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Fistula after attended delivery and the challenge of obstetric care capacity in the eastern Democratic Republic of Congo
International Journal of Gynecology and Obstetrics 130 (2015) 157–160
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Fistula after attended delivery and the challenge of obstetric care capacity in the eastern Democratic Republic of Congo☆ Nerys Benfield a,⁎, Nichole Young-Lin b, Christophe Kimona c, Luc M. Kalisya c, Rogatien M. Kisindja d a
Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, NY, USA University of California, San Francisco, San Francisco, CA, USA Department of Surgery, HEAL Africa Hospital, Goma, Democratic Republic of Congo d Department of Obstetrics and Gynecology, HEAL Africa Hospital, Goma, Democratic Republic of Congo b c
a r t i c l e
i n f o
Article history: Received 8 September 2014 Received in revised form 6 February 2015 Accepted 21 April 2015 Keywords: Healthcare capacity Maternal complications Obstetric fistula
a b s t r a c t Objective: To analyze the history of women with fistula in the eastern Democratic Republic of Congo (DRC) to understand the determinants of fistula development. Methods: In a retrospective observational study, data were analyzed from a survey of all women who underwent surgical fistula repair at HEAL Africa Hospital, Goma, between April 1, 2009, and March 1, 2012. Characteristics and obstetric histories were obtained by selfreport. Results: The mean age of the 202 participants at treatment was 30.7 years (range 5–69). The mean duration of fistula was 45.6 months (range 0–600). In total, 171 (91.4%) fistulas were caused by obstructed labor, and 147 (86.5%) were vesicovaginal. Most women (129/175 [73.8%]) reported having received care during early labor under the supervision of a nurse or doctor in a healthcare facility. Among 176 women for whom delivery data were available, 102 (57.9%) delivered at a hospital, 42 (23.8%) at a health center, and 32 (18.2%) at home. Only 46 (26.3%) of 175 women were transferred to a higher level of care during labor. Conclusions: In the eastern DRC, efforts to enable transport to a healthcare facility and to encourage attended births must be accompanied by improvements in the capacity of existing facilities and in the training of staff to enable the timely diagnosis of labor abnormalities and appropriate intervention. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Genital fistula—an abnormal connection between the vagina or uterus and the urethra, bladder, rectum, or colon—is a serious condition that affects an estimated 2–3 million women around the world [1,2]. Most genital fistulas are caused by obstructed labor complicated by a lack of access to emergency obstetric care. Worldwide, there are approximately 50 000–100 000 new cases each year, and in low-resource settings, the frequency can be as high as 2–5 cases per 1000 deliveries [3]. Genital fistula typically causes considerable physical and psychological problems including urinary and/or fecal incontinence, vaginal stenosis, pelvic pain, social isolation, rejection by husbands and families, and unemployment [4–7]. As in many other low-resource settings, genital fistula is a problem in the eastern Democratic Republic of Congo (DRC). The DRC is the fourth most populous country in Africa and has vast natural resources. However, since the mid-1990s, this area has been affected by civil war, resulting in the destruction of infrastructure, worsening poverty,
☆ Presented at the XX FIGO World Congress of Gynecology and Obstetrics; October 7–12, 2012; Rome, Italy. ⁎ Corresponding author at: 1695 Eastchester Rd, Suite 501, Bronx, NY 10461, USA. Tel.: +1 718 405 8030; fax: +1 718 405 8051. E-mail address: nbenfiel@montefiore.org (N. Benfield).
and massive displacement of its population; in 2014, the DRC ranked second to last (rank 186) on the Human Development Index [8]. It is estimated that over 5.4 million people have died because of this conflict, and more than 1 million girls and women have experienced sexual violence, with approximately 15 996 new cases of sexual violence in 2008, 65% of which occurred to children and adolescents younger than 18 years [9,10]. The fertility rate in the DRC remains high at 6.04 births per woman, with a maternal mortality ratio of 540 per 100 000 live births [11,12]. Nationally, 80.4% of births in 2010 were reported to be attended by skilled health professionals [11]. However, the government healthcare expenditure at the time was only US$7 per head, and the effect of the conflict on healthcare capacity has probably been significant. The incidence of genital fistulas in the DRC is not available, but a study of Sub-Saharan Africa [13] estimated that there are at least 33 000 new genital fistula cases each year. Given its history, the DRC will have a heavy—and probably disproportionate—fistula burden. In settings like the DRC, the lack of access to emergency obstetric care can be the result of delays in seeking care, getting to a care facility, and obtaining appropriate care once in a facility [14]. The present study aimed to describe the demographic and obstetric histories of women undergoing fistula repair in the eastern DRC to elucidate the factors that contribute to fistula development in this conflict-affected setting.
http://dx.doi.org/10.1016/j.ijgo.2015.02.032 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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N. Benfield et al. / International Journal of Gynecology and Obstetrics 130 (2015) 157–160
2. Methods The present retrospective observational study is an analysis of data from a survey of all women who underwent fistula surgery at HEAL Africa Hospital in Goma, North Kivu, in eastern DRC, between April 1, 2009, and March 1, 2012. All participants gave verbal consent for their information to be collected. The present research was approved by the institutional review boards of HEAL Africa Hospital and the University of California, San Francisco, USA. HEAL Africa Hospital is a tertiary care hospital that is run by a Congolese non-governmental organization, and has a dedicated fistula care program. Since 2004, more than 2000 fistula repair surgeries have been performed, with an average of 100–150 surgeries per year. Women with fistula in the region who might be candidates for surgical repair are identified through rural outreach campaigns, as well as word of mouth. Most patients remain in recovery at HEAL Africa Hospital for at least 1–2 months awaiting transportation home or additional surgery. The present survey was performed by healthcare providers and focused on the etiology, classification, and surgical treatment of fistulas, and on the recovery after fistula repair. Information was gathered through patient self-report and physician assessment at multiple timepoints throughout the patient’s hospitalization: obstetric history was obtained on admission, surgical details were recorded on completion of surgery, and data on postoperative recovery (including complications and response to pelvic physical therapy) were obtained during the recovery phase. The fistula cause was determined by the physician who performed the physical examination at admission on the basis of clinical judgment and patient history. Fistulas that were cervicovesical, uterovesical, or at the site of the hysterotomy or hysterectomy incision were classified as surgical in etiology. Fistulas that occurred with a history of genital trauma outside pregnancy were classified as traumatic. A hospital was defined as a healthcare facility with the capacity to perform cesarean delivery, and a health center was defined as a healthcare facility without this capacity. The data were initially recorded on a paper chart and transferred to an electronic database using Epi Info version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Descriptive statistics were obtained using Epi Info and Excel 2011 (Microsoft, Redmond, WA, USA). All women with a fistula were included in the demographic analysis. The analysis of delivery-related data included only the women whose fistulas were presumed to be obstetric in origin.
Table 1 Demographic characteristics.a Characteristic
Value
Age at treatment, y (n = 186) Gravidity (n = 197) Primigravid Parity (n = 197) Primiparous Number of living children (n = 192) Childless Age at marriage, y Marital status before fistula (n = 187) Married Single Widowed Divorced Marital status after fistula (n = 181) Married Single Widowed Divorced Education (n = 192) Illiterate Primary school Secondary school Province of origin (n = 202) North Kivu South Kivu Maniema Katanga Orientale Kasai Orientale
30.7 (5–69) 3.8 (1–13) 77 (39.1) 3.5 (0–12) 75 (38.1) 1.9 (0–9) 88 (45.8) 17.2 (12–40)
a
140 (74.9) 18 (9.6) 13 (7.0) 16 (8.6) 87 (48.1) 21 (11.6) 20 (11.0) 53 (29.3) 142 (74.0) 31 (16.1) 19 (9.9) 121 (59.9) 18 (8.9) 48 (23.7) 9 (4.5) 5 (2.5) 1 (0.5)
Values are given as mean (range) or number (percentage).
The average time between fistula formation and repair varied from 0 to 600 months, with a mean duration of 45.6 months (Table 2). Most fistulas were either repaired within 1 year of development (57/144 [39.6%]) or after more than 5 years (34/144 [23.6%]). The etiology of the genital fistulas was mostly obstetric (Table 2). After surgical repair, 38 (26.4%) of 144 women had persistent incontinence. Of the 154 women who reported their prenatal care access, 105 (68.2%) stated that they had attended at least one prenatal care visit, whereas 49 (31.8%) had not attended prenatal care. Overall, 44 (25.1%) of 175 women reported that they remained at home during early labor; 62 (35.4%) presented to a hospital, and 69 (39.4%) presented to a health center (Fig. 1). Overall, 8 (4.6%) of 175 women did not have any assistance during early labor, 19 (10.9%) had a family member
3. Results In total, 202 women were surveyed. The mean age at the time of treatment was 30.7 years (median 29). The patients came from six different provinces; most originated from North Kivu and Maniema (Table 1). Forty-five languages were represented, the most common being Kinyabwisha (spoken by 43/194 [22.2%]), Kinyarwanda (28/194 [14.4%]), and Kinande (19/194 [9.8%]). Most women were illiterate (Table 1). The average distance from their home to the nearest hospital was 52 km (range 0–600). Given the prevalence of violence against women in the conflict-affected DRC, it is not surprising that 53 (28.9%) of 183 women reported having experienced sexual violence at some point in their lives. The women were generally small, with a mean weight of 52 kg (median 50; range 32–76). Before developing the fistula, most respondents were married (Table 1). Among 169 women who had been married, 140 (82.8%) were married before the age of 20 years. The distribution of married versus divorced women changed dramatically after fistula development: less than half the patients were married (Table 1). The average age at fistula development was 24.2 years (Table 2); 102 (61.1%) of 167 fistulas occurred before the age of 25 years. Vesicovaginal fistula was the most common type, followed by rectovaginal fistula and combined rectovaginal and vesicovaginal fistulas (Table 2).
Table 2 Clinical characteristics.a Characteristic
Value
Age at fistula development, y (n = 167) Duration of fistula, mo (n = 144) Type of fistula (n = 170) Vesicovaginal Combined recto- & vesicovaginal Rectovaginal Other Fistula etiology (n = 187) Obstetric Surgical Trauma Neoplastic Neonatal outcome (n = 173) Stillbirth Died within b1 week Alive Mode of delivery (n = 176) Spontaneous vaginal delivery Assisted vaginal delivery Cesarean delivery
24.2 (5–59) 45.6 (0–600)
a
Values are given as mean (range) or number (percentage).
147 (86.5) 10 (5.9) 10 (5.9) 3 (1.8) 171 (91.4) 10 (5.3) 5 (2.7) 1 (0.5) 128 (73.9) 2 (1.2) 43 (24.9) 64 (36.3) 33 (18.7) 79 (44.9)
N. Benfield et al. / International Journal of Gynecology and Obstetrics 130 (2015) 157–160
120
Women, %
100 80 60 40 20 0 At home without assistance
At home
Early Labor
Health Center
Hospital
Delivery
Fig. 1. Location of early labor and eventual delivery (n = 175).
with them, 19 (10.9%) a traditional birth attendant, 35 (20.0%) a doctor, 75 (42.9%) a nurse, and 19 (10.9%) at least one doctor and one nurse (Fig. 2). Of the 44 women who started labor at home, 7 (15.9%) were transported to a health center and 6 (13.6%) were eventually brought to a hospital for the delivery. Of the 69 who began labor at a health center, 33 (47.8%) were transferred to a hospital and 1 (1.4%) left the health center to deliver the child at home. Therefore, 46 (26.4%) of the 175 patients with a fistula for whom obstetric history data were obtained were transferred to a higher level of care (e.g. from home to a health center or hospital, or from a health center to a hospital). Overall, 102 (57.9%) of 176 women eventually gave birth at a hospital; 42 (23.8%) delivered at a health center and 32 (18.2%) delivered at home (Fig. 1). The delivery of 4 (2.3%) of 175 women for whom data were available was unattended; 10 (5.7%) women had a family member attend the birth, 16 (9.2%) had a traditional birth attendant, 59 (33.7%) had a doctor, 48 (27.4%) had a nurse, and 38 (21.8%) had a doctor and a nurse attend the birth (Fig. 2). Nearly half the births were by cesarean delivery (Table 2). Moreover, 128 (73.9%) of 173 deliveries were stillbirths, and there were 2 (1.2%) neonatal deaths within 1 week of birth. Among the 40 women who had surviving neonates and delivery information, 19 (47.5%) delivered by cesarean, 18 (45.0%) had a spontaneous vaginal delivery, and 3 (7.5%) had an assisted vaginal delivery. 4. Discussion The present study results correlate in many ways with what is known about the population of women with fistula—i.e. that they are 80 70
Women, %
60 50 40 30
159
primarily young and illiterate, tend to become divorced after the development of a genital fistula, and tend to have a stillbirth in the fistulacausing delivery [15]. Despite the high incidence of sexual violence in the eastern DRC, the present results demonstrate that traumatic fistulas are rare compared with obstetric fistulas even in conflict zones, with 91.4% of women having had fistulas of obstetric etiology. In the present case series, 28.9% of the women reported having been sexually assaulted and 2.7% had a trauma-related fistula. This result is comparable with that from the only other publication on sexual-violence-related fistulas in the DRC [9], which showed that 3% of the women with a fistula assessed had a traumatic fistula. The women in the present series had varying access to healthcare facilities, and the reported rate of prenatal care (68.2%) was somewhat lower than the rate of 95% previously reported for all gravid women in North Kivu [16] and the national rate of 89% reported for 2010 [11]. Despite varying geographic access to healthcare facilities and the low frequency of attendance at prenatal care, a substantial proportion of women presenting for fistula repair in the present study reported initiating intrapartum care under the supervision of a nurse or doctor (or both) in a healthcare facility. Only 26.4% of the women were transferred to a higher level of care, and access to cesarean delivery for obstructed labor was available for only around half of the present cohort. In conjunction with the information on the place of early labor, this indicates that although there was a delay for some women in reaching a healthcare facility, there was also a considerable delay in receiving adequate emergency obstetric care at the healthcare facility. This speaks to a lack of physical and human resources in healthcare facilities in the eastern DRC, which could include adequate staff, training (e.g. training in the use of partographs and labor curves, and in the identification of warning signs), functioning operating room suites, and sufficient surgical supplies. More efforts need to be focused on investigating the healthcare capacity at existing facilities and improving resources and training at these facilities, in conjunction with the education of women to increase the rate of attended facility-based deliveries. The present study has several limitations. All historical information was by patient report, leading to a risk of recall bias, especially regarding information about intrapartum care during the incident delivery. There were also no specific criteria for “early labor,” and no information was obtained on the duration of labor and the timing of arrival at a healthcare facility, so it is not known at exactly what point during labor the women presented for care. A detailed evaluation of the significance of the delay in seeking medical care during labor for fistula development was therefore not possible. Moreover, the participants were receiving health care at the time of the present survey, which means that they may not be representative of all women who develop a fistula in this region of the DRC; many of the affected women might never interact with the healthcare system. There were also some issues with the consistency of data collection because of hardware and software difficulties. Nevertheless, the present study presents information on a large group of women with fistula in the eastern DRC. Because the eastern DRC continues to be affected by war and conflict, improvements in the healthcare infrastructure to prevent maternal morbidity and the development of genital fistulas will continue to be a great challenge. The present study indicates that delivering at a healthcare facility is not enough to prevent genital fistulas, and although dissemination of the message to seek intrapartum care is important, it is equally imperative to improve the quality of care at existing facilities.
20 10
Acknowledgments
0 No one
Family
TBA Early Labor
Nurse
Doctor
Doctor + nurse
Delivery
Fig. 2. Attendance at early labor and eventual delivery (n = 175). Abbreviation: TBA, traditional birth attendant.
The fistula repair and reintegration program at HEAL Africa Hospital is funded by EngenderHealth and the Tides Foundation. The present research was funded by the Fellowship in Family Planning and the Clinical and Translational Science Institute at the University of California in San Francisco, CA, USA.
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Conflict of interest The authors have no conflicts of interest. References [1] de Bernis L. Obstetric fistula: guiding principles for clinical management and programme development, a new WHO guideline. Int J Gynecol Obstet 2007; 99(Suppl. 1):S117–21. [2] Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006;368(9542):1201–9. [3] United Nations Population Fund, EngenderHealth. Obstetric fistula needs assessment report: findings from nine African countries. http://www.unfpa.org/fistula/ docs/fistula-needs-assessment.pdf. Published 2003. Accessed April 16, 2015. [4] Tebeu PM, de Bernis L, Doh AS, Rochat CH, Delvaux T. Risk factors for obstetric fistula in the Far North Province of Cameroon. Int J Gynecol Obstet 2009;107(1):12–5. [5] Muleta M, Hamlin EC, Fantahun M, Kennedy RC, Tafesse B. Health and social problems encountered by treated and untreated obstetric fistula patients in rural Ethiopia. J Obstet Gynecol Can 2008;30(1):44–50. [6] Gharoro EP, Agholor KN. Aspects of psychosocial problems of patients with vesicovaginal fistula. J Obstet Gynaecol 2009;29(7):644–7. [7] Alio AP, Merrell L, Roxburgh K, Clayton HB, Marty PJ, Bomboka L, et al. The psychosocial impact of vesico-vaginal fistula in Niger. Arch Gynecol Obstet 2011;284(2):371–8.
[8] United Nations Development Programme. 2014 Human Development Report. http:// http://www.undp.org/content/undp/en/home/librarypage/hdr/2014human-development-report.html. Published 2014. Accessed April 16, 2015. [9] Onsrud M, Sjøveian S, Luhiriri R, Mukwege D. Sexual violence-related fistulas in the Democratic Republic of Congo. Int J Gynecol Obstet 2008;103(3):265–9. [10] Peterman A, Palermo T, Bredenkamp C. Estimates and determinants of sexual violence against women in the Democratic Republic of Congo. Am J Public Health 2011;101(6):1060–7. [11] World Health Organization. Democratic Republic of Congo Country Profile – Health Statistics. http://www.who.int/gho/countries/cod.pdf?ua=1. Published 2015. Accessed April 16, 2015. [12] World Health Organization, United Nations Children’s Fund, United Nations Population Fund, The World Bank. Trends in maternal mortality: 1990 to 2010. http://www.who. int/reproductivehealth/publications/monitoring/9789241503631/en/. Published 2012. Accessed April 16, 2015. [13] Vangeenderhuysen C, Prual A, Ould el Joud D. Obstetric fistulae: incidence estimates for sub-Saharan Africa. Int J Gynecol Obstet 2001;73(1):65–6. [14] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38(8):1091–110. [15] Muleta M. Obstetric fistulae: a retrospective study of 1210 cases at the Addis Ababa Fistula Hospital. J Obstet Gynaecol 1997;17(1):68–70. [16] Ministry of Planning. Democratic Republic of the Congo: Demographic and Health Survey 2007 Key Findings. http://www.measuredhs.com/pubs/pdf/SR141/SR141. pdf. Published 2007. Accessed April 16, 2015.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Fistula after attended delivery and the challenge of obstetric care capacity in the eastern Democratic Republic of Congo☆ Nerys Benfield a,⁎, Nichole Young-Lin b, Christophe Kimona c, Luc M. Kalisya c, Rogatien M. Kisindja d a
Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, NY, USA University of California, San Francisco, San Francisco, CA, USA Department of Surgery, HEAL Africa Hospital, Goma, Democratic Republic of Congo d Department of Obstetrics and Gynecology, HEAL Africa Hospital, Goma, Democratic Republic of Congo b c
a r t i c l e
i n f o
Article history: Received 8 September 2014 Received in revised form 6 February 2015 Accepted 21 April 2015 Keywords: Healthcare capacity Maternal complications Obstetric fistula
a b s t r a c t Objective: To analyze the history of women with fistula in the eastern Democratic Republic of Congo (DRC) to understand the determinants of fistula development. Methods: In a retrospective observational study, data were analyzed from a survey of all women who underwent surgical fistula repair at HEAL Africa Hospital, Goma, between April 1, 2009, and March 1, 2012. Characteristics and obstetric histories were obtained by selfreport. Results: The mean age of the 202 participants at treatment was 30.7 years (range 5–69). The mean duration of fistula was 45.6 months (range 0–600). In total, 171 (91.4%) fistulas were caused by obstructed labor, and 147 (86.5%) were vesicovaginal. Most women (129/175 [73.8%]) reported having received care during early labor under the supervision of a nurse or doctor in a healthcare facility. Among 176 women for whom delivery data were available, 102 (57.9%) delivered at a hospital, 42 (23.8%) at a health center, and 32 (18.2%) at home. Only 46 (26.3%) of 175 women were transferred to a higher level of care during labor. Conclusions: In the eastern DRC, efforts to enable transport to a healthcare facility and to encourage attended births must be accompanied by improvements in the capacity of existing facilities and in the training of staff to enable the timely diagnosis of labor abnormalities and appropriate intervention. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Genital fistula—an abnormal connection between the vagina or uterus and the urethra, bladder, rectum, or colon—is a serious condition that affects an estimated 2–3 million women around the world [1,2]. Most genital fistulas are caused by obstructed labor complicated by a lack of access to emergency obstetric care. Worldwide, there are approximately 50 000–100 000 new cases each year, and in low-resource settings, the frequency can be as high as 2–5 cases per 1000 deliveries [3]. Genital fistula typically causes considerable physical and psychological problems including urinary and/or fecal incontinence, vaginal stenosis, pelvic pain, social isolation, rejection by husbands and families, and unemployment [4–7]. As in many other low-resource settings, genital fistula is a problem in the eastern Democratic Republic of Congo (DRC). The DRC is the fourth most populous country in Africa and has vast natural resources. However, since the mid-1990s, this area has been affected by civil war, resulting in the destruction of infrastructure, worsening poverty,
☆ Presented at the XX FIGO World Congress of Gynecology and Obstetrics; October 7–12, 2012; Rome, Italy. ⁎ Corresponding author at: 1695 Eastchester Rd, Suite 501, Bronx, NY 10461, USA. Tel.: +1 718 405 8030; fax: +1 718 405 8051. E-mail address: nbenfiel@montefiore.org (N. Benfield).
and massive displacement of its population; in 2014, the DRC ranked second to last (rank 186) on the Human Development Index [8]. It is estimated that over 5.4 million people have died because of this conflict, and more than 1 million girls and women have experienced sexual violence, with approximately 15 996 new cases of sexual violence in 2008, 65% of which occurred to children and adolescents younger than 18 years [9,10]. The fertility rate in the DRC remains high at 6.04 births per woman, with a maternal mortality ratio of 540 per 100 000 live births [11,12]. Nationally, 80.4% of births in 2010 were reported to be attended by skilled health professionals [11]. However, the government healthcare expenditure at the time was only US$7 per head, and the effect of the conflict on healthcare capacity has probably been significant. The incidence of genital fistulas in the DRC is not available, but a study of Sub-Saharan Africa [13] estimated that there are at least 33 000 new genital fistula cases each year. Given its history, the DRC will have a heavy—and probably disproportionate—fistula burden. In settings like the DRC, the lack of access to emergency obstetric care can be the result of delays in seeking care, getting to a care facility, and obtaining appropriate care once in a facility [14]. The present study aimed to describe the demographic and obstetric histories of women undergoing fistula repair in the eastern DRC to elucidate the factors that contribute to fistula development in this conflict-affected setting.
http://dx.doi.org/10.1016/j.ijgo.2015.02.032 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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N. Benfield et al. / International Journal of Gynecology and Obstetrics 130 (2015) 157–160
2. Methods The present retrospective observational study is an analysis of data from a survey of all women who underwent fistula surgery at HEAL Africa Hospital in Goma, North Kivu, in eastern DRC, between April 1, 2009, and March 1, 2012. All participants gave verbal consent for their information to be collected. The present research was approved by the institutional review boards of HEAL Africa Hospital and the University of California, San Francisco, USA. HEAL Africa Hospital is a tertiary care hospital that is run by a Congolese non-governmental organization, and has a dedicated fistula care program. Since 2004, more than 2000 fistula repair surgeries have been performed, with an average of 100–150 surgeries per year. Women with fistula in the region who might be candidates for surgical repair are identified through rural outreach campaigns, as well as word of mouth. Most patients remain in recovery at HEAL Africa Hospital for at least 1–2 months awaiting transportation home or additional surgery. The present survey was performed by healthcare providers and focused on the etiology, classification, and surgical treatment of fistulas, and on the recovery after fistula repair. Information was gathered through patient self-report and physician assessment at multiple timepoints throughout the patient’s hospitalization: obstetric history was obtained on admission, surgical details were recorded on completion of surgery, and data on postoperative recovery (including complications and response to pelvic physical therapy) were obtained during the recovery phase. The fistula cause was determined by the physician who performed the physical examination at admission on the basis of clinical judgment and patient history. Fistulas that were cervicovesical, uterovesical, or at the site of the hysterotomy or hysterectomy incision were classified as surgical in etiology. Fistulas that occurred with a history of genital trauma outside pregnancy were classified as traumatic. A hospital was defined as a healthcare facility with the capacity to perform cesarean delivery, and a health center was defined as a healthcare facility without this capacity. The data were initially recorded on a paper chart and transferred to an electronic database using Epi Info version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Descriptive statistics were obtained using Epi Info and Excel 2011 (Microsoft, Redmond, WA, USA). All women with a fistula were included in the demographic analysis. The analysis of delivery-related data included only the women whose fistulas were presumed to be obstetric in origin.
Table 1 Demographic characteristics.a Characteristic
Value
Age at treatment, y (n = 186) Gravidity (n = 197) Primigravid Parity (n = 197) Primiparous Number of living children (n = 192) Childless Age at marriage, y Marital status before fistula (n = 187) Married Single Widowed Divorced Marital status after fistula (n = 181) Married Single Widowed Divorced Education (n = 192) Illiterate Primary school Secondary school Province of origin (n = 202) North Kivu South Kivu Maniema Katanga Orientale Kasai Orientale
30.7 (5–69) 3.8 (1–13) 77 (39.1) 3.5 (0–12) 75 (38.1) 1.9 (0–9) 88 (45.8) 17.2 (12–40)
a
140 (74.9) 18 (9.6) 13 (7.0) 16 (8.6) 87 (48.1) 21 (11.6) 20 (11.0) 53 (29.3) 142 (74.0) 31 (16.1) 19 (9.9) 121 (59.9) 18 (8.9) 48 (23.7) 9 (4.5) 5 (2.5) 1 (0.5)
Values are given as mean (range) or number (percentage).
The average time between fistula formation and repair varied from 0 to 600 months, with a mean duration of 45.6 months (Table 2). Most fistulas were either repaired within 1 year of development (57/144 [39.6%]) or after more than 5 years (34/144 [23.6%]). The etiology of the genital fistulas was mostly obstetric (Table 2). After surgical repair, 38 (26.4%) of 144 women had persistent incontinence. Of the 154 women who reported their prenatal care access, 105 (68.2%) stated that they had attended at least one prenatal care visit, whereas 49 (31.8%) had not attended prenatal care. Overall, 44 (25.1%) of 175 women reported that they remained at home during early labor; 62 (35.4%) presented to a hospital, and 69 (39.4%) presented to a health center (Fig. 1). Overall, 8 (4.6%) of 175 women did not have any assistance during early labor, 19 (10.9%) had a family member
3. Results In total, 202 women were surveyed. The mean age at the time of treatment was 30.7 years (median 29). The patients came from six different provinces; most originated from North Kivu and Maniema (Table 1). Forty-five languages were represented, the most common being Kinyabwisha (spoken by 43/194 [22.2%]), Kinyarwanda (28/194 [14.4%]), and Kinande (19/194 [9.8%]). Most women were illiterate (Table 1). The average distance from their home to the nearest hospital was 52 km (range 0–600). Given the prevalence of violence against women in the conflict-affected DRC, it is not surprising that 53 (28.9%) of 183 women reported having experienced sexual violence at some point in their lives. The women were generally small, with a mean weight of 52 kg (median 50; range 32–76). Before developing the fistula, most respondents were married (Table 1). Among 169 women who had been married, 140 (82.8%) were married before the age of 20 years. The distribution of married versus divorced women changed dramatically after fistula development: less than half the patients were married (Table 1). The average age at fistula development was 24.2 years (Table 2); 102 (61.1%) of 167 fistulas occurred before the age of 25 years. Vesicovaginal fistula was the most common type, followed by rectovaginal fistula and combined rectovaginal and vesicovaginal fistulas (Table 2).
Table 2 Clinical characteristics.a Characteristic
Value
Age at fistula development, y (n = 167) Duration of fistula, mo (n = 144) Type of fistula (n = 170) Vesicovaginal Combined recto- & vesicovaginal Rectovaginal Other Fistula etiology (n = 187) Obstetric Surgical Trauma Neoplastic Neonatal outcome (n = 173) Stillbirth Died within b1 week Alive Mode of delivery (n = 176) Spontaneous vaginal delivery Assisted vaginal delivery Cesarean delivery
24.2 (5–59) 45.6 (0–600)
a
Values are given as mean (range) or number (percentage).
147 (86.5) 10 (5.9) 10 (5.9) 3 (1.8) 171 (91.4) 10 (5.3) 5 (2.7) 1 (0.5) 128 (73.9) 2 (1.2) 43 (24.9) 64 (36.3) 33 (18.7) 79 (44.9)
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120
Women, %
100 80 60 40 20 0 At home without assistance
At home
Early Labor
Health Center
Hospital
Delivery
Fig. 1. Location of early labor and eventual delivery (n = 175).
with them, 19 (10.9%) a traditional birth attendant, 35 (20.0%) a doctor, 75 (42.9%) a nurse, and 19 (10.9%) at least one doctor and one nurse (Fig. 2). Of the 44 women who started labor at home, 7 (15.9%) were transported to a health center and 6 (13.6%) were eventually brought to a hospital for the delivery. Of the 69 who began labor at a health center, 33 (47.8%) were transferred to a hospital and 1 (1.4%) left the health center to deliver the child at home. Therefore, 46 (26.4%) of the 175 patients with a fistula for whom obstetric history data were obtained were transferred to a higher level of care (e.g. from home to a health center or hospital, or from a health center to a hospital). Overall, 102 (57.9%) of 176 women eventually gave birth at a hospital; 42 (23.8%) delivered at a health center and 32 (18.2%) delivered at home (Fig. 1). The delivery of 4 (2.3%) of 175 women for whom data were available was unattended; 10 (5.7%) women had a family member attend the birth, 16 (9.2%) had a traditional birth attendant, 59 (33.7%) had a doctor, 48 (27.4%) had a nurse, and 38 (21.8%) had a doctor and a nurse attend the birth (Fig. 2). Nearly half the births were by cesarean delivery (Table 2). Moreover, 128 (73.9%) of 173 deliveries were stillbirths, and there were 2 (1.2%) neonatal deaths within 1 week of birth. Among the 40 women who had surviving neonates and delivery information, 19 (47.5%) delivered by cesarean, 18 (45.0%) had a spontaneous vaginal delivery, and 3 (7.5%) had an assisted vaginal delivery. 4. Discussion The present study results correlate in many ways with what is known about the population of women with fistula—i.e. that they are 80 70
Women, %
60 50 40 30
159
primarily young and illiterate, tend to become divorced after the development of a genital fistula, and tend to have a stillbirth in the fistulacausing delivery [15]. Despite the high incidence of sexual violence in the eastern DRC, the present results demonstrate that traumatic fistulas are rare compared with obstetric fistulas even in conflict zones, with 91.4% of women having had fistulas of obstetric etiology. In the present case series, 28.9% of the women reported having been sexually assaulted and 2.7% had a trauma-related fistula. This result is comparable with that from the only other publication on sexual-violence-related fistulas in the DRC [9], which showed that 3% of the women with a fistula assessed had a traumatic fistula. The women in the present series had varying access to healthcare facilities, and the reported rate of prenatal care (68.2%) was somewhat lower than the rate of 95% previously reported for all gravid women in North Kivu [16] and the national rate of 89% reported for 2010 [11]. Despite varying geographic access to healthcare facilities and the low frequency of attendance at prenatal care, a substantial proportion of women presenting for fistula repair in the present study reported initiating intrapartum care under the supervision of a nurse or doctor (or both) in a healthcare facility. Only 26.4% of the women were transferred to a higher level of care, and access to cesarean delivery for obstructed labor was available for only around half of the present cohort. In conjunction with the information on the place of early labor, this indicates that although there was a delay for some women in reaching a healthcare facility, there was also a considerable delay in receiving adequate emergency obstetric care at the healthcare facility. This speaks to a lack of physical and human resources in healthcare facilities in the eastern DRC, which could include adequate staff, training (e.g. training in the use of partographs and labor curves, and in the identification of warning signs), functioning operating room suites, and sufficient surgical supplies. More efforts need to be focused on investigating the healthcare capacity at existing facilities and improving resources and training at these facilities, in conjunction with the education of women to increase the rate of attended facility-based deliveries. The present study has several limitations. All historical information was by patient report, leading to a risk of recall bias, especially regarding information about intrapartum care during the incident delivery. There were also no specific criteria for “early labor,” and no information was obtained on the duration of labor and the timing of arrival at a healthcare facility, so it is not known at exactly what point during labor the women presented for care. A detailed evaluation of the significance of the delay in seeking medical care during labor for fistula development was therefore not possible. Moreover, the participants were receiving health care at the time of the present survey, which means that they may not be representative of all women who develop a fistula in this region of the DRC; many of the affected women might never interact with the healthcare system. There were also some issues with the consistency of data collection because of hardware and software difficulties. Nevertheless, the present study presents information on a large group of women with fistula in the eastern DRC. Because the eastern DRC continues to be affected by war and conflict, improvements in the healthcare infrastructure to prevent maternal morbidity and the development of genital fistulas will continue to be a great challenge. The present study indicates that delivering at a healthcare facility is not enough to prevent genital fistulas, and although dissemination of the message to seek intrapartum care is important, it is equally imperative to improve the quality of care at existing facilities.
20 10
Acknowledgments
0 No one
Family
TBA Early Labor
Nurse
Doctor
Doctor + nurse
Delivery
Fig. 2. Attendance at early labor and eventual delivery (n = 175). Abbreviation: TBA, traditional birth attendant.
The fistula repair and reintegration program at HEAL Africa Hospital is funded by EngenderHealth and the Tides Foundation. The present research was funded by the Fellowship in Family Planning and the Clinical and Translational Science Institute at the University of California in San Francisco, CA, USA.
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