Obstetric FistulaGeneva Foundation for Medical Education and Research GFMER Sudan 2012 Forum No: ( 1 )
Name of presenterName Position InstitutionMishkat Shehata Junior Doctor Federal Ministry of Health Name of contributorsName Position InstitutionHani Ibrahim Research Assistant RCRU
Content of the presentation• What is an Obstetric Fistula?• Epidemiology• The burden of living with OF• Causes• Local epidemiology in Sudan• Specialized centres for OF in Sudan• Long term goals of a national fistula programme• Development of OF prevention and treatment strategy• Data collection• Strategies for prevention• Monitoring and evaluation of a national fistula programme• Conclusion• References
What is an Obstetric Fistula?• Obstetric Fistula (OF) is an abnormal opening between a woman’s vagina and bladder and/or rectum, through which her urine and/or faeces will continually leak• OF can be surgically corrected by a surgery that costs no more than $300
Epidemiology• Worldwide, there are 2 million women living with untreated OF; the incidence being about 2 in every 1000 deliveries in Sub-Saharan Africa (1)• Between 50 000 and 100 000 women are annually affected (2)• In Sudan, an estimate of 5 000 new cases annually has been made (3)((Elkins et al, 1994. Columbia University sponsored Second Meeting of the Working Group for the Prevention and Treatment of Obstetric Fistula. UNFPA, FIGO, Addis Ababa, 2002. El Sadig et al, 2009)
The burden of living with OF• At the Addis Ababa Fistula Hospital, 53% of women had been abandoned by their spouse and one in every five said that she had to beg for food in order to just survive• Some women crumble, are no longer able to withstand the pain and suffering of being left and ostracized from their communities, and unfortunately resort to suicide (4)(Wall et al, 2001)
CausesPhysical causes; mainly prolonged and obstructed labour, rarely caused by rape, sexual abuse and unsafe abortionLack of emergency obstetric care, which includes lack of skilled professionals and availability of facilities. Recent studies done in some African countries by UNFPA and UNICEF showed that each country had ONE comprehensive obstetric facility per 500 000 inhabitants and none had the necessary quota of facilities for basic emergency obstetric care (5) (Report of a UNFPA/AMDD meeting, February 2005, (unpublished), Yaoundé, Cameroon)
Early marriage and childbirth; In Ethiopia and Nigeria, more than 25% of women suffering from fistula had become pregnant before the age of 15, and over 50% before the age of 18 (6). Fistula formation is more likely after a first labour(7)Harmful traditional practices; such as female genital mutilation (FGM). 15 percent of fistula formation in Africa is accountable to harmful cutting by unskilled birth attendants (8)Lack of knowledge regarding fistula repair(Ampofo, 1990. Kelly J, Kwast BE, 1993. Faces of Dignity, 2003, Women’s Dignity Project, Dar es Salaam, Tanzania)
• Poverty; Two epidemiologic studies of fistula have found that more than 99% of women undergoing surgical repair of fistula were illiterate (9,10). The incidence of OF in sub- Saharan Africa is estimated to be about 124 cases per 100 000 deliveries in rural areas, in comparison to almost no cases in major urban cities (11)(Tahzob F, 1983. Emembolu J, 1992. Vangeenderhuysen D, 2001)
Local epidemiology in Sudan• OF is a serious problem in Sudan; but the country is home to one of the few hospitals that specialize in treating and curing fistula: The Khartoum Teaching Hospital Fistula Centre• In Sudan, the incidence of obstructed labor (followed by instrumental delivery) in 1997 to 1999 was 1.27%. Vesicovaginal fistula occurred as a complication in 1.5% of these cases (12) and 4.8% in another study (13)• In one study in Wad Medani, the causes of fistula were obstructed labor (28%), forceps delivery (14%), Lower segment Caesarean sections (16%), hysterectomy (24%), other gynecological operations (12%) and radiation (6%) (Graph 1)(14)(Dafallah SE, 2003. A Ali, 2010. El Imam M, 2005)
• Poverty, early marriage, malnutrition and poor health services all seem to contribute to the obstetric fistula situation in Sudan. Low socioeconomic status contributed to over 80% of cases in one large study in 2008 (15)• However, the majority of these cases married before the age of 18 years. More than half of patients with obstetric fistula in Khartoum did not attend regular antenatal care, and about 40% delivered at home. Most cases of obstetric fistula in Sudan come from the Western regions, including Darfur. In this region, sexual violence (including rape) is common (16), and this has been shown to be a risk factor for fistula formation (17)(Mohammed EY et al, 2009. ACORD – Agency for Cooperation and Research in Development – Unfinished Business: Transitional Justice and Women’s Rights in Africa. Peterman A, 2009)
Specialized centres of OF in Sudan• In Sudan, there are four specialized fistula hospitals; the most renowned being Khartoum Teaching Hospital Fistula Center (a.k.a) Dr. Abbo National Fistula Center• It was named after Dr. Abbo who opened a small fistula unit in Khartoum in 1972 which was then upgraded into the center in the late 80s• Dr. Abbo Hassan Abbo established this centre as an extension of Khartoum Hospital’s Fistula ward in 1989. Currently, the centre sees more than 700 patients per year (18), and is tended to by 5 expert Fistula consultants. The hospital is a multidisciplinary effort including urologists, rectal surgeons and urogynaecologists. The centre is the second largest in Africa and the Middle East, second only to the one in Addis Ababa, Ethiopia (19)• The three other centres exist in Kassala, Elfashir and Zilingi(Salih A, 2010. Zacharin RF, 2000)
Long-term goal of a national fistula programme• Prevent women from developing fistula through health promotion and awareness, and the development of high-quality basic and comprehensive maternal health services, available to all.• Ensure that all women living with fistula have easy and early access to skilled professionals able to repair simple fistula and/or refer more complex cases to more experienced colleagues.• Ensure that each girl’s and woman’s right to health, including reproductive rights, which are closely linked with the prevention of OF, are recognized and protected by the provision of an enabling policy and regulatory environment.
Development of OF prevention and treatment strategy• Setting up a National OF strategy committee as an key part of the national Maternal and Newborn Health (MNH) strategy committee• Data collection on the prevalence and incidence of OF in the country. Identifying any specific local determinants, mapping current preventive and curative service provision, and undertaking a needs assessment to guide future policy development• Development of a policy framework with achievable short-, medium- and long-term objectives
Data Collection• Mapping existing services provides useful information to planners and policy- makers by identifying any gaps in services, equipment and human resources for emergency obstetric care, as well as fistula services.• Service Availability Mapping (SAM) is available to help with this(20) (SAM, WHO, 2004)
• Epidemiological:• Primary data collection (Most data are from hospital services; undervalues majority of women hidden in community)• Community-based surveys (qualitative approaches)• Proxy measures may also be available to estimate the prevalence and burden (Eg high maternal mortality rates or high rates of uterine rupture)• Stakeholder Analysis:• Drawing together the information and opinions of experts in the field, women and their families who live with fistula or have had fistula treated. Local providers of services, government, community-based organizations, NGOs as well as other relevant stakeholders are also involved.
• Community or facility based reviews:• Understanding the underlying causes that lead to fistula formation to help determine most effective ways to improve local situation• Community- or facility-based case reviews to identify particular local issues and provide potential solutions• Involvement of local health professionals and relevant policy-makers
Strategies for prevention• Primary-prevention: Ensure that pregnancies are planned, wanted, and occur at an optimal time in the woman’s life.• Secondary-prevention: Once pregnant, a woman, her family and the community need to be aware of the need to seek antenatal care, the importance of skilled care at childbirth, and the signs and symptoms of possible problems during pregnancy and childbirth• Tertiary-prevention: Identify and prevent the development of fistula in labour or in recently delivered high-risk women. Monitoring of labour and timely intervention when obstructed labour arises; or referral to a comprehensive emergency obstetric care facility if services are not available on site
Monitoring and evaluation of a national fistula programme• Clinical audit and research• Performance indicators:• Reproductive health indicators for global monitoring (21) (Reproductive health indicators for global monitoring. Report of the second Interagency meeting. Geneva, World Health Organization, 2000)• Percentage of births attended by skilled health personnel• Number of facilities with functioning basic essential obstetric care per 500 000 population• Number of facilities with functioning comprehensive essential obstetric care per 500 000 population
Conclusion• In Sudan, there are 5 000 new cases every year• Lack of emergency obstetric care, early marriage, childbirth and harmful traditional practices and poverty are all contributory factors• Four specialized fistula hospitals exist in Sudan• It has been recommended that the emphasis on antenatal care, the training of midwives and the general improvement of socioeconomic status of women in Sudan should take priority to help prevent obstetric fistula. Doctors should also be advised to carefully consider the risks of instrumental (forceps) delivery, and opt for a Caesarean section in difficult cases.• National fistula programmes require accurate data collection, prevention strategies tailored to local needs and good monitoring and evaluation• Finally lack of data and information makes it difficult to estimate the true percentages and distribution of OF in Sudan (mainly in rural conflict and post conflict areas)
References1. Elkins TE. Surgery for the obstetric vesicovaginal fistula: a review of 100 operations in 82 patients. Am J Obstet Gynecol. 1994;170:1108-1120.2. Columbia University sponsored Second Meeting of the Working Group for the Prevention and Treatment of Obstetric Fistula. UNFPA, FIGO, Addis Ababa, 2002.3. ElsadigYousif Mohamed, MahaFouadAbdallaBoctor, Hyder Abu Ahmed, HatimSeedahmed, Mohamed Ahmed Abdelgadir, Sawsan Mustafa Abdalla. Contributing factors of vesico-vaginal fistula (VVF) among fistula patients in Dr.Abbos National Fistula &Urogynecology Centre - Khartoum 2008. Sudanese Journal of Public Health. April 2009 vol 4(2): 259-264.
4. Wall, LL et al. Urinary incontinence in the developing world: The obstetric fistula. Proceedings of the Second International Consultation on Urinary Incontinence, Paris, July 1-3, 2001. Committee on Urinary Incontinence in the Developing World, pp. 1-67.5. Report of a UNFPA/AMDD meeting, February 2005, (unpublished), Yaoundé, Cameroon.6. Ampofo KE. Risk factors of vesico-vaginal fistula in Maiduguri, Nigeria: A case- control study. Tropical Doctor, 1990, 20(3):138-139.7. Kelly J, Kwast BE Epidemiologic study of vesico-vaginal fistula in Ethiopia. International Urogynecology Journal, 1993, 4:278-281.8. Faces of Dignity, 2003, Women’s Dignity Project, Dar es Salaam, Tanzania.9. Tahzob F. Epidemiological determinants of vesicovaginal fistula. BJOG An International Journal of Obstetrics and Gynecology, 1983, 09(5):387-391.10. Emembolu J. The obstetric fistula: factors associated with improved pregnancy outcome after a successful repair. International Journal Gynecology and Obstetrics, 1992, 39:205-212.
11. Vangeenderhuysen D, Prual A, Ould el Joud, D. Obstetric fistula: Incidence estimates for sub-Saharan Africa. International Journal of Gynecology and Obstetrics, 2001, 73:65-66.12. Dafallah SE, Ambago J, El-agib F. Obstructed labor in a teaching hospital in Sudan. Saudi Medical Journal 2003; Vol. 24 (10): 1102-1104.13. A. Ali and I. Adam Maternal and perinatal outcomes of obstructed labour in Kassala hospital, Sudan. Journal of Obstetrics &Gynecology 2010 30:4, 376-377.14. El-Imam M, El-Hassan el-HM, Adam I. Vesicovaginal fistula in Sudanese women. Saudi Med J. 2005 Feb; 26(2):341-2.15. Mohamed EY et al. Contributing factors of vesico-vaginal fistula (VVF) among fistula patients in Dr.Abbos National Fistula &Urogynecology Centre - Khartoum 2008. Sudanese Journal of Public Health. Vol 4 No 2 (2009).16. ACORD – Agency for Cooperation and Research in Development – Unfinished Business: Transitional Justice and Women’s Rights in Africa.
17. Peterman A., Johnson K. Incontinence and trauma: Sexual violence, female genital cutting and proxy measures of gynecological fistula (2009) Social Science and Medicine, 68 (5), pp. 971-979.18. Salih A and Salih A. The Legend of Dr. Abbo Hassan Abbo. Sudanese Journal of Public Health. Vol 5 No 2 (2010).19. Zacharin RF. A history of obstetric vesicovaginal fistula. Aust N Z J Surg. 2000;70:851-854.20. Service Availability Mapping (SAM) MHI/EIP/GIS/CDS. Geneva, World Health Organization. 2004.21. Reproductive health indicators for global monitoring. Report of the second Interagency meeting. Geneva, World Health Organization, 2000.