Psychological Symptoms and Social Functioning Following Repair of Obstetric Fistula in a Low-Income Setting

The economic consequences of obstetric fistula: A systematic search and narrative review

BACKGROUND

Obstetric fistula develops from obstructed labor and is a devastating condition with significant consequences across several domains of a woman's life. This study presents a narrative review of the evidence on the economic consequences of obstetric fistula.

METHODS

Three databases were searched, and search results were limited to English language papers published after 2003. Search results were reviewed for relevance based on title and abstract followed by full text review using specific inclusion and exclusion criteria. Bibliographies of papers were also scanned to identify relevant papers for inclusion. Data were extracted under three categories (defined a priori): the economic consequences of having the condition, the economic consequences of seeking care, and the macroeconomic impacts.

RESULTS

The search returned 517 unique papers, 49 of which were included after screening. Main findings identified from the studies include women losing their jobs, becoming dependent on others, and losing financial support when relationships are lost. Seeking care was economically costly for families or unaffordable entirely. There were no studies describing the impact of fistula on national economies.

CONCLUSION

Economic consequences of obstetric fistula are multifaceted, pervasive, and are intertwined with the physical and psychosocial consequences of the condition. Understanding these consequences can help tailor existing fistula programs to better address the impacts of the condition. Further research to address the dearth of literature describing the macroeconomic impact of obstetric fistula will be critical to enhance the visibility of this condition on the health agendas of countries.

Treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries: A scoping review

BACKGROUND

Obstetrical fistula is an abnormal opening between the reproductive tract and lower urinary and/or gastrointestinal tract resulting from obstetrical complications, affecting nearly two million women worldwide. It imposes physical, economic, social, and mental consequences on the affected women. Treatment outcomes vary and, mostly, surgical treatment results in improved quality of life and successful subsequent pregnancy for survivors.

OBJECTIVES

The review aimed to chart and examine the treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries.

SEARCH STRATEGY

This is a scoping review study to identify treatment outcomes of obstetrical fistula surgical repair in low- and middle-income countries. The search was conducted from databases (PUBMED, Embase, CINAHL, Scopus, and Web of Science), and gray literature (Google Scholar, Google, and conference proceedings).

SELECTION CRITERIA

The eligibility criteria were constructed using a participant, concept, and context framework and included study types of primary research, reviews, and reports. Studies without full text and in languages other than English were excluded.

DATA COLLECTION AND ANALYSIS

The relevant characteristics of the included studies were extracted on an Excel spreadsheet and analyzed to chart treatment outcomes.

MAIN FINDINGS

The review examined the full text of 57 studies on the treatment outcomes of obstetrical fistula. The findings were grouped into two themes: early and late outcomes. The early outcomes included incontinence, surgical-site infection, urine retention, hemorrhage, and retained catheter. The late outcomes included fistula recurrence, residual incontinence, quality of life, reproductive issues, mental health, family and social support, and financial status.

CONCLUSION

The treatment outcomes of obstetrical fistula can be grouped into short-term and long-term outcomes. Although this review found adequate studies for the analysis, most study designs were poor. Stronger studies are recommended in the future to guide policy and decision-making. We would like to suggest that researchers conduct systematic reviews and meta-analyses independently for short-term and long-term outcomes.

Impact of Beyond Fistula programming on economic, psychosocial and empowerment outcomes following female genital fistula repair: A retrospective study

OBJECTIVE

To retrospectively assess changes in economic status, psychosocial status and empowerment among women who participated in Beyond Fistula reintegration programming following fistula repair.

METHODS

We conducted a retrospective study among 100 Beyond Fistula program participants capturing sociodemographic characteristics, obstetric and fistula history, program participation, and our primary outcomes: economic status, psychosocial status, and empowerment via quantitative survey at two time points: before program participation and currently. Data were collected from November 2020 to July 2021 from 2013 to 2019 program participants. We compared outcomes across these two time points using paired t tests or McNemar's tests.

RESULTS

The proportion of individuals owning property (28.0% vs. 38.0%, P = 0.006), having a current source of income (19.0% vs. 56.0%, P < 0.001), and saving or investing income (11.0% vs. 37.0%, P < 0.001) increased significantly from pre- to post-programming. We also identified statistically significant increases from pre- to post-programming in self-esteem (5.0 [IQR 4.0-5.0] vs. 5.0 [IQR 5.0-5.0], P < 0.001), reintegration (53.0 [IQR 43.0-69.0] vs. 65.0 [IQR 51.0-72.0], P < 0.001) and level of input into household economic decision making (2.0 [SD 1.0] vs. 2.3 [SD 1.0], P = 0.004).

CONCLUSION

Beyond Fistula programming likely improved economic status, psychosocial status, and empowerment of participants. Post-surgical interventions incorporating a holistic approach can advance recovery through supporting psychosocial and economic wellbeing and should be offered to women undergoing genital fistula repair.

Development and Pilot Test of a Group Cognitive Behavioral Intervention for Women Recovering From Fistula Repair Surgery in Ethiopia

Obstetric fistula is a serious complication that affects thousands of women in low-income countries. Women who suffer from obstetric fistulae are at risk of developing mental health problems, but to date most interventions have focused on repairing the physical consequences of fistulae through surgery. The goal of the current study is to develop an evidence-based intervention targeting symptoms of depression, anxiety, and trauma in women recovering from fistula repair surgery. First, hospital staff and patients awaiting surgery at a fistula hospital in Ethiopia participated in qualitative interviews to provide information on the mental health needs of women with fistulae, how the hospital tends to these women's psychological needs, and the training needs of staff members. Data from these interviews were used to develop the COFFEE intervention (CBT with Obstetric Fistula for Education and Empowerment). COFFEE is a modular, group intervention that teaches psycho-education, behavioral activation, relaxation, problem solving, cognitive restructuring, and includes a trauma narrative. Patients then participated in an open trial of the COFFEE intervention at the University of Gondar Hospital. Five separate groups were conducted with 24 women who were enrolled post-fistula repair surgery. Women completed pre-treatment self-report questionnaires, participated in group sessions conducted by nurses (with 8 sessions delivered across 10–14 days), and were assessed post-treatment and at 3-month follow-up. Results indicate a significant reduction on depression and anxiety symptoms scores across the three time points [F_{(2, 40)} = 68.45, p < 0.001 partial η² = 0.774]. Additionally, there was a significant decrease in traumatic stress scores from baseline to post-treatment [F_{(1.10, 21.98)} = 100.51, p < 0.001 partial η² = 0.834]. Feedback forms completed by nurses and patients suggest the intervention was well-received. Results of this open-trial suggest the COFFEE intervention is feasible, acceptable, and clinically beneficial to treat symptoms of depression, anxiety, and traumatic stress in women post-fistula repair surgery in a hospital setting.

Building a country-wide Fistula Treatment Network in Kenya: results from the first six years (2014-2020)

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences, such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a 2014 population-based survey suggest that 1% of reproductive-aged women have experienced fistula-like symptoms.

In collaboration with key stakeholders, Fistula Foundation launched the Fistula Treatment Network (initially known as Action on Fistula) in 2014 to increase access to timely, quality fistula treatment and comprehensive post-operative care for women with fistula in Kenya. The integrated model built linkages between the community and the health system to support women through all parts of their treatment journey and to build capacity of healthcare providers and community leaders who care for these women. Fistula Foundation and its donors provided the program’s funding. Seed funding, representing about 30% of the program budget, was provided by Astellas Pharma EMEA.

Over the six-year period from 2014 to 2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center, trained eleven surgeons and 424 Community Health Volunteers, conducted extensive community outreach, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months.

The Fistula Treatment Network facilitated collaboration across hospital and community actors to enhance long-term outcomes for women living with fistula. This model improved awareness and reduced stigma, increased access to surgery, strengthened the fistula workforce, and facilitated post-operative follow-up and reintegration support for women. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Validation of an adapted instrument to measure female genital fistula-related stigma

Female genital fistula results in severe physical, psychological, and social sequelae. Qualitative research confirms stigma pervasiveness; however, no quantitative instrument exists to measure fistula-related stigma. We adapted an existing HIV-related stigma instrument to fistula-related stigma and assessed its reliability and validity. We recruited 60 Ugandan women seeking genital fistula surgery (December 2014-June 2015). We used exploratory factor analysis to explore the scale's latent structure and evaluated internal consistency reliability with Raykov's ρ statistic. We assessed construct validity through linear regression of stigma with quality of life, depressive symptoms and self-esteem. We retained 15 items across factors 'enacted stigma' and 'internalised stigma' (ρ = 0.960 and ρ = 0.748, respectively). Stigma was inversely associated with all quality of life domains; effect sizes were largest for environmental (enacted stigma, 0.69-point reduction) and psychological (internalised stigma, 0.67-point reduction) domains. Both stigma domains were associated positively with depressive symptoms and inversely with self-esteem, with 0.75 and 1.05-point increases in depressive symptoms and 0.45 and 0.77-point decreases in self-esteem for enacted and internalised stigma, respectively. Results suggest the reliability and validity of the adapted fistula stigma instrument. This instrument may help us understand stigma levels, compare stigma across individuals and communities, prioritise stigma-reduction strategies, and assess intervention impact.

Obstetric and Gynecologic Genitourinary Fistulas

Urinary incontinence shortly after childbirth or gynecologic surgery can be the result of obstetric or iatrogenic fistula formation. This can be a confusing and challenging diagnosis for medical providers. While the number of iatrogenic fistula cases is rising worldwide, obstetric fistulas are an issue uniquely particular to resource poor settings. Appropriate treatment of genitourinary fistulas spans beyond surgical intervention of leakage, and includes re-integration into the community, widespread education and counseling, and battling social stigma and cultural biases. Current and future research must focus on rigorous, unified efforts to set evidence-based practices to help the millions of women affected.

Prevalence of depression among women with obstetric fistula in low-income African countries: a systematic review and meta-analysis

Depression is one of mental health consequences that present in women with obstetric fistula. It is estimated that over 264 million people of all ages suffer from depression globally. The objective of this systematic review and meta-analysis was to synthesize the epidemiologic evidence from previous studies on the prevalence of depression among women with obstetric fistula in low-income African countries. We followed the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines to conduct this meta-analysis. The common databases (PubMed, SCOPUS, EMBASE, Psych INFO, Google Scholar, African Index Medicus, and African Journals Online (AJOL)) were searched for the relevant literature. We used a random-effect meta-analysis model to estimate the overall prevalence of depression and the Q -and I² -statistics were used to assess the heterogeneity between the studies included in the meta-analysis. Egger's test and visual inspection of the symmetry in funnel plots were used to check for the presence of publication bias. The pooled estimated prevalence of depression among women with obstetric fistula in low-income African countries was 56.2% (95% CI 43.1-68.4). The prevalence of depression among women with obstetric fistula was 74.4% in Ethiopia, 72.9% in Kenya, 46.0% in Malawi, 41.0% in Sudan, 34.8% in Nigeria, and 27.7% in Tanzania. Furthermore, the prevalence of depression was higher (97.0%) when it was measured by using Beck's Depression Inventory (BDI) when compared with Patient Health Questionnaire (PHQ9) (62.7%), General Health Questionnaire (GHQ-28) (36.7%), Hamilton Depression Rating Scale (HDRS) (41.0%), and Center for Epidemiologic Studies Depression Scale (CES-D) (27.7%). Moreover, the pooled estimated prevalence of depression among women with obstetric fistula was ranged from 48.1 to 57.7% in a leave-one-out sensitivity analysis. The prevalence of depression among women with obstetric fistula in low-income African countries was high. Screening and appropriate management of depression among women with obstetric fistula are warranted.

Validation of an adapted instrument to measure female genital fistula-related stigma

Female genital fistula results in severe physical, psychological, and social sequelae. Qualitative research confirms stigma pervasiveness; however, no quantitative instrument exists to measure fistula-related stigma. We adapted an existing HIV-related stigma instrument to fistula-related stigma and assessed its reliability and validity. We recruited 60 Ugandan women seeking genital fistula surgery (December 2014-June 2015). We used exploratory factor analysis to explore the scale's latent structure and evaluated internal consistency reliability with Raykov's ρ statistic. We assessed construct validity through linear regression of stigma with quality of life, depressive symptoms and self-esteem. We retained 15 items across factors 'enacted stigma' and 'internalised stigma' (ρ = 0.960 and ρ = 0.748, respectively). Stigma was inversely associated with all quality of life domains; effect sizes were largest for environmental (enacted stigma, 0.69-point reduction) and psychological (internalised stigma, 0.67-point reduction) domains. Both stigma domains were associated positively with depressive symptoms and inversely with self-esteem, with 0.75 and 1.05-point increases in depressive symptoms and 0.45 and 0.77-point decreases in self-esteem for enacted and internalised stigma, respectively. Results suggest the reliability and validity of the adapted fistula stigma instrument. This instrument may help us understand stigma levels, compare stigma across individuals and communities, prioritise stigma-reduction strategies, and assess intervention impact.

Integrated mental health screening for obstetric fistula patients in Mali: From evidence to policy

BACKGROUND

Obstetric fistula significantly impacts women's mental health and well-being. Routine screening for mental health in fistula repair programs can be a gateway to link patients to services, and can produce routine data to inform programmatic investments. This study observed the integration of a mental health screening program into an obstetric fistula repair program in Mali, with two specific objectives: 1) to describe the social and mental health well-being of women presenting with obstetric fistulas in Mali, and 2) to document the impact of the mental health screening pilot on policy change in Mali.

METHODS

Seven fistula repair campaigns were conducted between June 2016 and May 2017. All individuals presenting for fistula repair completed a mental health assessment at intake, including a depression screener (PHQ-9) and an assessment of psycho-social impacts of fistula. The depression screener was repeated three months following inpatient discharge. Findings were shared with stakeholders in Mali and impacts on policy were documented.

RESULTS

Of 207 women who presented for fistula repair, 167 patients completed the mental health assessment at surgical intake, and 130 patients repeated the screener at 3-month follow-up. At intake, 36.5% of women had moderate or severe depression, decreasing to 16.9% at follow-up. The mean depression score differed significantly by timepoint (9.14 vs. 6.72, p <0.001). Results were shared in a report with stakeholders, and consultations with the Mali Ministry of Health. As a result of advocacy, mental health was a key component of Mali's National Fistula Prevention and Treatment Strategy (2018-2022).

CONCLUSION

The high prevalence of depression in Malian fistula patients underscores a need for more robust mental health support for patients after surgery. Data on mental health from routine screening informs community reintegration strategies for individual patients, elevates the overall quality of care of fistula repair programs by addressing patients' holistic health needs, and contributes to evidence-informed decision-making and data-driven policy change within the larger health system.

Women's experiences of rectovaginal fistula: an ethno- religious experience

BACKGROUND

Obstetric fistulas are one of the most tragic injuries that occur after difficult, prolonged childbirth without timely intervention. These fistulas cause discomfort to patients and result in emotional, social, and even physical suffering. The present study aimed to explore the experiences of women with rectovaginal fistula in Kamyaran city, in Kurdestan province, west of Iran.

METHODS

In a phenomenological study, 16 patients, healthcare personnel, and patients' families were investigated. Purposive sampling was performed and Study participants were interviewed in-depth semi-structured interviews. All interviews were audio-recorded, transcribed verbatim (word by word), and analyzed by Colaizzi's method. For determining the validity of the study, Lincoln and Guba's criteria, which include credibility, dependability, transferability, and confirmability, were considered.

RESULTS

Five general themes and 10 sub-themes emerged after investigating interviews. Themes include religious harassment the sub-theme of being defiled), fail (sub-themes of loss and negative attitudes, disrupted sex (the sub-theme of sexual dissatisfaction), consequence (three sub-themes of sleep disturbance, mental crisis, and isolation), and ultimately panic (three sub-themes of humiliation, secrecy, and fear).

CONCLUSION

The rectovaginal fistula is a complex and multifaceted problem with social, individual, familial, religious, and ethnic-environmental dimensions, so there is no simple solution to interact with this problem and there is a need to find a solution, considering the dimensions of the problem and plan for help these patients cope with their disease, and take steps to fully treat it.

Psychosocial health of patients receiving orthopaedic treatment in northern Tanzania: A cross-sectional study

Background

Patients with musculoskeletal injuries in Sub-Saharan Africa often receive prolonged inpatient treatment due to limited access to surgical care. Little is known regarding the psychosocial impact of prolonged conservative treatment for orthopaedic injuries, which may add to disability and preclude rehabilitation.

Methods

A cross-sectional, questionnaire study was conducted to characterize the psychosocial health of orthopaedic inpatients at a tertiary hospital in Moshi, Tanzania. Three validated surveys assessing coping strategies, functional social support, and symptoms of depression were orally administered to all orthopaedic patients with a length of stay (LOS) ≥ 6 days by a Tanzanian orthopaedic specialist.

Results

Fifty-nine patient surveys were completed, and revealed 92% (54) of patients were more likely to utilize more adaptive than maladaptive coping strategies. Patients with chest or spinal column injuries were more likely to use maladaptive coping strategies (p = 0·027). Patients with head injuries had more social support compared to others (p = 0·009). Lack of insurance, limited education, and rural origins were associated with less functional social support, although this finding did not reach statistical significance. 23·7% (14) of patients had symptoms consistent with mild depression, 33·9% (20) with moderate depression, and 3·4% (2) with moderately-severe depression. LOS was the only significant predictor for depression severity.

Conclusions

61% (36) of orthopaedic inpatients exhibited depressive symptoms, indicating that the psychosocial health in this population is sub-optimal. Mental health is a crucial element of successful orthopaedic care. Access to timely surgical care would greatly decrease LOS, the most prominent predictor of depressive symptom severity.

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The majority of orthopaedic patients were found to have symptoms of depression.

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Length of stay was the only significant predictor of depression symptom severity.

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Patients with torso injuries tended to use more maladaptive coping strategies.

Research in Obstetric Fistula: Addressing Gaps and Unmet Needs

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are "dry" tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.

Persistent depression after obstetric fistula repair

OBJECTIVE

To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression.

METHODS

A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status.

RESULTS

A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression. Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up.

CONCLUSION

Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center

OBJECTIVES

To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula.

METHODS

We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted.

RESULTS

Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion.

CONCLUSIONS

Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Reintegration needs of young women following genitourinary fistula surgery in Uganda

INTRODUCTION AND HYPOTHESIS

Genitourinary fistulas (usually arising following prolonged obstructed labor) are particularly devastating for women in low-income counties. Surgical repair is often difficult and delayed. While much attention has been devoted to technical surgical issues, the challenges of returning to normal personal, family, and community life after surgical treatment have received less scrutiny from researchers. We surveyed young Ugandan women recovering from genitourinary fistula surgery to assess their social reintegration needs following surgery.

METHODS

A cross-sectional survey of 61 young women aged 14-24 years was carried out 6 months postoperatively. Interviews were carried out in local languages using a standardized, interviewer-administered, semistructured questionnaire. Data were entered using EpiData and analyzed using SPSS.

RESULTS

Ongoing reintegration needs fell into interrelated medical, economic, and psychosocial domains. Although >90% of fistulas were closed successfully, more than half of women had medical comorbidities requiring ongoing treatment. Physical limitations, such as foot drop and pelvic muscle dysfunction impacted their ability to work and resume their marital relationships. Anxieties about living arrangements, income, physical strength, future fertility, spouse/partner fidelity and support, and possible economic exploitation were common. Sexual dysfunction after surgery-including dyspareunia, loss of libido, fear of intercourse, and anxieties about the outcome of future pregnancies-negatively impacted women's relationships and self-esteem.

CONCLUSIONS

Young women recovering from genitourinary fistula surgery require individualized assessment of their social reintegration needs. Postoperative social reintegration services must be strengthened to do this effectively.

Effects of surgical repair of obstetric fistula on severity of depression and anxiety in Ethiopia

BACKGROUND

The surgical repair of fistula can address the physical symptoms, but may not end the psychological challenges that women with fistula face. There are a few studies that focus on women with this condition in Ethiopia. Hence, the aim of this study was to determine the effects of surgical repair of obstetric fistula on the severity of depression and anxiety in women with obstetric fistula in Ethiopia.

METHOD

The study employed a longitudinal study design to investigate the changes in 219 women with obstetric fistula admitted to six fistula management hospitals in Ethiopia. The data were collected on admission of the patients for obstetric fistula surgical repair and at the end of six-month post repair. A structured questionnaire was used to obtain socio-demographic information and medical history of the respondents. Depression and anxiety symptoms were measured using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) scales. The data was entered using Epi-Data software and then exported to SPSS for further analysis. The Mann-Whitney-U test, the Kruskal-Wallis test and Paired t-test were performed to measure the change in psychological symptoms after surgical repair.

RESULT

Though 219 respondents were interviewed pre-obstetric fistula surgical repair, only 200 completed their follow up. On admission, the prevalence of depression and anxiety symptoms were 91 and 79% respectively. After surgical repair, the prevalence rate was 27 and 26%. The differences in the prevalence of screen-positive women were statistically significant (P < 0.001).

CONCLUSION

The study concluded that the severity of depression and anxiety symptoms decrease post-obstetric fistula surgical repair. However, a woman with continued leaking after surgery seems to have higher psychological distress than those who are fully cured. Clinicians should manage women with obstetric fistula through targeted and integrated mental health interventions to address their mental health needs.

Trajectories of women's physical and psychosocial health following obstetric fistula repair in Uganda: a longitudinal study

OBJECTIVES

To explore trajectories of physical and psychosocial health, and their interrelationship, among women completing fistula repair in Uganda for 1 year post-surgery.

METHODS

We recruited a 60-woman longitudinal cohort at surgical hospitalisation from Mulago Hospital in Kampala Uganda (Dec 2014-June 2015) and followed them for 1 year. We collected survey data on physical and psychosocial health at surgery and at 3, 6, 9 and 12 months via mobile phone. Fistula characteristics were abstracted from medical records. All participants provided written informed consent. We present univariate analysis and linear regression results.

RESULTS

Across post-surgical follow-up, most women reported improvements in physical and psychosocial health, largely within the first 6 months. By 12 months, urinary incontinence had declined from 98% to 33% and general weakness from 33% to 17%, while excellent to good general health rose from 0% to 60%. Reintegration, self-esteem and quality of life all increased through 6 months and remained stable thereafter. Reported stigma reduced, yet some negative self-perception remained at 12 months (mean 17.8). Psychosocial health was significantly impacted by the report of physical symptoms; at 12 months, physical symptoms were associated with a 21.9 lower mean reintegration score (95% CI -30.1, -12.4).

CONCLUSIONS

Our longitudinal cohort experienced dramatic improvements in physical and psychosocial health after surgery. Continuing fistula-related symptoms and the substantial differences in psychosocial health by physical symptoms support additional intervention to support women's recovery or more targeted psychosocial support and reintegration services to ensure that those coping with physical or psychosocial challenges are appropriately supported.

Profile and outcome of patients with recurrent urogenital fistula in a fistula centre in Nigeria

INTRODUCTION AND HYPOTHESIS

Management of a recurrent urogenital fistula is very challenging and requires experienced surgeons. The aim of this study was to describe the characteristics, success rates, and associated factors related to surgical repairs of patients with recurrent urogenital fistulas by an experienced team at a fistula centre in Nigeria.

METHODS

This was a retrospective cohort study of 154 patients that had repeat urogenital fistula repairs at the National Obstetric Fistula Centre, Abakaliki, Nigeria, between January 2014 and December 2016. Information was retrieved from their hospital records. Successful repair was defined by continent status at 3 months after repair. Data were analyzed with SPSS version 20 by IBM Inc., and p < 0.05 was taken as statistically significant. Chi-square test was used to determine the association between the factors and successful repair.

RESULTS

The mean age was 36.27 ± 12.96 years. Obstetric fistula occurred in 92.2% of the patients. The success rates for the first, second, third, and fourth repeat repairs were 68.8%. 56.2%, 50%, and 0% respectively. Significant factors were the number of previous attempts at repair (χ² = 20.44, p = 0.002), age group (χ² = 16.95, p = 0.03), Waaldijk's classification (χ² = 13.31, p = 0.04), duration of fistula (χ² = 19.6, p = 0.03), surgeons' experience (χ² = 7.11, p = 0.04), and place of previous attempt at repair (χ² = 6.35, p = 0.02). There were no complications in 86.4%.

CONCLUSIONS

The success rate was good. Patients who had previous failed repairs at the fistula centre had better outcomes after the repeat surgeries. Centralizing fistula care will enhance optimal outcomes. It may also boost training and research in this specialty.

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study

INTRODUCTION

Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.

METHODS

The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.

RESULTS

During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial.

CONCLUSION

The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.

A nurse-delivered mental health intervention for obstetric fistula patients in Tanzania: results of a pilot randomized controlled trial

Background

Obstetric fistula has severe psychological consequences, but no evidence-based interventions exist to improve mental health in this population. This pilot trial evaluated a psychological intervention for women receiving surgical care for obstetric fistula.

Methods

A parallel two-armed pilot RCT was conducted between 2014 and 2016. The intervention was six individual sessions, based on psychological theory and delivered by a nurse facilitator. The study was conducted at a tertiary hospital in Moshi, Tanzania. Women were eligible if they were over age 18 and admitted to the hospital for surgical repair of an obstetric fistula. Sixty participants were randomized to the intervention or standard of care. Surveys were completed at baseline, post-treatment (before discharge), and 3 months following discharge. Standardized scales measured depression, anxiety, traumatic stress, and self-esteem. Feasibility of an RCT was assessed by participation and retention. Feasibility and acceptability of the intervention were assessed by fidelity, attendance, and participant ratings. Potential efficacy was assessed by exploratory linear regression and clinical significance analysis.

Results

Eighty-five percent met criteria for mental health dysfunction at enrollment. All eligible patients enrolled, with retention 100% post and 73% at 3 months. Participants rated the intervention acceptable and beneficial. There were sharp and meaningful improvements in mental health outcomes over time, with no evidence of differences by condition.

Conclusions

A nurse-delivered mental health intervention was feasible to implement as part of in-patient clinical care and regarded positively. Mental health treatment in this population is warranted given high level of distress at presentation to care.

Trial registration

ClinicalTrials.Gov NCT01934075.

Social Experiences of Women with Obstetric Fistula Seeking Treatment in Kampala, Uganda

BACKGROUND

Obstetric fistula is a preventable and treatable condition predominately affecting women in low-income countries. Understanding the social context of obstetric fistula may lead to improved prevention and treatment.

OBJECTIVES

This study investigated social experiences of women with obstetric fistula seeking treatment at Mulago Hospital in Kampala, Uganda.

METHODS

A descriptive study was conducted among women seeking treatment for obstetric fistula during a surgical camp in July 2011 using a structured questionnaire. Descriptive statistics were computed regarding sociodemographics, obstetric history, and social experience.

FINDINGS

Fifty-three women participated; 39 (73.58%) leaked urine only. Median age was 29 years (range: 17-58), and most were married or separated. About half (28, 47.9%) experienced a change in their relationship since acquiring obstetric fistula. More than half (27, 50.94%) acquired obstetric fistula during their first delivery, despite almost everyone (50, 94.3%) receiving antenatal care. The median years suffering from obstetric fistula was 1.25. Nearly every participant's social participation changed in at least one setting (51, 96.23%). Most women thought that a baby being too big or having kicked their bladder was the cause of obstetric fistula. Other participants thought health care providers caused the fistula (15, 32.61%; n = 46), with 8 specifying that the bladder was cut during the operation (cesarean section). Knowing someone with obstetric fistula was influential in pursuing treatment. The majority of participants planned to return to family (40, 78.43%; n = 51) and get pregnant after repair (35, 66.04%; n = 53).

CONCLUSION

Study participants experienced substantial changes in their social lives as a result of obstetric fistula, and there were a variety of beliefs regarding the cause. The complex social context is an important component to understanding how to prevent and treat obstetric fistula. Further elucidation of these factors may bolster current efforts in prevention and holistic treatment.