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 virtually eliminated in Europe and USA between 1935 to 1950 because of universal access to safe delivery. 14 Areas with centres of excellence have better outcomes in surgical repair. While obstetric fistula that are repaired immediately can result in closure rates of up to 90% 6,15 these can vary by repair centre and other factors including size of fistula, urethral involvement, preoperative bladder size, extent of vaginal scarring, technique, surgical experience, and number of attempted previous repairs. 16,17 Successful urinary continence may not always be attained immediately after repair despite surgical closure of fistula, the residual incontinence may improve in due course. Breakdown of surgical repairs can occur because of suboptimal postoperative care or negligent catheter management as documented in several studies. This will present in the post discharge period often associated with resumption of heavy work, coitus, wound infections and subsequently in the case of the next pregnancy18 ,with another episode of prolonged labour or poor managed vaginal birth. Several studies have accounted for risk factors, fistulae characteristics and outcomes of repairs. Most have been either focused on smaller studies. 6,15,19,20 The United Nations Population Fund (UNFPA) and its partners launched the Global Campaign to End Fistulae in 2003 to help redress the unacceptable human rights and equity dimensions of obstetric fistula. Collectively they have helped more than 20,000 women and girls to access fistula treatment and care. In Malawi annually, nearly 400 surgeries for different urogenital fistula are done annually. Since the establishment of the Bwaila Fistula Centre, over 2000 fistula repairs have been done. METHODOLOGY: This study sought to determine surgical outcomes and predictors of failure of obstetric fistulae repairs (e.g. clinical and surgical determinants) in patients attending at Bwaila Fistula Centre in Malawi. Women who underwent obstetric fistulae repair at this centre between January 2012 to December 2022, were included in this study. Those with incomplete data records, incomplete postoperative care follow-ups and fistulae caused by non-obstetric causes (such as hysterectomy or rape), age less than 18 years were excluded from the study. Malawi is a country in southern Africa with a population of about 18 million. It is among the low-income countries with majority of its population living in rural areas. Health Indicators are poor including maternal mortality ratio in 2020 of 381 per 100,000 live births, however with decrease from 439 in 2017, Neonatal Mortality of 26 per 1000 live births. (WHO 2023) The data variables The socio-demographic and clinical characteristics of fistulae patients were extracted from database, and included age at admission for repair, marital status, age at marriage, occupation, level of education, residence, parity, previous repairs, mode of delivery, duration of fistula, neonatal outcome at causal delivery, and type of fistulae (Rectovaginal -RVF, Vesicovaginal VVF or both). DATA PROCESSING AND ANALYSIS A standardized data collection form was used to enter data, including variables such as patient demographics (age, parity), fistula characteristics (size, location), preoperative health status (nutritional status, anaemia), timing of repair (early vs. delayed), surgical techniques employed, and postoperative outcomes (fistula closure, continence status, complications). Descriptive statistics were used to describe the patient characteristics and treatment outcomes and inferential statistics of binary logistics regression was performed to examine the relationship between the various factors and outcome variables. In the bivariate logistic regression, variables with p-value less than 0.20 were put into multivariate logistic regression. In multivariable logistic regression, variables with a p-value less than 0.05 were regarded as statistically significance with the outcome variables. Ethical approval was granted by The Human Research Ethics Committee(HREC) of the Faculty of Health Sciences, University of Cape Town, REF 744/2022. and permission from the Lilongwe District Health Office Research Committee, Malawi. RESULTS Demographic and clinical characteristics 2783 files were reviewed and 383 women were excluded due to incomplete data and/or non-obstetric causes of fistula. The mean age was 30 years(Interquartile range, IQR 18 to 83), and collectively, the group of women consisted of 852 (36%) with no secular education, 1143 (48.5%) with primary school education, and 350 (15%) with up to secondary school education. Marital status revealed 1569 women (66%) were married, 78 (3.3%) separated, 523 (22.2%) divorced, and 145 (6%) widowed. Successful fistula repair outcomes were achieved in 2236 (92%) women. The highest successful repair rates (60%) were observed among those with less than 2 days of labour compared to those with 3 days of labour. Among the 2362 (97%) women undergoing index fistula repair, 92% achieved successful outcomes. Repeat surgery was noted in 67 (2.8%), with Second, third, and fourth attempts at surgery were observed in 56, 11, and 1 patient(s), respectively. On average, women suffered from obstetric fistula for 7.24 years ( IQR 1 - 52 years). 1429 (58.8%) women had been in labour between 12-24 hours, while a further 984(40%) women for over more than 24 hours. Incontinence recurrence occurred in 195/2430 (8%) patients, with 65/194 (33%) being primiparous and 129/194 (66%) multiparous. Of these, 68 women reported pure stress incontinence. Postoperatively, VVF recurrence was established in 28/194 (14.4%) patients during the 4 to 8 weeks follow-up. Fecal incontinence was observed in 28 women (14.4%), of which 10 had both urine and fecal incontinence, and 6 had isolated stool incontinence, with 3 patients having RVF. Fistula Characteristics and Obstetric History The distribution of fistula cases included 844 (34.7%) VVF, 1486 (61.2%) UVF, and 100 (4.1%) RVF. Most patients experienced obstructed labour, with a mean duration of 35.57 hours for the index pregnancy. The last pregnancy outcome resulted in vaginal delivery for 1962 (81%) women. Pearson’s chi-squared test revealed a positive correlation with increasing age, duration of labour and duration of fistula and unsuccessful repair (Table 1). African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 18