AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | Outcomes Of Surgical Repair of Obstetric Fistulae at a Tertiary Referral Centre in Malawi ABSTRACT Introduction: Obstetric fistula remains a significant public health challenge in Malawi and other low- and middle-income countries, with surgical repair serving as the primary treatment modality. The success of fistula repair, however, hinges on a multitude of factors. Rationale of the study: To determine surgical repair outcomes and the predictors of failure of obstetric fistulae repairs (e.g. clinical and surgical determinants) in patients attending at Bwaila Fistula Centre in Malawi Methodology: This was a retrospective study which aimed to identify predictors of failure following obstetric fistula repair in Bwaila , Malawi from 2012 to 2022. A total of 2,430 women were included in the assessment for sociodemographic, obstetric and fistula characteristics, perioperative factors, and surgical outcomes. Multivariate analysis determined the association between these variables and outcomes of obstetric fistula repair. Results: The mean age of the women was 30 years (range 18-83), with 92% achieving successful repair (fistula closed with continence), 2.6% experiencing residual stress incontinence). The average duration of fistula before repair was 7.24 years. Notably, there was a temporal decline in obstetric fistula repair failure rates, decreasing from 28.8% in 2012 to 3.7% in 2022. Multivariate analyses revealed several significant predictors of repair failure. Prolonged duration with fistula (AOR 1.7, p < 0.001), labour exceeding 24 hours (p = 0.006), urethral involvement (AOR 1.35, p < 0.001), larger fistula size (>1.5 cm) (AOR 1.7, p = 0.01), the presence of fibrosis (p < 0.001), closure mechanism involvement (AOR 1.7, p = 0.018), vaginal scarring (p = 0.013), and postoperative catheterization for more than 14 days (AOR 1.2, p < 0.001) were all identified as significant contributors to repair failure. Conclusion: This study underscores the critical impact of delays in care, both in terms of prolonged labour and delayed fistula repair, along with the complexity of fistula characteristics, on the failure of obstetric fistula repair. Addressing these challenges necessitates ongoing efforts to ensure comprehensive obstetric care, community advocacy and education, and access to safe, high-quality surgical interventions within the realm of fistula repair services. Keywords: obstetric fistula, repair failure, predictors, surgical outcomes, access to surgery , perioperative factors. INTRODUCTION Globally, pregnancy related complications claim the lives of over 300,000 women annually. Nearly all of these occur in low-and middle-income countries. 1 Estimates have shown that for each woman that dies another 15-30 suffer serious complications such as obstetrics fistulae, which may be entirely preventable and treatable. Obstetric fistula is a devastating childbirth injury that occurs because of prolonged obstructed labour, leading to the formation of an abnormal connection between the birth canal and the urinary or gastrointestinal tract. 2 It primarily affects women in low-resource settings, where access to timely and adequate obstetric care is limited. Obstetric fistula has profound physical, psychological, and social consequences for affected women, often resulting in social isolation, stigma, and reduced quality of life. 2 Surgical repair is the mainstay treatment for obstetric fistula, aiming to close the abnormal connection and restore normal anatomical and functional integrity. Over the past decade, substantial international community mobilisation towards attaining a fistulae free generation, has resulted in improved management of fistula cases with high closure rates at time of discharge from hospital 3 and an attainment of more than 100,000 surgical fistula repairs across sub-Saharan Africa and south Asia. 4–6 The aim of repair is to attain at least 85% closure success set by the WHO7. Access to surgery in sub-Saharan Africa has improved overall, however, the success of surgical repair varies, and several factors can influence the outcomes of the procedure. Furthermore, women may continue to encounter a myriad physical and psychological challenges. Longitudinal studies from across sub-Saharan Africa have identified risks of adverse outcome in women who have undergone fistulae surgery, including fistula recurrence, persistent fistula related symptoms, subsequently subfertility and poor perinatal outcomes. 8–10 In Uganda,its noted that 33% of women had persisted urinary leakage one year post-surgical repair. 11 In Guinea, the cumulative incidence of fistulae recurrence was 16 % at 2 years. 4 In Malawi only 1 in 5 women of reproductive potential were able to conceive a year after fistula repair. 9 The lifetime risk of obstetric fistula has been reported as 1.6/1000 women of reproductive age in Malawi. 12,13 This is relative to other countries like Ethiopia which is one of the countries with the highest numbers of women living with fistula reported at 7.3 per 1000 women. 14 Maheu et al reported on the lifetime prevalence of vaginal fistula symptoms across 19 countries, Burkina Faso had the lowest 0.4 per 1000 to Uganda 19.2 per 1000 women of reproductive age group. 4 It’s been noted as with other resource limited countries the capacity to diagnose and manage fistula surgically is limited. Obstetric fistula was K Jere 1 , AAdelowo 2 , S Maswime 3 1 Urogynaecology Unit, Department of Obstetrics and Gynaecology University of Stellenbosch, South Africa 2 Division of Urogynaecology, Reliant Medical Group / Optum Health, Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester MA, USA 3 Division of Global Surgery, Professor and Head of Division, University of Cape Town, South Africa CORRESPONDENCE: Dr K Jere| Email: kjere@sun.ac.za Outcomes Of Surgical Repair of Obstetric Fistulae at a Tertiary Referral Centre in Malawi African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 17