Prevention and management of obstetric fistulae requires both a long-term strategy and long-term care
Authors: Jeremy Torquil Wright
Journal: The Lancet Global Health (2017)

Undertaking research, particularly longitudinal research, in resource-poor countries is a daunting task, and Alexandre Delamou and colleagues1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar are to be congratulated on managing to collect and analyse this important dataset. Of the 888 women identified who had undergone fistula repair, 682 (77%) were eligible for inclusion in the study and 481 (71%) of these eligible women were located. Eight (1%) women died over the study period and 73 (15%) located women had recurrent cases of fistula.1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar To reduce recurrence, women who have undergone successful fistula repair should be strongly advised to have an elective caesarean section for any subsequent pregnancies to protect that repair. Some fistula centres offer caesarean sections as a free service to their former patients to encourage them to follow this advice. However, in a paternalistic society where women have few choices and transport is poor in rural areas, access to or use of such services is not always possible. Of the 50 women who delivered a child subsequent to fistula repair, 31 (62%) delivered in a health centre, 29 (58%) delivered vaginally, and 12 (24%) delivered by emergency caesarean section, with a high stillbirth incidence of 12 (24%). Seven women (14%) suffered a recurrent fistula and there was one (2%) maternal death.1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar These data are a stark reminder that one-off surgical interventions with inadequate aftercare carry a poor prognosis for long-term symptom relief, and are associated with substantial morbidity and mortality. Given the social stigma associated with fistula, it is interesting that the data reveal an increase in urban residence after surgery—from 6·2% to 12·9%.1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar The authors report that non-pregnancy-related fistula recurrence is associated with rural activities, such as farming, in addition to walking and penetrative sexual activity. This strongly suggests that those who return to their rural communities are most at risk of recurrence, probably from a combination of hard manual labour and poor access to health care. The incidence of obstetric fistula seems to be closely associated with maternal death, and the maternal mortality ratio in Guinea is particularly high at 724 maternal deaths per 100 000 livebirths.1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar Ethiopia invested in maternal care over the same time period as the data collection reported by Delamou and colleagues,1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar and the maternal mortality ratio was reduced to 420 deaths per 100 000 livebirths.2Central Statistical Agency (Ethiopia) and ICF InternationalEthiopia Demographic and Health Survey 2011. Central Statistical Agency and ICF International, Addis Ababa, Ethiopia and Calverton, Maryland2012Google Scholar A community-based study of fistula prevalence in rural Ethiopia3Ballard K Ayenachew F Wright J Atnafu H Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia.Int Urogynecol J. 2016; 27: 1063-1067Crossref PubMed Scopus (22) Google Scholar done during this period of maternal death reduction reported a significant reduction in fistulae, with an overall prevalence of obstetric fistula of six per 10 000 women (95% CI 3–8). Thus, a concentrated effort to improve maternal care might also have a marked effect on fistula prevalence. In this study,1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar two women who delivered by emergency caesarean section developed a fistula recurrence. It is not possible to say whether these recurrences were associated with fistula breakdown due to prolonged pressure of the fetal head on the operation site or a new fistula due to operative intervention. In health-care centres where facilities are scarce, relatively poorly trained personnel might carry out emergency surgery. In a study of new obstetric fistulae presenting to three of the hospitals run by Hamlin Fistula Ethiopia,4Wright J Ayenachew F Ballard K The changing face of obstetric fistula surgery in Ethiopia.Int J Womens Health. 2016; 8: 243-248Crossref PubMed Scopus (20) Google Scholar the incidence of women presenting with new fistulae decreased year on year, but fistulae associated with caesarean section increased, accounting for 36% of all new fistulae in the final year of the study. To make any impact on maternal mortality and obstetric fistula incidence, women must be empowered to reach the care they need, and this care must be delivered by competent practitioners who can recognise obstructed labour and act appropriately and safely. Although Delamou and colleagues1Delamou A Delvaux T El Ayadi AM et al.Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal study.Lancet Glob Health. 2017; (published online Sept 20.)http://dx.doi.org/10.1016/S2214-109X(17)30366-2PubMed Google Scholar have not classified the fistulae using a scheme such as the Koh classification,5Goh JWT Kraus HG Female genital tract fistula. University of Queensland Press, Brisbane, QLD2004Google Scholar most fistulae seem to be low and involve the bladder neck and urethra. Although continence from the fistula closure itself seemed to be high, the authors do not report the incidence of stress urinary incontinence, usually associated with a short urethra and bladder neck scarring, or urinary frequency associated with reduced bladder capacity. These injuries are associated with significant vaginal scarring, which might make future sexual intercourse impossible. Furthermore, women with these injuries might dread the thought of future childbirth, the social impact being a reluctance to return to their rural community, where they face possible rejection, future pregnancy, and hard physical labour, possibly leading to a further fistula breakdown. This paper clearly shows the appalling health and social outcomes of obstetric fistula, even after successful closure—death, stillbirth, and recurrent fistula affect those who attempt to deliver in their communities, and social isolation or fistula breakdown associated with pelvic floor strain affect those forced to toil in the fields. Obstetric fistula is practically unknown where there is recourse to timely competent caesarean section, and it would seem that a relatively modest drop in maternal mortality has a large effect on new fistulae. Therefore, concentration of efforts on reducing maternal mortality should have a major impact on fistula prevalence. For those unfortunate enough to have had this complication, aftercare needs to be ongoing, emphasising to the woman and her family the imperative of elective caesarean section for both her and her child and, ideally, offering these services free of charge. I declare no competing interests. Fistula recurrence, pregnancy, and childbirth following successful closure of female genital fistula in Guinea: a longitudinal studyRecurrence of female genital fistula and adverse pregnancy-related maternal and child health outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair. Full-Text PDF Open Access