The latest obstetric fistula research summarized for you in one place.
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March 2019


Fistula Research Update


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

Photo Credit: Jeff Wilkinson
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 some long-term findings that are hopeful for the lives of our patients years after returning home. We also have an announcement for a new research grant for research in Obstetric Fistula. Please scroll to the bottom for more information! /rp


   Continence, quality of life, and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study

     In this study we evaluated women who underwent obstetric fistula repair at the Fistula Care Center in Lilongwe, Malawi at one to four years post-operatively. 290 patients were evaluated in their homes (usually in a village setting) given the difficulty in long-term follow-up in the hospital. These women were questioned about their quality of life, residual incontinence, depression and other matters. 80% of women were completely dry and few women were depressed. All of these women with depression were still experiencing urinary incontinence. This study benefited from the long duration of follow-up and relatively large sample size. Also, the patients’ reports of urinary incontinence were confirmed by perhaps the most reliable indicator of incontinence, the pad test.

The results of the study were mostly predictable with incontinence measure being largely consistent with prior studies. However, the longer term follow-up in this study when compared to most others should give providers of fistula care services some hope that the improvement seen after surgery persists. Also, this study encourages us to follow our patients closely after surgery for persistent urinary incontinence, as this seems to be the best predictor of future quality of life and potential depression. /jw     


  After obstetric fistula repair; willingness of women in Northern Nigeria to use family planning

  Delaying conception is an essential component of obstetric fistula (OF) repair. Family planning (FP) allows patients to engage in sexual activity while preventing pregnancy which could lead to the breakdown of a recently repaired fistula. This study employed a cross-sectional design to select and evaluate the perspectives of 420 pre- and post-operative OF patients in the states of Kaduna, Sokoto, and Zamfara in Northern Nigeria, where usage of FP services is severely limited. Semi-structured interviews were administered by trained research assistants using a questionnaire developed from Ogilvie, Morin, and their colleagues.

Results demonstrated that few women had employed FP methods previously, though the majority were willing to use it in the future. The mean age of respondents was 26.4±8.4 years, with 39% of women interviewed while living with fistula, and 60.5% interviewed after repair. 56.7% of respondents were aware of FP, but only 0.3% used a modern form of birth control before their fistula and 1.3% employed it afterwards. 63.8% of respondents expressed a willingness to use FP in the future. The Chi-squared test demonstrated that women who were over eighteen years, and monogamously married with children were significantly more likely to be willing to employ birth control.
Researchers behind the study were surprised by the low levels of FP awareness (56.7%), given that all patients at the research sites are provided with FP counseling services. They hypothesize that these results are a consequence of teaching about birth control in a large group format, and recommend that an individualized model of FP counseling, which is also better integrated into OF care, be used in the future. The increase in usage of birth control before and after repair (0.3% and 1.3%, respectively) indicates that FP counseling is vital to improving usage, but reform is needed to improve its effectivity.


The Experience of Women with Obstetric Fistula following Corrective Surgery: A Qualitative Study in Benadir and Mudug Regions, Somalia 

Mohamed at el. found that women living with obstetric fistula in Somalia face physical, psychosocial and economic challenges due to their incontinence. Physical challenges include the smell, irritation, pain, weakness, and wounds that develop due to wetness and friction between thighs when walking. Similar to other studies, the authors noted psychosocial challenges including social stigmatization, which prevents them from participating in community activities and reduces social support. Due to the fact that they cannot have a normal sex life, women face disrupted marital relationships leading to divorce. Culturally, women in Somalia depend on their husbands economically such that divorce leads to financial constraints. Women end up depending on their extended families and they spend the little funds they have to keep themselves clean and towards medical treatment. The authors suggest improved emergency obstetric services and community-level birth preparedness campaigns to prevent the ripple effect an obstetric fistula has on a woman's life. /sc

Estimating the cost and cost effectiveness for obstetric Fistula repair in Uganda: a low income country

The results from a two-phased study conducted in Uganda aimed at assessing the cost effectiveness of surgical intervention for obstetric fistula to provide appropriate data for policy makers to prioritize fistula repair and reduce women's suffering. Using a decision-analysis model, the authors compared the cost-effectiveness for Uganda's National Health Service to repair vesico-vaginal and recto-vaginal fistulas compared to not repairing them. For a 20 year old woman, repairing her fistula would decrease her disability-adjusted life year from 8 to 1.5. Therefore, fistula surgery was found to be highly cost-effective.

Development of strategies that would help in formulation of health policies would be targeted to prioritize funding the health budget to accomplish universal health coverage. Authors explain the need to train more obstetricians to be placed in referral hospitals, and a need to expand surgical services to other centers with full infrastructure to increase the number of obstetric fistulas repaired in a year. The factors that contribute to women's marginalization including lack of access to quality health services and education, persistent poverty and socioeconomic inequality, must also be addressed. /wn

Pubococcygeal Sling versus Refixation of the Pubocervical Fascia in Vesicovaginal Fistula Repair: A Retrospective Review

Due to an ongoing challenge to close the "continence gap," we evaluated our database for differences in outcome between surgical repairs that employ a pubococcygeus (PC) sling versus those that use a refixation of pubocervical fascia (RPCF) as an anti-incontinence method. We excluded women who also had a urethral plication and found 173 with a PC sling, 47 with an RPCF and 32 women with both. Dye tests were negative in 84%, 89.9%, and 93.8% respectively. Urethral incontinence was found in 49%, 47.8%, and 43.8% respectively. There was no difference in one hour pad weights in any of the groups. We could therefore, not recommend either procedure over the other, however found that using both simultaneously might be useful. Although the group size limited our ability to find statistical significance for those with both a PC sling and an RPCF, their continence rates trended towards a more favorable outcome. /rp
Baylor College of Medicine/Texas Children's Hospital Research Grant
$3,000 Grant for Research in an area of Obstetric Fistula needing evidence.

Email: to be put on the distribution list for application information.
Guest Contributor: Rachel Mernoff: Rachel graduated from UCLA last spring with a B.S. in anthropology and a passion for global health. She is currently working as a Fulbright fellow in Malawi on an ethnographic study and as a research assistant at FCC helping with data analysis. She originally came to Malawi to conduct fieldwork for her undergraduate thesis during the summer of 2018, and is excited to be back in Lilongwe this year and to start medical school in the fall!
Regular Contributors: 
WN: William Nundwe
SC: Sperecy Chigwale
Special thanks to Freedom from Fistula Foundation  
Presented by:
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