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 4. Linear Regression on Factors associated with obstetric fistula repair failure Variables Sig. Exp(B) 95% C.I.for EXP(B) Duration of fistula <.001 1.705 (1.339-2.171) Labour duration .006 1.241 (1.064-1.449) Urethra status prior to surgery <.001 1.349 (1.189-1.529) GOH 3 <.001 2.168 (1.422-3.305) WAALDJIK 1 .018 1.774 (1.105-2.847) WAALDJIK 2 .031 .911 (0.837-0.992) Vaginal Scarring .013 .845 (0.741-0.965) The study findings in table after linear regression reveal significant associations between various factors and the outcomes of fistula repair, in relation to urinary incontinence/ failure of repair. Notably, the duration of fistula demonstrated a strong association with outcome success, with a P-value of <.001 and an Adjusted Odds Ratio (AOR) of 1.705 [95% CI: (1.339, 2.171)]. This implies that each unit increase in duration corresponds to a 1.705-fold increase in the odds of experiencing incontinence. Similarly, the duration of labour exhibited a significant association (P-value: .006) with repair outcomes, indicating that for each unit increase in labour duration (i.e., 12 hours to 24 hours to 48 hours), the odds of incontinence increase by a factor of 1.241 [95% CI: (1.064, 1.449)]. The status of the urethra prior to surgery also proved to be a crucial factor, as an abnormal and damaged urethra status was associated with 1.349 times higher odds of incontinence compared to a normal status (P-value: <.001, AOR: 1.349, 95% CI: 1.189, 1.529). Additionally, the size of the fistula, classified by the GOH 2 system, showed statistical significance with repair outcomes (P-value: 0.011). Individuals with fistulas larger than 1.5 cm had 1.753 times higher odds of incontinence compared to those with smaller fistulas [AOR: 1.753, 95% CI: (1.140, 2.695)]. Fibrosis in the GOH 3 classification was associated with a 2.168-fold increase in the odds of incontinence (P-value: <.001, AOR: 2.168, 95% CI: 1.422, 3.305). Waaldijk’s 1 classification highlighted that individual with closure mechanism involvement had 1.774 times higher odds of incontinence compared to those without this involvement (P-value: 0 .018, AOR: 1.774, 95% CI: 1.105, 2.847). However, the utilization of a flap in repair did not significantly determine the success of repair (P-value: 0.142). Vaginal scarring, on the other hand, was associated with repair outcomes (P-value: 0.013), with individuals having no scarring exhibiting 0.845 times the odds of incontinence compared to those with scarring [AOR: 0.845, 95% CI: (0.741, 0.965)]. Lastly, postoperative catheterization for more than 14 days was linked to 1.273 times higher odds of incontinence (P-value: <.001, AOR: 1.273, 95% CI: 0.926, 1.749). DISCUSSION In this study, the failure rate of fistula repair among women undergoing the index repair closure was 8 %. This rate was however significantly lower than obstetric fistula repair failure rates reported in other low to middle-Income Countries(LMICs), such as Benin 26.8% 21and 28.3 % In Congo. 22 Rates were comparable to those in Jos, Nigeria (9%), 23 Uganda (11%), 24 Rwanda (14 %) 25 and Jimma in Ethiopia (15.5 %). 26 The reasons maybe due to similar settings and established fistula repair service. We recognise that this rate is much lower to other extreme outcomes in other centres as reported from Bahir-dar, Ethiopia (35.3%), 27 Tanzania (42.9%), 28 Angola (58%). 29 Possible reasons for this difference include temporal data as recent as 2022 whereas the 3 centres included data from earlier investigative years such as Bahir-dar, Ethiopia (from 2013 to 2017), Tanzania (from 2014 to 2015), and Angola (from 2011 to 2016). In addition, improvement of obstetric fistula repair and care in established centres is a possible reason for the lower failure rate. Repeat fistula repair impact Repeat fistula surgeries, was undertaken in 3% of patients with prior failed attempts, exhibited lower success rates compared to primary repairs. Success rates decreased significantly with increasing repair attempts, aligning with findings from other studies. 30–32 The need for skilled surgeons and optimizing the initial repair attempt is emphasized, as success rates diminish with each subsequent attempt Tebeu et al highlighted the success rates of 69.2 and 49.1 % with 2nd and 3rd attempts respectively. 33 Delays in accessing fistula repair Women had an obstetric fistula for a mean duration of 7.4 years and those living with fistula for over 1 year had poorer odds for successful outcomes. Studies in East African women demonstrated higher closure rates when repairs were done within 3 months of fistula development compared to later repairs. 34 Delay in seeking care contributes to fibrotic tissue changes, reducing the effectiveness of surgical repairs. Community-level initiatives are essential for increasing awareness and access to fistula repair services. 34 Delays is seeking care for fistula repair and delay in receiving care may contribute to these outcomes. There is only one national centre addressing all fistula repair cases and the two other regional hospitals involved in fistula repair only when visiting surgeons are available usually once a year. Prolonged labour impact In this study, factors affecting obstetric fistula repair failure showed that women who had labour for more than 24 hours were more likely (twice the chances) to have failed repair than those in labour for lesser than 24 hours. This finding is comparable to findings from Ethiopia Bahir-dar 27 and Rwanda. 25 This accounts for any form of delay in access to care, be it indecisions or delay in arrival at the facility, or delay in receiving quality care at the facility, resulting in increasing duration of labour and likelihood of obstructed labour. Prolonged labour, especially exceeding 24 hours, was associated with higher odds of poor-quality repair outcomes. The ischemic necrosis of soft tissues due to prolonged labour contributes to worsened tissue damage and scarring. Limited surgical facilities in resource-limited settings may result in more aggressive procedures, further elevating the risk of fistula development. Access to quality obstetric care, including catheterization, is imperative, especially in regions with limited specialized facilities Access to antenatal care Antenatal attendance of 75.5 % in this study is lower than the national data form MDHS 2015-16 at 95%. This population African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 20