The latest obstetric fistula research summarized for you in one place.
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April 2018


Fistula Research Update


Presented by Texas Children's Hospital® Global Women's Education, Research and Care Program

Photo Credit: Freedom from Fistula Foundation
Welcome back to the Fistula Research Update! This newsletter is created for researchers, fistula surgeons, medical providers, nurses, social activists and advocates. We hope that it is shared widely and that it will help us all to reach the collective goal of ending fistula.
-Editors Rachel Pope, MD, MPH & Jeffrey Wilkinson, MD  
Baylor College of Medicine 
Texas Children's Global WERC
This edition we have interesting articles on fertility and pregnancy after obstetric fistula repair. We also have concerning findings on gender-based violence among women with OF from a large DHS database, as well as interesting risk factors for OF in Tigray. Enjoy! /rp


     Pelvic Ultrasound Findings in Women with Obstetric Fistula:
A Cross-Sectional Study of Cases and Controls

Women with OF experience profound injury and have high rates of infertility and poor obstetric outcomes. A cross sectional study conducted at the Fistula Care Center in Malawi enrolled 110 women, 98 cases and 12 controls who underwent vaginal ultrasound with measurements of cervical dimensions.   The number of controls was low because of recruitment at the fistula center and strict inclusion criteria.  Participants were aged 25–34 years, had given birth to 2-3 children, and had a normal body mass index (18.5–25.0). While not statistically different, women with OF were more likely to not be married (32% versus 8%), to have not gone to school or only have gone to primary school (93% versus 75%), and to be a peasant farmer (71% versus 58%), compared to women without OF. There were no significant differences in cervical width, endometrial thickness, or uterine volume between cases and controls. It was discovered that women with OF have shorter cervical length and anterior and posterior cervical stroma as compare to controls. Women with more severe fistula classifications had slightly shorter final cervical lengths on average. However, there were no statistically significant associations between stage of the fistula as determined by the Waaldijk classification system and cervical length. Up to 70% of women with OF will never have a living child.  Destruction of the cervix and other pelvic structures could play a role in this. Future studies may be implemented in the area of surgical revision of the cervix at the time of fistula surgery. Patients who have a shortened cervix may benefit from cerclage, pessary, and/or hormonal therapy to prevent preterm delivery or pregnancy loss. /WN      

This study could be limited by a number of factors including the low number of controls and the fact that the ultrasonographer could have been biased when performing the scans.  However, there is a clear pathophysiologic basis for these findings in women with OF due to obstructed labor.  When performing hysterectomy in women with OF, we often find little or no remaining cervix, especially anteriorly.  In this study, the confirmation of our clinical impressions that women with OF have shorter cervices was nice, but does relatively little to help us decide how to help them in the future. /jw

  Fertility Outcomes Following OF Repair: A prospective cohort study

  Fertility outcomes of women after fistula repair were measured in a study published in 2017 in the Journal of Reproductive Health. Reproductive potential of 297 women was  analyzed (excluding menopausal, post hysterectomy and post tubal ligation women) with a final subanalysis of 148 women. A non-clinician conducted home interviews of these women questioning relationship status, sexual activity, pregnancy since surgery, amenorrhea, family planning and dyspareunia status. 54 women within the subanalysis also had hormone markers (AMH, FSH, and estradiol) at time of fistula surgery as part of another study. Results showed 21% of women with reproductive potential became pregnant and most deliveries were cesareans, 11% of women reported dyspareunia, 78.1% had resumed menses who were amenorrheic at time of repair and 34.4% were using a method of family planning. No significant difference in hormone markers were seen between women who were able to conceive and those who were not nor was there a difference between those with amenorrhea and those without. However, as not all women had hormone markers collected, the sample size was small. 
This study is novel as it brings long term, prospective data regarding reproductive health in the post repair obstetric fistula population. It also shows encouraging reproductive results that should strengthen clinicians resolves to include contraceptive and reproductive counseling post repair. /HH

Risk Factors for Obstetric Fistula in Tigray   

In this case-control study conducted in Tigray, Ethiopia, 75 women with history of obstetric fistula were compared with 150 parous controls with no history of fistula. The objective of the study is to determine if there are differences in demographics and clinical/medical history between the two groups. Wall et al. found significant socio-economic and demographic differences and differences in obstetric history. Patients with fistulas are significantly shorter, younger, less educated, have a history of assisted vaginal deliveries, fewer antenatal visits, and have labour lasting > 1 day. The strength in this study includes the access to large number of completed patient records. This study is limited by the single-country study, and that the cases and controls were not matched. Without a post-hoc power analysis, it is unclear as to the generalizability of this study. This study describes that despite the biological risk factors that can predispose women to obstetric fistulas, there are additional factors which prevent timely access to obstetrical care. The authors suggest that governments should make infrastructure development to poor communities a priority in health systems planning as part of a strategy to reduce obstetric fistulas. /OC

The Association between Female Genital Fistula Symptoms and Gender-Based Violence: A multicountry secondary analysis of household survey data

 Mallick and Tripathi conducted a study to examine association between Gender Based Violence GBV and female genital fistula symptoms.  Using Demographic and Health Surveys (DHS) from multiple African countries, GBV was examined among women with self-reported fistula symptoms and those without from a sample of 95,625 women. Self-reported fistula symptoms ranged from 0.3%-1.8%. Violence may occur both before and after onset of fistula and risk of violence increases after the onset of fistula symptoms. However, sexual assault is not frequently cited as cause of fistula, most respondents cited delivery as the most common cause of fistula symptoms. One-third (28.2%) of those with fistula symptoms report physical violence in the last year, compared to 19.2% of those without symptoms of fistula. More striking, 16% of those with fistula symptoms report sexual violence whereas 8% of those without fistula symptoms report sexual violence. Controlling for demographic and maternal health variables, regression analysis demonstrates significant associations between ever experiencing physical and sexual violence and self-reported fistula symptoms. /SC

Despite the weakness of this study being the self-reported fistula symptoms and not a confirmation of OF, the sample size is large and the associations between GBV and fistula are concerning. Women with OF are a vulnerable population and providers should be aware of the risks of GBV among this patient population./rp


Baylor adjunct assistant professor and founder/CEO of Operation Fistula, Seth Cochran, is launching his data collection program, GOFER this year. In order to generate more and stronger research, data is needed. We hope that GOFER helps everyone in the Fistula community to improve research and gain more insight to improve the care of women with obstetric fistulas. Contact Seth for more information:
Guest Contributor: Dr. Helai Hesham is an OB/Gyn currently training in Female Pelvic Medicine and Reconstructive Surgery at Massachusetts General Hospital with a special interest in obstetric fistula repair and research.
Other Contributors: 
WN: William Nundwe
OC: Olivia Chang
SC: Sperecy Chigwale
Special thanks to Freedom from Fistula Foundation  

and One By One
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