Obstetric fistula management and predictors of successful closure among women attending a public tertiary hospital in Rwanda: a retrospective review of records

Abstract

BackgroundGlobally, 50,000–100,000 women develop obstetric fistula annually. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Among women with fistula seeking care at public health facilities in resource-limited settings, there is paucity of data on quality of care received. The aim of this study was to characterize obstetric fistula among Rwandan women managed at a public tertiary hospital and evaluate for predictors of successful fistula closures.MethodsA retrospective review of records for all obstetric fistula women managed at a public referral health facility between 2007 and 2013 was performed. Patient socio-demographics, obstetric characteristics and fistula repair outcomes data were reviewed. A multivariate logistic regression model was used to analyse for predictors of successful fistula repair outcomes.ResultsA total of 272 women aged between 16 to 78 years and with a mean age of 34.6 years were included. Of these, 93 (34.2 %), 48 (17.6 %), 65 (24 %) and 64 (23 %) women had vesico-vaginal fistula, recto-vaginal fistula, urethro-vaginal fistula and vesico-uteral fistula types, respectively. Successful fistula closure was achieved among 86.3 %. Women with fistula who reported being in labour for ≥3 days, having ≥1 previous fistula repair attempt, and having lived with the fistula for >1 year, had significantly lower odds of successful repair outcomes.ConclusionsAmong 272 women with obstetric fistula managed in this study, 69.5 and 26.5 % of their fistula were causally associated with obstructed labour complications and iatrogenic factors, respectively. Successful fistula closure rates of about 89 % among women of index repair attempt were achieved. Conversely, reported histories of ≥3 days in labour, ≥1 previous failed attempts at repair and a fistula duration of >1 year, were significant determinants of failed fistula closures. To effectively mitigate obstetric fistula burden in Rwanda, a comprehensive package of services including quality emergency obstetric care, increased availability of and access to quality fistula repair, active surveillance to identify community-based women with fistula and a strong political will towards effective fistula care, are recommended.

Management of complex genital fistula: experience in a tertiary sub-Saharan hospital

“…Other patients in this category include those with large fistulae, diminished bladder capacity and loss of the continence mechanisms. 27 Two of our patients had irreparable vesicovaginal fistulae and had construction of continent catheterizable ileal neo-bladder. In one of such patients the fistula had occurred in late childhood after what appeared to be measles and by the time of presentation in early adolescence, initial repair showed a large fistula with severely compromised bladder capacity and that initial repair had failed.…”

“…As reported by Amitava et al and Egziabher et al, the successful repair of genital fistulas is most likely to occur in the first than in subsequent attempts and a number of our patients had had previous failed attempts at repairs and the number of the previous attempts ranged between to 4 times prior to their referral to our facility. 14,27 These previous failed attempts would have resulted from increased vaginal scarring, larger fistula sizes and reduced bladder capacities; factors which have been documented to further reduce the success/cure rate. 28 Three patients had fistula closure but developed stress urine incontinence (SUI) as has been reported by Sori et al 29 These patients who were observed to have developed stress urinary incontinence were probably those who had some urethral involvement or those who had existing preoperative SUI which were not apparent to the patient nor recognized by the surgeon till after fistula closure.…”

Prognostic factors and long‐term outcomes of obstetric fistula care using the Tanguiéta model

“…Successful surgical repair, verified by a negative dye test, is the principal outcome of fistula repair; however, treatment success is also defined in other studies by signs of the woman's return to overall well‐being, such as regular menses, sexual intercourse, and urinary continence. The present results show that these three aspects were progressively reinstated by succeeding follow‐up visits.…”

Treatment-seeking for vaginal fistula in sub-Saharan Africa

“…The lower success rate may suggest the suboptimal quality of the surgical care or presence of other contextual factors that limit surgical closure (e.g malnutrition) in the region. Facility-based studies conducted in Ethiopia, Rwanda, Nigeria and Guinea reported complete continence rates between 83 and 89% [20][21][22][23]. However, the figures cannot be directly compared to each other due to multiple reasons including differences in treatment success ascertaining approaches.…”