- Email: [email protected]
Reflections on the knowledge base for obstetric fistula
International Journal of Gynecology and Obstetrics (2007) 99, S21–S24
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
CRITICAL ISSUES
Reflections on the knowledge base for obstetric fistula J. Kelly ⁎,1 , H.R. Winter Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, England, B15 2TT, UK
KEYWORDS Epidemiology; Obstetric fistula; Prevention; Treatment
Abstract This article presents the reflections of an experienced fistula surgeon and an epidemiologist on the current knowledge base for obstetric fistula. The incidence, prevention, and management of vesico-vaginal and recto-vaginal fistula are discussed. The authors call for more randomized controlled trials to determine the effectiveness of surgical interventions for fistula repair. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction This article presents the reflections of an experienced fistula surgeon and an epidemiologist on the current knowledge base for obstetric fistula. We cite the results of appropriate research on the occurrence, prevention, and management of vesico-vaginal and recto-vaginal fistula. This article serves as a backdrop to the development of an epidemiological research agenda for the prevention and management of obstetric fistula. The cause and the socio-economic factors involved in obstetric fistula have long been known to those of us involved in treating the unfortunate women who live with this condition. Much, however, is unknown about the different forms of treatment and their outcomes, and how to manage patients not amenable to cure. Fistula prevention is closely linked with strategies to reduce maternal mortality and morbidity as well as perinatal death. We discuss examples from some of the regions in which we have worked, and the overview includes input from an epidemiologic perspective. These approaches have helped many women with obstetric fistula and have also prevented fistula—and therefore ⁎ Corresponding author. Tel.: +44 121 414 2704. E-mail address: [email protected] (J. Kelly). 1 Fistula surgeon to many countries in the developing world.
reduced maternal mortality and morbidity as well as perinatal death.
2. Occurrence Those of us who have been and are involved in the treatment and prevention of obstetric fistula in the developing world are aware of certain facts. Where an appropriate service for the management of obstetric fistula is provided, large numbers of women appear. The incidence of obstetric fistula in developing countries is, however, unknown. Most of the estimates are from facility-based data. Knowledge regarding the incidence and prevalence of fistula is needed to plan adequately for the provision of appropriate services and to monitor progress. More robust, population-based methods of data collection are needed [1,2].
3. Etiology There is no dispute that the main cause of obstetric fistula is obstructed labor. Obstructed labor causes ischemic pressure necrosis, which results in a slough, which becomes a vesicovaginal or a recto-vaginal fistula, or both, as it comes away. The main risk factor is a lack of access to appropriate emergency obstetric care 7 days per week, 24 h per day.
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.017
S22 Poverty, with its many ramifications, also plays a role. In countries subjected to structural adjustment programs, patients are no longer able to access care because of an increase in, or imposition of, user fees [3,4]. For example, a cesarean delivery costs the equivalent of 9 months of average wages in Nigeria [5], and the number of patients seeking care at the University College Hospital fell by two-thirds between 1990 and 1994 when user fees were increased [6]. The effects of poverty on security mean that it is difficult in rural areas to obtain transportation (including ambulances and hospital vehicles) during the 12 h of darkness. For this reason, a decision about whether to transfer a woman in labor to a hospital providing emergency obstetric care should be made by 3:00 PM. Other postulated risk factors, such as pregnancy at a young age and some local practices (e.g., female genital cutting), though undesirable, do not result in obstetric fistula in the developed world, where emergency obstetric care is easily accessed. However, these risk factors are important to consider when targeting services at those women in the developing world who seem least likely to obtain emergency obstetric care. Emergency obstetric care, however, must be improved in the developing world. The growing number of ureteric fistulas associated with cesarean delivery may reflect a lack of senior supervision, with the senior surgeon required to perform other tasks elsewhere [7].
4. Prevention Strategies to reduce maternal mortality and the incidence of stillbirths should also reduce the incidence of obstetric fistula. Yet, despite considerable international will to achieve these goals, there are few evidence-based data to inform those responsible for delivering maternity services [8,9]. In various settings where obstetric fistula is common, we have seen and been involved with excellent initiatives attempting to prevent maternal deaths and morbidities, including fistula. In Zambia, Dr. M. Tyndall saw the difficulty of providing effective care to women and infants in crowded hospitals. Her effort to provide efficient, safe, and convenient services to the patients resulted in a reduction in overcrowding at the teaching hospital, achieved by increasing the number of deliveries at urban maternity clinics. Through strict protocols and a dedicated ambulance and radio linkage to a hospital, the number of deliveries at the teaching hospital fell from 23,496 to 10,525 between 1982 and 1998 and the corresponding values for the maternity clinics were 2200 and 32,341 [10]. A maternity waiting area is a place (not a ward) within, or close to, the hospital compound, where women identified as being at risk can reside in the last few weeks of pregnancy. They are then close to functioning, and appropriate, obstetric care should operative delivery be required [11]. A maternity waiting area at Attat Hospital, in Ethiopia, was successfully designed to be acceptable to the local women. We are currently analyzing data for 15,627 women who were delivered between 1987 and 2002 at that hospital. Preliminary results suggest that deaths were avoided among the women identified as requiring emergency obstetric care before the
J. Kelly, H.R. Winter onset of labor, and who were admitted via the maternity waiting area. In Nigeria, with the support of trained traditional birth attendants, a fully integrated hospital, a community antepartum and intrapartum care system, and a maternity waiting area and prayer hall on hospital grounds, Dr. Maureen Brennan and team have managed to reduce the facility’s maternal mortality ratio from 790 to 581 per 100,000 total births [12,13]. An effect on maternal mortality was also seen when comparing outcomes for groups of villages with and without trained traditional birth attendants; but these interventions were not designed as a study, and their effectiveness cannot be proven. Results from a recent cluster randomized controlled trial in Sindh province, Pakistan, assessed the effectiveness of training and integrating traditional birth attendants into existing services. The study, which involved 20,000 pregnant women, showed that their model of training and integrating traditional birth attendants into services significantly reduced perinatal mortality. There was also a nonsignificant reduction in maternal mortality [14].
5. Human resource Human resource is a critical factor in health system performance. The workforce of health care providers in the poorest countries is being weakened by various problems including HIV/AIDS [15], a preference by health care professionals to work in urban areas, and the migration of physicians, nurses, and midwives from the developing to the developed world. All of these issues must be addressed [16]. The Minister of Health in Malawi was quoted as saying, “We have got to face this situation [of trained nurses leaving for the West] by training a lot more of our nurses at another level, where they will not be marketable in the UK, the US, and other countries. I wouldn’t say underqualified, but trained, qualified enough to meet the skill requirements of looking after our patients” [17]. The same journal also reported that in the United Kingdom the government promised to close loopholes that allowed its health service to poach thousands of nurses and physicians from developing countries. The clamp-down followed talks with the United Kingdom’s Department for International Development, which had been alarmed by the crippling impact of the medical “brain drain” on sub-Saharan Africa. In rural East and Central Africa, much of the emergency surgery, including obstetrics, is not performed by physicians but by trained clinical or assistant medical officers [18]. Through the licentiate and other programs, the grade of some of these officers has been elevated to allow them to perform more specialized services, e.g., orthopedics in Malawi and obstetrics in Zambia. The training of these selected medical officers should involve all procedures, just as if they were physicians specializing in obstetrics. They should be able to perform all operative vaginal deliveries, including ventouse delivery and symphysiotomy; to perform cesarean deliveries; and to manage a ruptured uterus and other problems. The teaching must also include training on when, and when not, to perform these procedures. The services offered must be sensitive to local beliefs and opinions. For example, at Attat Hospital, in Ethiopia, we
Reflections on the knowledge base for obstetric fistula
S23
Table 1 Experience in fistula repair work by J. Kelly in various countries: type of fistula
Table 3 Experience in fistula repair work by J. Kelly in various countries: operative outcome of fistula
Type
No. (%)
Outcome
Vesico-vaginal fistula (VVF) Recto-vaginal fistula (RVF) VVF and RVF Total
2202 114 756 3072
Vesico-vaginal fistula Cured Stress incontinence Failed Total Recto-vaginal fistula Cured Failed Total
(71.7) (3.7) (24.6) (100.0)
treated patients with ruptured uteri by hysterectomy until we noticed that women were no longer coming to the hospital. We soon learned that they did not want to risk undergoing hysterectomy, which led to a stream of work on the treatment of ruptured uteri [19]. When a woman has no living children and/or desires more children, it is culturally acceptable to repair the uterine rupture; it is also medically safe, with important provisos [20].
6. Treatment A protocol for the systematic review of the surgical management of vesico-vaginal and/or urethro-vaginal fistula currently exists in the Cochrane database, though it is incomplete [21]. We are aware of only one randomized controlled trial addressing the management of fistula. In that trial, antibiotic prophylaxis was evaluated in relation to failure of closure and objective incontinence [22]. The success rate was low overall, and lower among women who received prophylaxis, but the study was small and lacked statistical power. There are no trials relating to techniques used to repair fistulas. Because of the reasonably high success rates, i.e., cure rates, in good centers [23], the numbers required to show a difference between techniques will be large. Allowance must be made for case mix, operator expertise, and, often forgotten, the quality of preoperative and postoperative care. Treatment must also include rehabilitation, physiotherapy, counseling, and skill building, including outreach skills to spread awareness about prevention and treatment [24].
7. Clinical issues Tables 1–3 include the results of 37 years’ experience at fistula repair, mostly obstetric fistula repair, by the author (J.K.) in a variety of countries. Within this series, the high proportion of complicated fistulas is a function of referral Table 2 Experience in fistula repair work by J. Kelly in various countries: causes of fistula, all cases Cause
Developing countries, No. (%)
Developed countries, No. (%)
Obstetric Surgical Malignancy Other Total
2624 (92.4) 84 (3.0) 52 (1.8) 80 (2.8) 2840 (100)
12 (5.2) 167 (72.0) 32 (13.8) 21 (9.0) 232 (100)
No. (%) 2455 370 133 2958
(83.0) (12.5) (4.5) (100.0)
785 (90.2) 85 (9.8) 870 (100.0)
patterns, and the outcomes reflect the levels of complication. Cases of uretero-vaginal fistula alone are not included. Treatment may be governed by local circumstances. Since commencing outreach work in Somalia in 1985, the author has rarely used a Martius fat graft outside the Addis Ababa Fistula Hospital. Using the graft demands more from the nursing staff, increases operative time, and perhaps also increases blood loss. The care provided at the fistula hospital, especially by former patients, now trained helpers or aides, is excellent, and may have no equivalent elsewhere. When extraurethral support is required, tissue is mobilized from both sides under the urethra (the “bulbocavernosus graft”). As with all clinical methods of repairing obstetric fistula, this approach requires robust evaluation. Using a local infiltration containing an analgesic or a vasoconstrictor may be hazardous. If the concentration of lignocaine is too strong, and some of the solution is injected intravascularly, the patient may have convulsions. Vasoconstrictors, if absorbed too quickly, may have hazardous effects on heart rate and rhythm and on blood pressure. Research is needed to establish whether it is safer to use no infiltration or to infiltrate with a saline solution. It is mandatory for the team, with advice from the anesthesiologists, to agree on anesthesia guidelines regarding the appropriate response to problems which may arise. There must be someone present who is capable of performing intubation, if required. Compassion is also required, which is not the same as pity. Compassion means being with the patient at the same level. Repairing obstetric fistulas is no private practice activity. Some degree of dedication is useful, but the rewards are immense. Before treatment the patients are depressed, dirty, always trying to hide their leaking dejections and offensive smell. After successful repair and reintegration into their families and society, they wear clean clothes and a smile. For some, healing is complete when they go on to have a healthy baby.
8. Conclusion Good data regarding the incidence of obstetric fistula are not available, but the cause of obstetric fistula is known: a lack of access to appropriate emergency obstetric care. Most published studies on the prevention and treatment of obstetric fistula were poorly designed, and there are very few randomized controlled trials. We require better studies on maternal mortality and morbidity, and on the prevention and treatment of obstetric fistula. Where individual
S24 randomization cannot be done, greater use should be made of cluster randomized controlled trials. Conflict of interest None. Role of the funding source The UK Department for International Development kindly supported J.K. for sutures, catheters, and travel but has no involvement with the study.
References [1] Graham W. Now or never: the case for measuring maternal mortality. Lancet 2002;359:701–4. [2] Graham W, Fitzmaurice A, Bell J, Cairns J. The familial technique for linking maternal death with poverty. Lancet 2004;363:23–7. [3] Structural adjustment too painful? [editorial]. Lancet 1994;344: 1377–278. [4] Evans J. SAPing maternal health. Lancet 1995;346:1046. [5] Harrison K. Macroeconomics and the African mother. J R Soc Med 1996;89:361–2. [6] Anonymous. Science and technology: good intentions, road to hell? Economist 1995:147–8. [7] Kelly J. Outreach programmes for obstetric fistulae. J Obstet Gynaecol 2004;24:117–8. [8] Miller S, Sloan N, Winikoff B, Langer A, Fikree F. Where is the “E” in MCH? The need for an evidence-based approach in safe motherhood. J Midwifery Women’s Health 2003;48:10–8. [9] Sibley L, Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20:51–60. [10] Corcoran B, Wall B, Mtonga V. Evaluation report, Lusaka Urban Maternity Clinics Project. Irish Aid, Dublin, Ireland: Evaluation and Audit Unit; 1999.
J. Kelly, H.R. Winter [11] Poovan P, Kifle F, Kwast B. A maternity waiting home reduces obstetric catastrophes. World Health Forum 1991;11:440–5. [12] Ada-Ogar AM, Umoh EK, Brennan M. The effect of training traditional birth attendants on maternal mortality in an area of Akwa Ibom State, Nigeria. Postgrad Doct Afr 1996;18:86–90. [13] Brennan M. Training traditional birth attendants reduces maternal mortality and morbidity. Trop J Obstet Gynaecol 1988;1: 44–7. [14] Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352:2091–9. [15] Chen L, Evans T, Anand PS, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364:1984–90. [16] Coombes R. Developed world is robbing African countries of health staff. BMJ 2005;330:923. [17] Anonymous. The brain drain: Malawi’s nursing crisis. Afr Health 2004;26:5. [18] Bergstrom S. Who will do the caesarean sections when there is no doctor? Finding creative solutions to the human resource crisis. BJOG 2005;112:1168–9. [19] Fekadu S, Kelly J, Lancashire RJ, Poovan P, Redito A. Ruptured uterus in Ethiopia. Lancet 1997;349:622. [20] Kelly J, Fekadu S, Lancashire RJ, Poovan P, Redito A. A follow-up of repair of ruptured uterus in Ethiopia. J Obstet Gynaecol 1998;18(1):50–2. [21] Lapitan MC, Rienhardt G. Surgical management of vesico-vaginal and/or urethrovaginal fistulae (protocol for a Cochrane Review). The Cochrane Library; 2005. [22] Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. BJOG 1998;105: 397–9. [23] Wall LL, Karshima JA, Kirschner C, Arrowsmith S. The obstetric vesico-vaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011–6. [24] Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Women’s Health 2005;50: 286–94.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / i j g o
CRITICAL ISSUES
Reflections on the knowledge base for obstetric fistula J. Kelly ⁎,1 , H.R. Winter Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, England, B15 2TT, UK
KEYWORDS Epidemiology; Obstetric fistula; Prevention; Treatment
Abstract This article presents the reflections of an experienced fistula surgeon and an epidemiologist on the current knowledge base for obstetric fistula. The incidence, prevention, and management of vesico-vaginal and recto-vaginal fistula are discussed. The authors call for more randomized controlled trials to determine the effectiveness of surgical interventions for fistula repair. © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction This article presents the reflections of an experienced fistula surgeon and an epidemiologist on the current knowledge base for obstetric fistula. We cite the results of appropriate research on the occurrence, prevention, and management of vesico-vaginal and recto-vaginal fistula. This article serves as a backdrop to the development of an epidemiological research agenda for the prevention and management of obstetric fistula. The cause and the socio-economic factors involved in obstetric fistula have long been known to those of us involved in treating the unfortunate women who live with this condition. Much, however, is unknown about the different forms of treatment and their outcomes, and how to manage patients not amenable to cure. Fistula prevention is closely linked with strategies to reduce maternal mortality and morbidity as well as perinatal death. We discuss examples from some of the regions in which we have worked, and the overview includes input from an epidemiologic perspective. These approaches have helped many women with obstetric fistula and have also prevented fistula—and therefore ⁎ Corresponding author. Tel.: +44 121 414 2704. E-mail address: [email protected] (J. Kelly). 1 Fistula surgeon to many countries in the developing world.
reduced maternal mortality and morbidity as well as perinatal death.
2. Occurrence Those of us who have been and are involved in the treatment and prevention of obstetric fistula in the developing world are aware of certain facts. Where an appropriate service for the management of obstetric fistula is provided, large numbers of women appear. The incidence of obstetric fistula in developing countries is, however, unknown. Most of the estimates are from facility-based data. Knowledge regarding the incidence and prevalence of fistula is needed to plan adequately for the provision of appropriate services and to monitor progress. More robust, population-based methods of data collection are needed [1,2].
3. Etiology There is no dispute that the main cause of obstetric fistula is obstructed labor. Obstructed labor causes ischemic pressure necrosis, which results in a slough, which becomes a vesicovaginal or a recto-vaginal fistula, or both, as it comes away. The main risk factor is a lack of access to appropriate emergency obstetric care 7 days per week, 24 h per day.
0020-7292/$ - see front matter © 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.06.017
S22 Poverty, with its many ramifications, also plays a role. In countries subjected to structural adjustment programs, patients are no longer able to access care because of an increase in, or imposition of, user fees [3,4]. For example, a cesarean delivery costs the equivalent of 9 months of average wages in Nigeria [5], and the number of patients seeking care at the University College Hospital fell by two-thirds between 1990 and 1994 when user fees were increased [6]. The effects of poverty on security mean that it is difficult in rural areas to obtain transportation (including ambulances and hospital vehicles) during the 12 h of darkness. For this reason, a decision about whether to transfer a woman in labor to a hospital providing emergency obstetric care should be made by 3:00 PM. Other postulated risk factors, such as pregnancy at a young age and some local practices (e.g., female genital cutting), though undesirable, do not result in obstetric fistula in the developed world, where emergency obstetric care is easily accessed. However, these risk factors are important to consider when targeting services at those women in the developing world who seem least likely to obtain emergency obstetric care. Emergency obstetric care, however, must be improved in the developing world. The growing number of ureteric fistulas associated with cesarean delivery may reflect a lack of senior supervision, with the senior surgeon required to perform other tasks elsewhere [7].
4. Prevention Strategies to reduce maternal mortality and the incidence of stillbirths should also reduce the incidence of obstetric fistula. Yet, despite considerable international will to achieve these goals, there are few evidence-based data to inform those responsible for delivering maternity services [8,9]. In various settings where obstetric fistula is common, we have seen and been involved with excellent initiatives attempting to prevent maternal deaths and morbidities, including fistula. In Zambia, Dr. M. Tyndall saw the difficulty of providing effective care to women and infants in crowded hospitals. Her effort to provide efficient, safe, and convenient services to the patients resulted in a reduction in overcrowding at the teaching hospital, achieved by increasing the number of deliveries at urban maternity clinics. Through strict protocols and a dedicated ambulance and radio linkage to a hospital, the number of deliveries at the teaching hospital fell from 23,496 to 10,525 between 1982 and 1998 and the corresponding values for the maternity clinics were 2200 and 32,341 [10]. A maternity waiting area is a place (not a ward) within, or close to, the hospital compound, where women identified as being at risk can reside in the last few weeks of pregnancy. They are then close to functioning, and appropriate, obstetric care should operative delivery be required [11]. A maternity waiting area at Attat Hospital, in Ethiopia, was successfully designed to be acceptable to the local women. We are currently analyzing data for 15,627 women who were delivered between 1987 and 2002 at that hospital. Preliminary results suggest that deaths were avoided among the women identified as requiring emergency obstetric care before the
J. Kelly, H.R. Winter onset of labor, and who were admitted via the maternity waiting area. In Nigeria, with the support of trained traditional birth attendants, a fully integrated hospital, a community antepartum and intrapartum care system, and a maternity waiting area and prayer hall on hospital grounds, Dr. Maureen Brennan and team have managed to reduce the facility’s maternal mortality ratio from 790 to 581 per 100,000 total births [12,13]. An effect on maternal mortality was also seen when comparing outcomes for groups of villages with and without trained traditional birth attendants; but these interventions were not designed as a study, and their effectiveness cannot be proven. Results from a recent cluster randomized controlled trial in Sindh province, Pakistan, assessed the effectiveness of training and integrating traditional birth attendants into existing services. The study, which involved 20,000 pregnant women, showed that their model of training and integrating traditional birth attendants into services significantly reduced perinatal mortality. There was also a nonsignificant reduction in maternal mortality [14].
5. Human resource Human resource is a critical factor in health system performance. The workforce of health care providers in the poorest countries is being weakened by various problems including HIV/AIDS [15], a preference by health care professionals to work in urban areas, and the migration of physicians, nurses, and midwives from the developing to the developed world. All of these issues must be addressed [16]. The Minister of Health in Malawi was quoted as saying, “We have got to face this situation [of trained nurses leaving for the West] by training a lot more of our nurses at another level, where they will not be marketable in the UK, the US, and other countries. I wouldn’t say underqualified, but trained, qualified enough to meet the skill requirements of looking after our patients” [17]. The same journal also reported that in the United Kingdom the government promised to close loopholes that allowed its health service to poach thousands of nurses and physicians from developing countries. The clamp-down followed talks with the United Kingdom’s Department for International Development, which had been alarmed by the crippling impact of the medical “brain drain” on sub-Saharan Africa. In rural East and Central Africa, much of the emergency surgery, including obstetrics, is not performed by physicians but by trained clinical or assistant medical officers [18]. Through the licentiate and other programs, the grade of some of these officers has been elevated to allow them to perform more specialized services, e.g., orthopedics in Malawi and obstetrics in Zambia. The training of these selected medical officers should involve all procedures, just as if they were physicians specializing in obstetrics. They should be able to perform all operative vaginal deliveries, including ventouse delivery and symphysiotomy; to perform cesarean deliveries; and to manage a ruptured uterus and other problems. The teaching must also include training on when, and when not, to perform these procedures. The services offered must be sensitive to local beliefs and opinions. For example, at Attat Hospital, in Ethiopia, we
Reflections on the knowledge base for obstetric fistula
S23
Table 1 Experience in fistula repair work by J. Kelly in various countries: type of fistula
Table 3 Experience in fistula repair work by J. Kelly in various countries: operative outcome of fistula
Type
No. (%)
Outcome
Vesico-vaginal fistula (VVF) Recto-vaginal fistula (RVF) VVF and RVF Total
2202 114 756 3072
Vesico-vaginal fistula Cured Stress incontinence Failed Total Recto-vaginal fistula Cured Failed Total
(71.7) (3.7) (24.6) (100.0)
treated patients with ruptured uteri by hysterectomy until we noticed that women were no longer coming to the hospital. We soon learned that they did not want to risk undergoing hysterectomy, which led to a stream of work on the treatment of ruptured uteri [19]. When a woman has no living children and/or desires more children, it is culturally acceptable to repair the uterine rupture; it is also medically safe, with important provisos [20].
6. Treatment A protocol for the systematic review of the surgical management of vesico-vaginal and/or urethro-vaginal fistula currently exists in the Cochrane database, though it is incomplete [21]. We are aware of only one randomized controlled trial addressing the management of fistula. In that trial, antibiotic prophylaxis was evaluated in relation to failure of closure and objective incontinence [22]. The success rate was low overall, and lower among women who received prophylaxis, but the study was small and lacked statistical power. There are no trials relating to techniques used to repair fistulas. Because of the reasonably high success rates, i.e., cure rates, in good centers [23], the numbers required to show a difference between techniques will be large. Allowance must be made for case mix, operator expertise, and, often forgotten, the quality of preoperative and postoperative care. Treatment must also include rehabilitation, physiotherapy, counseling, and skill building, including outreach skills to spread awareness about prevention and treatment [24].
7. Clinical issues Tables 1–3 include the results of 37 years’ experience at fistula repair, mostly obstetric fistula repair, by the author (J.K.) in a variety of countries. Within this series, the high proportion of complicated fistulas is a function of referral Table 2 Experience in fistula repair work by J. Kelly in various countries: causes of fistula, all cases Cause
Developing countries, No. (%)
Developed countries, No. (%)
Obstetric Surgical Malignancy Other Total
2624 (92.4) 84 (3.0) 52 (1.8) 80 (2.8) 2840 (100)
12 (5.2) 167 (72.0) 32 (13.8) 21 (9.0) 232 (100)
No. (%) 2455 370 133 2958
(83.0) (12.5) (4.5) (100.0)
785 (90.2) 85 (9.8) 870 (100.0)
patterns, and the outcomes reflect the levels of complication. Cases of uretero-vaginal fistula alone are not included. Treatment may be governed by local circumstances. Since commencing outreach work in Somalia in 1985, the author has rarely used a Martius fat graft outside the Addis Ababa Fistula Hospital. Using the graft demands more from the nursing staff, increases operative time, and perhaps also increases blood loss. The care provided at the fistula hospital, especially by former patients, now trained helpers or aides, is excellent, and may have no equivalent elsewhere. When extraurethral support is required, tissue is mobilized from both sides under the urethra (the “bulbocavernosus graft”). As with all clinical methods of repairing obstetric fistula, this approach requires robust evaluation. Using a local infiltration containing an analgesic or a vasoconstrictor may be hazardous. If the concentration of lignocaine is too strong, and some of the solution is injected intravascularly, the patient may have convulsions. Vasoconstrictors, if absorbed too quickly, may have hazardous effects on heart rate and rhythm and on blood pressure. Research is needed to establish whether it is safer to use no infiltration or to infiltrate with a saline solution. It is mandatory for the team, with advice from the anesthesiologists, to agree on anesthesia guidelines regarding the appropriate response to problems which may arise. There must be someone present who is capable of performing intubation, if required. Compassion is also required, which is not the same as pity. Compassion means being with the patient at the same level. Repairing obstetric fistulas is no private practice activity. Some degree of dedication is useful, but the rewards are immense. Before treatment the patients are depressed, dirty, always trying to hide their leaking dejections and offensive smell. After successful repair and reintegration into their families and society, they wear clean clothes and a smile. For some, healing is complete when they go on to have a healthy baby.
8. Conclusion Good data regarding the incidence of obstetric fistula are not available, but the cause of obstetric fistula is known: a lack of access to appropriate emergency obstetric care. Most published studies on the prevention and treatment of obstetric fistula were poorly designed, and there are very few randomized controlled trials. We require better studies on maternal mortality and morbidity, and on the prevention and treatment of obstetric fistula. Where individual
S24 randomization cannot be done, greater use should be made of cluster randomized controlled trials. Conflict of interest None. Role of the funding source The UK Department for International Development kindly supported J.K. for sutures, catheters, and travel but has no involvement with the study.
References [1] Graham W. Now or never: the case for measuring maternal mortality. Lancet 2002;359:701–4. [2] Graham W, Fitzmaurice A, Bell J, Cairns J. The familial technique for linking maternal death with poverty. Lancet 2004;363:23–7. [3] Structural adjustment too painful? [editorial]. Lancet 1994;344: 1377–278. [4] Evans J. SAPing maternal health. Lancet 1995;346:1046. [5] Harrison K. Macroeconomics and the African mother. J R Soc Med 1996;89:361–2. [6] Anonymous. Science and technology: good intentions, road to hell? Economist 1995:147–8. [7] Kelly J. Outreach programmes for obstetric fistulae. J Obstet Gynaecol 2004;24:117–8. [8] Miller S, Sloan N, Winikoff B, Langer A, Fikree F. Where is the “E” in MCH? The need for an evidence-based approach in safe motherhood. J Midwifery Women’s Health 2003;48:10–8. [9] Sibley L, Sipe T. What can a meta-analysis tell us about traditional birth attendant training and pregnancy outcomes? Midwifery 2004;20:51–60. [10] Corcoran B, Wall B, Mtonga V. Evaluation report, Lusaka Urban Maternity Clinics Project. Irish Aid, Dublin, Ireland: Evaluation and Audit Unit; 1999.
J. Kelly, H.R. Winter [11] Poovan P, Kifle F, Kwast B. A maternity waiting home reduces obstetric catastrophes. World Health Forum 1991;11:440–5. [12] Ada-Ogar AM, Umoh EK, Brennan M. The effect of training traditional birth attendants on maternal mortality in an area of Akwa Ibom State, Nigeria. Postgrad Doct Afr 1996;18:86–90. [13] Brennan M. Training traditional birth attendants reduces maternal mortality and morbidity. Trop J Obstet Gynaecol 1988;1: 44–7. [14] Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352:2091–9. [15] Chen L, Evans T, Anand PS, Boufford JI, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364:1984–90. [16] Coombes R. Developed world is robbing African countries of health staff. BMJ 2005;330:923. [17] Anonymous. The brain drain: Malawi’s nursing crisis. Afr Health 2004;26:5. [18] Bergstrom S. Who will do the caesarean sections when there is no doctor? Finding creative solutions to the human resource crisis. BJOG 2005;112:1168–9. [19] Fekadu S, Kelly J, Lancashire RJ, Poovan P, Redito A. Ruptured uterus in Ethiopia. Lancet 1997;349:622. [20] Kelly J, Fekadu S, Lancashire RJ, Poovan P, Redito A. A follow-up of repair of ruptured uterus in Ethiopia. J Obstet Gynaecol 1998;18(1):50–2. [21] Lapitan MC, Rienhardt G. Surgical management of vesico-vaginal and/or urethrovaginal fistulae (protocol for a Cochrane Review). The Cochrane Library; 2005. [22] Tomlinson AJ, Thornton JG. A randomised controlled trial of antibiotic prophylaxis for vesico-vaginal fistula repair. BJOG 1998;105: 397–9. [23] Wall LL, Karshima JA, Kirschner C, Arrowsmith S. The obstetric vesico-vaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004;190:1011–6. [24] Miller S, Lester F, Webster M, Cowan B. Obstetric fistula: a preventable tragedy. J Midwifery Women’s Health 2005;50: 286–94.