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 with lower attendance rates may be more prone to obstetric complications. Quality obstetric care, encompassing antenatal care (ANC) and emergency obstetric surgeries, plays a crucial role in mitigating obstetric complications, including fistula development. 25 The ANC attendance rates in Malawi is documented at 95% by MDHS 2015 however this population was a high risk and lacked adequate antenatal care, coupled with health facility delivery rates, underscore the need for improved screening and follow-up, particularly for high-risk pregnancies. Identifying and supporting at-risk mothers during ANC and labour are pivotal in preventing obstructed labour, a primary cause of obstetric fistula. MDHS 2015, 35 highlighted the challenges faced in maternity care being difficulties in accessing money in 52.8%, distance to health facility in 55.6%, not wanting to go alone in 30%, at least one problem in accessing health care service in 72%. This demonstrates huge access problems at national level and even more to these group of women at high risk. Clinical determinants of failure of repair Further findings demonstrated that women with larger (>3 cm) fistula size had nearly two fold the odds of likely to have fistula repair failure .Similar findings have been supported in studies form Ethiopia, 27 Uganda, 36 and Democratic Republic of Congo. 24 Surgically this may be due to a large fistula being challenging to mobilise tissues or inadequate bladder tissues to achieve a tension free closure. Arising from this difficulty closure is encountered. 20,36 Women who had Goh Type 3 fistulas were twice at risk of fistulae repair failure than women with Goh Type 1 fistula. This finding is supported by Ethiopian study findings from their Hamlin Fistula centre. 27 The reason being the closeness of the fistula to the urethra meatus and associated fibrosis, affects the urinary continence mechanism and leads to high chances of repair failure. Furthermore this study reveals that women with a significant urethral damage were 2 times likely to experience fistulae repair failure .This finding is validated by findings in Ethiopian’s Addis Ababa Hospital, 31 Democratic Republic of Congo, 37 Guinea 38 and Cameroon. 33 It’s been suggested that with a damaged urethra length, becomes de-nerverted and shortened .This is witnessed where urethral fistula repair is found to be complex which results in patients becoming incontinent even after surgical repair as reported by Goh et al. 28,39 Waaldijk’s classification emerged as a significant predictor of success rates, highlighting the importance of considering complexity and continence mechanism involvement in classifying fistula. Post operative duration of an indwelling catheter beyond 14 days conferred and increased risk of 1.2 times of repair failure. This is also supported from publications from Ethiopia with more established fistula centres like the Hamlin Centre. The possible explanation is that urinary catheterization for over 14 days may be associated with “increased risk of pain, infection and formation of stones and erosion related catheter complications” emphasizing the need to adhere to the WHO post op catheter care following obstetric fistula repair. WHO recommends a short duration of bladder catheterization following obstetric fistula repair. 40 Study Limitations The study included a diverse population attending a public referral health facility in a developing country over ten years. To date this is one of the largest retrospective series. Data as regards causes of incontinence after successful closure was not possible and this study reported the continence outcome on discharge. CONCLUSIONS In conclusion, this study showed decreasing magnitude of repair failure over a decade which were within WHO recommend rates. This demonstrates feasibility of successful fistula repair services with adequate resources in an established fistula repair centre. Longer duration of labour, with delayed repair of the fistula, and scarred tissue, large fistula, prolonged indwelling catheter were significantly associated with repair failure. Addressing fistula burden in Malawi requires ongoing improvement in holistic access to comprehensive emergency obstetric care, increased access to quality, safe fistula repair services, training more surgeons, and community-level support on advocacy and education for early identification and referral of at-risk women. REFERENCES ³ § © ¯ ¯ ¯ ¡ § § ® ¸ § § § § ¥¥ ¥ ¥ ¥ ¥ ¥ ® ¥ ¬ ® ¢ ¥ ® ¢ ¥« « ¥ ® ¢ § ¥« « ® ¥ ¬ ® ¥ § ¹ ® ¢ ¥ « © ® § ¢ ¥ African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | 21