Frequency and management of non‐obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care <i>Plus</i> project

Mafu, Michel Mpunga; Banze, Don Félicien; Nembunzu, Dolores; Maroyi, Raha; Paluku, Justin; Kinja, Rachel; Kitambala, Esther; Aussak, Brian Tena-Tena; Bobina, Ruth Bulu; Notia, Amisi; Mukuliboy, Ange; Diop, Altine; Tripathi, Vandana; Romanzi, Lauri J.; Délamou, Alexandre

doi:10.1111/tmi.13394

Cited by 5 publications

(6 citation statements)

References 13 publications

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“…There is growing concern that cesarean births are the most important cause of iatrogenic fistulas in sub-Saharan Africa [ 4 ]. Reports indicate that between 77 and 80.2% of iatrogenic fistulas follow surgery for obstetric complications, whether cesarean section, uterine rupture repair or hysterectomy [ 3 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

“…In Niger 9.9% of 624 fistulas were iatrogenic, [ 6 ] while in the D.R. Congo 19.4% of 1984 fistulas were non-obstetric, with iatrogenic fistulas accounting for an unspecified share [ 5 ]. In Ethiopia, a review of 2593 women with fistula found that 24.6% had “high bladder fistula (predominantly after surgery).” [ 7 ] High fistula similarly accounted for 26.3% (119/452) of vesico-vaginal fistulas in Malawi, “likely due to operative injury rather than obstructed labor.” [ 8 ] Among 229 women with fistula following cesarean birth in the D.R.Congo, 24.0% had iatrogenic injuries [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

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Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review

Ngongo

Raassen

Mahendeka

et al. 2022

BMC Pregnancy Childbirth

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Background Genito-urinary fistulas may occur as complications of obstetric surgery. Location and circumstances can indicate iatrogenic origin as opposed to pressure necrosis following prolonged, obstructed labor. Methods This retrospective review focuses on 787 women with iatrogenic genito-urinary fistulas among 2942 women who developed fistulas after cesarean birth between 1994 and 2017. They are a subset of 5469 women who sought obstetric fistula repair between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. We compared genito-urinary fistula classifications following vaginal birth to classifications following cesarean birth. We assessed whether and how the proportion of iatrogenic genito-urinary fistula was changing over time among women with fistula, comparing women with iatrogenic fistulas to women with fistulas attributable to pressure necrosis. We used mixed effects logistic regression to model the rise in iatrogenic fistula among births resulting in fistula and specifically among cesarean births resulting in fistula. Results Over one-quarter of women with fistula following cesarean birth (26.8%, 787/2942) had an injury caused by surgery rather than pressure necrosis due to prolonged, obstructed labor. Controlling for age, parity, and previous abdominal surgery, the odds of iatrogenic origin nearly doubled over time among all births resulting in fistula (aOR 1.94; 95% CI 1.48–2.54) and rose by 37% among cesarean births resulting in fistula (aOR 1.37; 95% CI 1.02–1.83). In Kenya and Rwanda the rise of iatrogenic injury outpaced the increasing frequency of cesarean birth. Conclusions Despite the strong association between obstetric fistula and prolonged, obstructed labor, more than a quarter of women with fistula after cesarean birth had injuries due to surgical complications rather than pressure necrosis. Risks of iatrogenic fistula during cesarean birth reinforce the importance of appropriate labor management and cesarean decision-making. Rising numbers of iatrogenic fistulas signal a quality crisis in emergency obstetric care. Unaddressed, the impact of this problem will grow as cesarean births become more common.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review

Ngongo

Raassen

Mahendeka

et al. 2022

BMC Pregnancy Childbirth

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“…Location and circumstances can indicate that a fistula is iatrogenic rather than attributable to pressure necrosis [ 7 , 11 ]. Evidence has been mounting about the proportion of iatrogenic fistula amongst repaired fistulas [ 18 – 21 ]. In a separate analysis we reported that 26.8% (787/2,942) of women with fistula after cesarean section have injuries caused by surgery rather than pressure necrosis from prolonged, obstructed labor [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

A retrospective review of genital fistula occurrence in nine African countries

Ngongo

Raassen²,

Mahendeka

et al. 2022

BMC Pregnancy Childbirth

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Background Female genital fistulas are abnormal communications that lead to urinary and/or fecal incontinence. This analysis compares the characteristics of women with fistulas to understand how countries differ from one another in the circumstances of genital fistula development. Methods This retrospective records review evaluated demographics and circumstances of fistula development for 6,787 women who sought fistula treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia, and Ethiopia. Results Most women developed fistula during childbirth, whether vaginal (3,234/6,787, 47.6%) or by cesarean section (3,262/6,787, 48.1%). Others had fistulas attributable to gynecological surgery (215/6,787, 3.2%) or rare causes (76/6,787, 1.1%). Somalia, South Sudan, and Ethiopia had comparatively high proportions following vaginal birth and birth at home, where access to care was extremely difficult. Fistulas with live births were most common in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia, indicating more easily accessible care. Conclusions Characteristics of women who develop genital fistula point to geographic differences in obstetric care. Access to care remains a clear challenge in South Sudan, Somalia, and Ethiopia. Higher proportions of fistula after cesarean birth and gynecological surgery in Kenya, Malawi, Rwanda, Uganda, Tanzania, and Zambia signal potential progress in obstetric fistula prevention while compelling attention to surgical safety and quality of care.

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“…Primary infection and malignancy have also been cited as rare causes of RVF. 7 8 Etiologies such as inflammatory bowel disease (IBD) and radiation therapy are common in Western countries, but their prevalence is not well known in LMICs where the diagnosis of IBD is uncommon and access to radiation therapy rare.…”

Section: Prevalence and Etiologymentioning

confidence: 99%

“…Current literature generally does not cite sexual violence as a cause of RVF but documented cases exist in Rwanda, Sierra Leone, Sudan, and the Democratic Republic of Congo. 8 19 One report of 4,715 women who suffered sexual violence in Eastern Congo found 702 (14.9%) patients had a genital fistula. The authors define genital fistula as either VVF or RVF and report that of the 702 women with genital fistula, 26.6% were obstetric and 63.4% were traumatic.…”

Section: Prevalence and Etiologymentioning

confidence: 99%

Rectovaginal Fistula Management in Low-Resource Settings

Lussiez

Nardos

Lowry

2022

Clin Colon Rectal Surg

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Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.

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Frequency and management of non‐obstetric fistula in the Democratic Republic of Congo: experience from the Fistula Care Plus project

Cited by 5 publications

References 13 publications

Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review

Iatrogenic genito-urinary fistula following cesarean birth in nine sub-Saharan African countries: a retrospective review

A retrospective review of genital fistula occurrence in nine African countries

Rectovaginal Fistula Management in Low-Resource Settings

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