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 Table 1. Baseline demographics, fistula characteristics and repair outcomes Variable characteristic (n=2430) Repair Success outcomes n(%) p values Age group (years) </=20 278(93) p = 0.007 21-30 695(91.3) 31-40 655(91) 41-50 384(92.5) >50 200(84.7) Parity 1 581(89.3) p=0.210 2 -5 1154(91.4) >6 477(92) Duration of labour (hours) <12 16(94) p<0.001 12-24 1332(93) >24 864(87.8) Fistula duration (years) <1 401(96) p<0.003 1-5 962(93) 6-10 292(90) 10> 557(85) Obstetric Characteristics and Reproductive Outcomes The mean age at first delivery was 27 years, and the average parity at presentation for fistula repair was 3. The overall reproductive outcome revealed that 450 (18.5%) had a stillbirth in the index pregnancy, and the average number of living children was 1.9. Antenatal care was sought by 1837 women (75.5%), with 62.5% delivering at a hospital. Obstructed labour occurred in 68%, and 21% sustained a footdrop. HIV co-infection was noted in 171(7%). Table 2: Obstetric fistulae characteristics of women who underwent obstetric fistula repair in Malawi Variables Category n(%) Age at index delivery with fistulae(years) <18 182(7.4) 18-30 1414(58.3) 31-50 834(34.3) Number of deliveries (Parity) I 650(26.7) II-V 1262(51.9) >V 518(21.3) Missing 192(7.9) Number of alive children None 762(31.3) 1-4 1359(55.9) >5 256(10.6) Missing 245(10) Presence of Ante Natal Clinic (ANC) Yes 1837(75.5) No 239(9.8) Unknown 510(20.9) Place of delivery Home 230(9.4) Health Centre 365(15) Hospital 1520(62.5) Unknown 315(12.9) Duration of labour (hours) 0-12 774(31.8) 13-48 1205(49.5) >48 451(18.5) Mode of delivery Spontaneous Vaginal Birth 894(36.7) Instrumental 39(1.6) Caesarean Section 1194(49.1) Missing 305(12.5) Fetal Outcome Stillbirth 237(9.8) Live Birth/other 2193(90.2) Fistula Characteristics Approximately two-fifth, 978 (40%) of the study participants had been living with an obstetric fistula for over 60 months. According to the Goh Type Classification, over half 1292 (53%) of the women had a type II of higher fistula, while 455(20%) women were unclassified. Furthermore 486(20%) women had a large fistula size >3cm (Table 5). Most of the study participants’ cases were urogenital fistula 2401(98 %) and 100 were RVF (of which 33 had both RVF and VVF). PERIOPERATIVE HISTORY Most participants 2307 (95%) underwent transvaginal surgery with spinal anaesthesia. Of the 2430 surgeries, 97% were first attempts at fistula repair, with 76% using single-layer closure 56.6% had a catheter for less 14 days post operatively as illustrated in table 3 below. Postoperative complications included bleeding (29 cases), infection (92 cases), and urinary retention (157 cases). The extent of repair failure was 8.9%, with 218 women experiencing incontinence. Table 3. Perioperative history of women who underwent obstetric fistulae repair Variables Category n(%) Surgical approach Vaginal 2307(94.9) Abdominal 123(5.1) Surgical attempt Primary 2362(97) Secondary 56(2.3) Tertiary 12(0.7) Layer of closure Single 1849(76.2) Double 210(8.6) Unknown 371(15.2) Duration of catheter <14 1375(56.6) >14 1055(44.4) TEMPORAL TRENDS IN REPAIR FAILURE Over a 10-year period, obstetric fistula repair failure rates decreased from 28.8% in 2012 to 3.7% in 2022. The temporal changes were showing improvement in outcomes. However, during Covid 19 pandemic (2020 to 2022) the centre had less operated cases since the centre became an Emergency Covid 19 patient admission Centre. See figure 1 below Figure1. Temporal Changes in Fistula Repair Outcomes from 2012 to 2022 Factors Associated with Repair Failure The bivariate logistic regression analysis explored factors associated with repair failure, considering patient, clinical characteristics, and perioperative variables as highlighted in Table 4 below. African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 19