnancy interval. 62% of the women breast fed for more than 12 months. The greater the length of postpartum amenorrhea, the longer the pregnancy interval was. Other factors which had a positive association with pregnancy interval were postpartum sexual abstinence and contraceptive use. The most common contraceptive methods were oral contraceptives and IUD. Women who experienced an adverse preceding pregnancy outcome had a shorter pregnancy interval than those who had a positive pregnancy outcome ( 2 years, 27% for perinatal deaths vs. 70.7% for good outcome; p .05). No correlations existed between pregnancy interval and index pregnancy outcome. This was unexpected and could be explained by the fact that most of the women received prenatal care and delivered at the hospital, that husbands and families have traditionally cared well for pregnant women, or that the women were of good nutritional status. the researchers recommended that health education should stress the factors linked to long pregnancy intervals to help Tanzania reduce its high fertility rates.

Acute pelvic infection following hysterosalpingography at the Kenyatta National Hospital, Nairobi.

A total of 150 women who had hysterosalpingography (HSG) for investigation of infertility, at the Kenyatta National Hospital over a five month period, were recruited into the study to determine the prevalence of pelvic infection following the procedure. 44.0% of the total study group developed pelvic infection disease (PID) within the first week after the procedure. There were no obvious determining factors. It is possible that most women with infertility have quiescent genital tract infection, prior to HSG, with the latter only facilitating the entry of micro-organisms into the upper genital tract, thus causing pelvic infection or reactivating a pre-existing infections. Further studies should be conducted to determine the microbial patterns of the infection. There should be routine provision of prophylactic antimicrobial agent(s) to all women undergoing HSG in our unit to minimise the risk of developing pelvic infection and further damage to the uterine tubes which will worsen the prognosis.

PIP: Between September 1988 and January 1989 in Kenya, health care providers recruited 150 infertile women, 15-39 years old, who had gone to a gynecological outpatient clinic at Kenyatta National Hospital in Nairobi to undergo hysterosalpingography to determine the condition of the uterus and fallopian tubes. The aim of the study was to determine whether there was an association between hysterosalpingography and pelvic inflammatory disease (PID) and the determinants for PID. Most women were between 20-29 years old, married, and had a primary education (67.3%, 90.7%, and 55.3%, respectively). One week after hysterosalpingography, 44% developed acute PID, defined as having at least 2 of the following signs or symptoms: lower abdominal pain, rebound tenderness, cervical/adnexal tenderness, foul smelling vaginal discharge, adnexal mass(es), and fever of at least 38 degrees Celsius. The most frequent signs and symptoms were lower abdominal pain and tenderness. Married women were more likely to have PID than unmarried women (47.1% vs. 14.3%). The small numbers of unmarried women made it difficult to determine the significance of the difference, however. Sexual intercourse within the 1st week after hysterosalpingography was not associated with PID (45.2% for PID cases vs. 42.1% for non-PID cases). The researchers believed that hysterosalpingography pushed existing pathogens in the vagina into the uterus, or the women already had asymptomatic PID. They recommended further studies to determine whether physicians should administer prophylactic antibiotic therapy to all women undergoing hysterosalpingography.