The changing face of obstetric fistula surgery in Ethiopia

Abstract

ObjectiveTo examine the incidence and type of obstetric fistula presenting to Hamlin Fistula Ethiopia over a 4-year period.Study designThis is a 4-year retrospective survey of obstetric fistula treated at three Hamlin Fistula Hospitals in Ethiopia, where approximately half of all women in the country are treated. The operation logbook was reviewed to identify all new cases of obstetric fistula presenting from 2011 to 2015. New cases of urinary fistula were classified by fistula type (high or low), age, and parity of the woman.ResultsIn total, 2,593 new cases of urinary fistulae were identified in the study period. The number of new cases fell by 20% per year over the 4 years (P<0.001). A total of 1,845 cases (71.1%) were low (ischemic) fistulae, and 804 cases (43.6%) of these had an extreme form of low circumferential fistula. A total of 638 (24.6%) women had a high bladder fistula, which predominantly occurs following surgery, specifically cesarean section or emergency hysterectomy, and 110 (4.2%) women had a ureteric fistula. The incidence of high fistulae increased over the study period from 26.9% to 36.2% (P<0.001). A greater proportion of multiparous women had a high bladder fistula (70.3%) compared with primigravid women (29.7%) (P<0.001). Conversely, a greater proportion of primiparous women experienced a low circumferential fistulae (68.6%) compared with multiparous women (31.4%) (P<0.001).ConclusionThere appears to be a decline in the number of Ethiopian women being treated for new obstetric urinary fistulae. However, the type of fistula being presented for treatment is changing, with a rise in high fistulae that very likely occurred following cesarean section and a decline in the classic low fistulae that arise following obstructed childbirth.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda

“…A recent study in Ethiopia found increasing numbers of "high" fistulas that occurred after the cesarean section rather than "low" fistulas, which are more commonly caused by obstructed labor. 19 A review article recently published also supports the idea that there may be more iatrogenic fistulas than previously thought. 20 Further clinical examination would be required to clarify the true cause of the fistulas in this study and in other women in Uganda experiencing obstetric fistula.…”

“…20 Further clinical examination would be required to clarify the true cause of the fistulas in this study and in other women in Uganda experiencing obstetric fistula. The fact that there were higher resourced patients (eg, those with college education) as well as a relatively high rate of live births (19,35.85%) could indicate a subset of the population had iatrogenic injury. A total of 31 (58.4%) of the participants had delivered by caesarian sections.…”

“…During this birth that resulted in obstetric fistula, almost every participant received some form of antenatal care (50, 94.34%; n = 53) and the majority had at least 4 visits (30, 56.60%; n = 53). Meurice et al Social Experiences of Women with OF Seeking Treatment in Kampala, Uganda Stillbirth was the most common neonatal outcome (31, 58.49%, n = 53), followed by live birth (19,35.85%; n = 53).…”

Trajectories of women's physical and psychosocial health following obstetric fistula repair in Uganda: a longitudinal study

“…Our sample included participants with childbirth-related fistula due to pressure necrosis from obstructed labour and iatrogenic aetiologies; however, designation of likely iatrogenic among this sample was retrospectively assigned using medical record criteria [36]. Our findings can be considered generally representative of women with obstetric fistula, but further research exploring differences in recovery trajectories by aetiology is of interest, particularly as iatrogenic female genital fistula appears to be increasing [66]. Our study is both strengthened and limited by the length of follow-up; our focus on the 12 months following surgery expands the length of follow-up conducted in many other studies, yet may be inadequate to understand the rates and consequences of fistula recurrence and adverse perinatal outcome over a woman's reproductive life, both of which have been found to be high among women receiving surgical repair for obstetric fistula [67].…”

Obstetric fistula: a paradigm shift is needed in research and prevention

“…Fistulae in high‐income countries tend to complicate surgery and radiation therapy, unlike in LMICs where the majority of fistulae occur as a result of obstructed labour. However, with increased access to caesarean sections in LMICs, it has been noted that the number of postsurgical fistulae is increasing, which is assumed to be related to the quality of surgical care …”