An Agenda for
Epidemiological Research and
Clinical Management of
Obstetric Fistula
John Kelly FRCOG FRCS OBE
Fistula Surgeon to many countries in the developing world
Honorary Senior Lecturer
Dept of Public Health & Epidemiology
University of Birmingham
What is the evidence ?
Frequency of occurrence
Unknown
1
What is the evidence
Aetiology
Obstructed labour
PRESSURE
NECROSIS
2
3
4
5
What is the evidence ?
Risk factors
z Lack
of access to appropriate emergency
obstetric care 7 days per week, 24 hours per
day
z?
Younger age
z ? Low parity
Refs: Kelly J & Kwast BE Int Eurogynecol J 1993; 4:278-281
Miller S et al J Midwifery Womens Health 2005; 50: 286-294
What is the evidence:
Treatment
z Randomised
controlled trials
– Prophylactic antibiotics
– Surgical Techniques
Tomlinson & Thornton Br J Obstet Gynaecol. 1998 Apr;105(4):397-9
6
Effects of Poverty
A CS costs the equivalent of nine months
average salary
Patients not accessing care
Training sub-standard
Harrison KA 1997 Afr J Reprod Health.1(1):7-13
Kelly J 2004 J Obstetrics & Gynecology 24:117-118
Prevention
and
Treatment
7
Prevention and Treatment
1855 New York Fistula Hospital (Sims)
1895 Converted to a General Hospital
Strategies to reduce
maternal mortality
should also reduce
maternal morbidity
8
The most important single
factor in prevention of
maternal mortality and
morbidity is access to
appropriate emergency
obstetric care
Problems in rural areas
z Doctors,
nurses, midwives prefer to work in
urban areas
z Migration
9
Initiatives which may work
where obstetric fistula are
common
Involve non-doctors and
others with appropriate
(initial and in-service)
training
10
Ensure they are
recognised,
accountable members
of health care team
TTBAs
Clinical officers
(licentiates)
11
Nigeria – Dr M Brennan
Trained TBAs
Fully integrated hospital and community ante
and intra-partum care system
MWA and prayer hall on hospital grounds
Maternal deaths before and
after introduction of trained
TBAs
Year
Number
Births
Rate per
100,000
79-82
64
8100
790
83-97
201
34570
581
St. Mary’s Hospital, Urua, Akpan
12
Community survey of
maternal deaths before & after
introduction of TTBAs
21 villages with
TTBAs
12 villages
without TTBAs
Before
(79-82)
64
After
(83-87)
29
29
32
Ada-Ogar AM, et al 1996: Postgraduate Doctor, Africa, 18, 86-90
Study Design
z Cluster
randomised controlled trial
z Unit of randomisation taluka (subdistrict)
z Simple cluster randomisation sampling
scheme
z Computer generated procedure
z 3 intervention and 4 control talukas
13
Results
z 19,557
women recruited May to October
1998
z Intervention 10,114 women (84% of
estimated eligible), all but 21 followed to 6
weeks postpartum, 9980 babies born.
Birth outcome not known for 2 women
z Control 9443 women (79% of est eligible),
all but 11 followed up, 9250 babies born
Primary Outcomes
Indicator
Perinatal
Intervention
Control
Cluster Adjusted
p
n (%)
n (%)
823 (8.47)
1077 (11.9)
0.70 (0.59-0.82)
<0.001
27 (0.27)
34 (0.36)
0.74 (0.45-1.23)
0.24
340 (3.50)
439 (4.88)
0.71 (0.62-0.83)
<0.001
483 (4.97)
638 (7.10)
0.69 (0.57-0.83)
<0.001
Odds ratio 95% CI
death*
Maternal
death
Neonatal
death*
Stillbirth*
*Singleton births only
14
Conclusions
z
This model of training and integrating TBAs
with improvements to existing services was
effective in reducing perinatal mortality
z
The cluster randomised controlled
methodology represents a step forward in
providing high quality scientific evidence to
inform policy decisions towards reducing
neonatal and maternal mortality in developing
countries
Zambia – Dr M Tyndall
Urban maternity clinic run by midwives who
adhere to strict guidelines
Radio linkage
Dedicated ambulance
15
Lusaka –
Number of deliveries per year
Teaching
hospital
Urban maternity
clinic
1982
23,496
2,200
1998
10,525
32,341
Corcoran B, et al. 1999: Evaluation Report, Lusaka Urban Maternity
Clinics Project. Dublin, Evaluation & Audit Unit, Irish Aid
Maternity Waiting Area
This is a place (not a ward) within, or close to
the hospital compound where women
identified as being at risk can reside in the
last few weeks of pregnancy
They are then close to appropriate,
functioning emergency obstetric care should
operative delivery be required
Poovan et al World Health Forum 1991; 11: 440-5
16
Maternal mortality and
stillbirth rate
Maternity
Waiting Area
Direct to
Hospital
MM rate
148.3
1539.0
SB rate
1.7
21.9
Effect of a Maternity Waiting Area
on maternal mortality and stillbirth
in rural Ethiopia
The results from this large series of
15,627 women add weight to the
role of Maternity Waiting Areas
linked to effective EOC in
preventing maternal mortality and
stillbirth for high risk women
17
LISTEN TO THE
PATIENT
CONSUMER
OPINION
Ruptured uterus
OUTCOME
SB
NND
LIVE BIRTH
239
1
5
(97.6%)
MAT. DEATHS
FISTULA
13
26
(5.3%)
(10.8%)
TOTAL
245
(2.0%)
18
Primigravidae
Ruptured uterus
0.8 %
V.V.F.
63 %
Operative procedure
Repair
238
Hysterectomy
6
Slough
1
19
Ruptured uterus follow-up
Mothers
Babies
One subsequent CS
75
75
Two subsequent CS
3
6
One subsequent vag delivery
30
30
Two subsequent vag deliveries
2
4
Vag delivery followed by CS
1
2
Treatment
Where woman has no living
children and / or desires
more children, repair of
uterine rupture is culturally
acceptable and medically
safe, with PROVISOS
Fekadu et al 1997: Lancet 349, 622.
Kelly et al 1998: J Obs & Gyne, 18, 50-52.
20
Research on management
of fistulae
Spontaneous cure, with or without
catheter drainage, does occur.
Most do not seek treatment for some
time, even up to 40 years
Treatment may be governed by
local circumstances
Staff
Expertise
COMPASSION
21
Local infiltration with or without
vasoconstrictor maybe
hazardous
Might be safer to use no
infiltration
Anaesthesia guidelines agreed by
the team, with advice from
anaesthesiologist, about what to
do when certain problems arise.
(Someone capable of
intubation).
22
Beware, that in
treating a maternal
morbidity we do not
end with a mortality
Clinicians should work in
close liaison with a
department of public health
and epidemiology so that
results are meaningful and
evidence-based.
23
V.V.F.-Techniques in addition to
basics
Reconstruction of urethra
Reanastomosis of urethra
to bladder
Reimplantation of ureters
Martius graft
Gracilis graft
No additional
428
403
%
14.5
13.6
391
385
30
1321
13.2
13.0
1.0
44.7
24
TYPE OF FISTULA REPAIR
Vesico-vaginal
2202
%
71.7
Recto-vaginal
114
3.7
Both vesico-vaginal
& recto-vaginal
756
24.6
25
26
27
28
29
30
31
32