Postgraduate Training Course in Reproductive Health 2004

Characteristics of women admitted with obstetric fistula
in the rural hospitals in West Pokot, Kenya

Hillary M. Mabeya. M.D. Obs/Gyn
Moi Referral and Teaching Hospital
Eldoret, Kenya

See also presentation

Abstract

Objective: To determine the prevalence rate and characteristics of women admitted with obstetric fistula in rural hospitals in West Pokot, Kenya.
Design: A 5-year descriptive study from January 1999 to December 2003 including all obstetric fistula patients. A total number of 66 patients were analysed. Information extracted included age, age at onset of fistula, parity, education, occupation, marital status, duration of labor, place and mode of delivery, obstetric outcome, presence or absence of severe female genital mutilation (infibulation) and surgical outcome.
Results: The prevalence  of obstetric fistula was 1 per 1000 women. Sixty five percent had onset of fistula at 20 years of age and less; 55% were primigravida; 59% had no formal education. The success rate at first repair attempt was 87%. Eighty percent had undergone severe female genital mutilation, 68% of the deliveries were stillbirths and 73% of women had prolonged labor.
Conclusion: prolonged labor, age, severe female genital mutilation, level of education, parity, occupation, lack of access to transport and primary health care in the rural community and early marriage were characteristics of the fistula patients. Successful repair was high at first attempt in good hands of trained fistula surgeons, trained nurses and well set hospital facilities.

Keywords: Obstetric fistula, female genital mutilation (FGM), obstetric outcome, labor and parity.

Introduction

Although Kenya has made great progress in addressing maternal health since the inauguration of the Safe Motherhood Initiative in Nairobi in 1987, maternal health indicators have shown a deteriorating trend as evidenced by the maternal mortality ratio, which has increased from 365 maternal deaths/100,000 live births in 1993 to 590/100,000 in 1998(1). Obstetric fistula is considered as 'near miss death' and its prevalence could indicate the level of obstetric care and also provide indicators for verbal autopsy. Its prevalence has not been assessed in the rural setting where the problem is high hence the need for this study (24).
An obstetric fistula is a hole in the wall of the vagina connecting to the bladder, and a hole to the rectum is known as a rectovaginal fistula. Both types of fistula are a result of prolonged and obstructed labour. The anterior vaginal wall and the bladder become compressed between the fetal skull and the maternal symphysis, resulting in pressure necrosis, which gives rise to obstetric fistula (2).
Obstetric fistula is a health condition caused by an interplay of numerous physical factors and the social, cultural, political and economic situation of women. This interplay determines the status of women, their health, nutrition, fertility, behaviour and susceptibility to fistula(3). The physical factors that influence the incidence of obstetric fistula include obstructed labour, accidental surgery, injury related to pregnancy and crude attempts at induced abortion.  Traditional surgical procedures that lead to obstetric fistula are commonly employed during pregnancy and labour, and lead not only to obstetric fistula, but also cause haemorrhage and sepsis. These include female genital mutilation(FGM) and Gishiri cut (practised in Nigeria) (3,4). Socio-cultural factors contribute to the prevalence of obstetric fistula in women e.g. early marriage, health seeking behaviour and availability and utilization of essential obstetric care. Illiteracy is also a major factor which determines what kind of medical help is sought. It deters people from attending hospitals particularly when they are made to feel stupid and when hospital staff are from an alien culture with differing traditions, custom and language(5). Education gives young women better access to profitable employment. It also reduces the incidence of high-risk pregnancies and unwanted pregnancies and this may reduce the incidences of obstetric fistula(3). 
Women with obstetric fistula suffer from urinary incontinence which if not properly managed cause them to smell of urine. This continuous urine leakage makes them vulnerable to urinary tract infection, vaginitis and excoriation of the vulva, vaginal stenosis, secondary amenorrhea, possible future inability to carry a child even after repair of fistula. A low child survival rate has been shown to be  related to obstetric fistula(9,10).
Obstetric fistulas are repaired through orthodox surgical correction, a successful repair is gauged by whether the woman is continent of urine and the operation could be by vaginal, transperitoneal or transvesical approach. Repairs are generally successful, depending on the extent of damage and duration of condition(1).
Prevalence data on obstetric fistula are not available for most settings in the developing world. The magnitude and severity of the problem on available resources has an impact on policy hence the need for awareness of obstetric fistula as a problem. This study was designed to get information on how severe the obstetric fistula is in the developing world.

Broad objective

To determine the prevalence and characteristics of women admitted with obstetric fistula in rural hospitals of West Pokot, Kenya

Specific objectives

• To determine the prevalence rate of obstetric fistula cases in the years January 1999 to December 2003

• To determine the characteristics of women admitted with obstetric fistula

• To assess the outcome of pregnancies of obstetric fistula patients

• To assess the socio-cultural characteristics of obstetric fistula patients.

Study design and method

This was a descriptive study that was carried out in two rural hospitals of West Pokot, Kenya from January 1999 to December 2003.  The total number of obstetric fistula patients treated over a 5-year period covering January 1999 to December 2003 were recorded using a data collection sheet. The source of the information was from the records department of the two main hospitals in West Pokot District,  Kapenguria District hospital and Ortum mission hospital and their respective theatre entry books.  The records were confirmed with the records that were kept by the only surgeons who operated on these patients during the requested period. The surgeons were the author of this report and Dr Tom Raassen from the African Medical Research Foundation (AMREF). Sensitization for the availability of this surgical facility had been extensively done through the efforts of Sentinelles (a non governmental organization based in West Pokot). Patients were also given free transport to these two hospitals and free operations were offered.  More information through the district medical officer to sensitize the community on surgical services was provided and continued as the patients were operated on and reintegrated into the community. The study was carried out in West Pokot District which is one of the 18 districts in Rift Valley province bordering Turkana in the north, Baringo and Marakwet in the East Trans Nzoia in the South and the Republic of Uganda in the West. The study involved these two main hospitals were obstetric and gynaecological services are offered including obstetric fistula repairs. The district has a total population of about 360,000 with 150,000 being women of reproductive age and expected births of 20,000 per year. All fistula cases as a result of obstetric problems and seen in the two main hospitals between January 1999 to December 2003 were analysed. Other types of fistula other than obstetric were excluded.  A data collection sheet containing social demographic and medical data was used by the investigator where all the files from the records department, theatre books of the hospitals mentioned were collected and cases seen during this period recorded in the data collection sheet. Other sources of information included the records of the two surgeons. The cases were those patients who had been seen, diagnosed and treated for obstetric fistulae.  Diagnosis was based on the patients' history and medical doctor's findings on examination during January 1999 to December 2003.  The completed data collection sheet was verified and then coded for computer analysis by a statistician. The analysis was done using SPSS/JPCT computer package and analysed by frequency table cross tabulations. The permission to carry out the study was sought from the ethical and research committee of Kenyatta National Hospital (KNH),West Pokot District Medical Officer of Health and the medical officer in charge of Ortum mission hospital.

Results

The prevalence of obstetric fistula was 1 per 1000 women. The age of obstetric fistula patients in the study ranged from 15-46 with a mean of 22.8 ( SD +/-6.6) and a median of 20 (see table 1).  The age at onset of fistula ranged from 14-38 years with a mean of 20.5 (SD+/- 5.5) and median of 19 (see table 1).  About half of the women were primigravida (55%).Fifty nine (59%) percent had no formal education and 72% had no occupation. Fifty six (56%) percent were still married at admission and 80% of all admitted patients had undergone severe female genital mutilation (FGM) also referred to as infibulation (see table 1).  Seventy five (75%) had prolonged labor  and 79% delivered in the hospital of which 50% underwent Cesarean section and 20% had vacuum delivery. Perinatal mortality consisted of 72% (see table 2).  Over 46% had urine leakage for one year and over before presentation to hospital and the lag time between onset of fistula and presentation to hospital could not be computed because the age of one patient could not be found (see table 2).  The success at first attempted repair confirmed by no leakage after removal of the urinary catheter depending on each individual patient was 86% (see table 2).

Discussion

Obstetric fistula is a health condition caused by the interplay of numerous physical factors and the social, cultural, political and economic situation of women. This interplay determines the status of women, their health, nutrition, fertility, behaviour and susceptibility to obstetric fistula (2,15,24).  It is important to recognise that this study and most studies are largely hospital based and therefore cannot be fully indicative of the magnitude of the problem. In this study extensive sensitization was carried out and patients were transported to the hospitals for repairs and it is assumed that a majority of the patients were attended to(1).  Current reliable data on the prevalence of obstetric fistula is scarce. In 1989, WHO estimated that more than 2 million girls and women around the world had this condition, with an additional 50,000 to 100,000 new cases occurring each year. These figures are based on women seeking treatment , and are therefore likely to be gross underestimates(2,15,24).  In some countries the incidence is up to 350 per 100,000 live births, with a backlog of untreated cases close to 1 million in northern Nigeria alone. In situations where there is no functioning obstetric unit, the incidence rate can be calculated at a minimum of 1-2 per 1000 deliveries where the mother survives(6,14,16,24)
The most common cause of obstetric fistula is obstructed labour (85%) following prolonged labor, which is made worse more likely by malnutrition leading to the stunting of the pelvis. Early marriage, poverty and women's limited control over the use of family resources increase a woman's risk of fistula(4,5)
The data from one month at the Kenyatta National Hospital found that 26.6% of women were 20 years and below and 81.3% were 30 years and below. In Africa, where the problem appears to be most prevalent, studies have shown that at least 70% of women with fistulae are 30 years and under(7,13)
Tahzib's study showed that 5.5% of VVF sufferers were under 13 years of age. He also found out that 33% of patients who attended Ahmadu Bello University Hospital, Nigeria between 1969 and 1990 were aged 16 years and under and 83% were under 30 years of age(5)
Other studies in Africa have shown that 58-80% of women with obstetric fistulae are under the age of 20, with the youngest patient only 12 or 13 years of age. Waaldijk , working in Northern Nigeria found that 73% of the patients he saw between 1984 and 1988 were under the age of 21(2,20).
A study of the patients at the fistula centres in Kano and Katsina, Nigeria, showed that most of them (70%) were at the age of 20 when the fistula happened and around 40% were under the age of 16 (7,8,20).
The age distribution at Kenyatta National Hospital (KNH)in 1982 showed a peak incidence for women aged 20-40 years, with primigravida accounting for 42% of the cases. In Asia, a greater concentration of women with obstetric fistula fell within the 20-24 year age group (except in Bangladesh, where almost half were under 20 years). This suggests that the age of marriage in Asia is generally higher than it is in Africa. Another finding of these case studies is that women often develop obstetric fistula during their first pregnancy. A similar study in KNH in 1984 reported that 36.6% of the patients were primigravida and they constituted the single largest group of patients who developed obstetric fistula (11,12,14).
There is a prolonged lag time between onset of fistula and first hospital visit. This shows that the availability of centres for fistula repair is limited or the patients are not aware of existence of the facilities. They may be afraid to use the facilities because of stigmatization. Modern health care is not acceptable to most obstetric fistula patients nor available to those with the condition. The reason for the delay to seek earlier care could be because most of fistula patients are ostracized by relatives and divorced by their husbands(5,16,18,22).
Illiteracy is a factor which determines what kind of medical help is sought. It deters people from attending hospitals. Education gives young women better access to profitable employment alternatives. It also reduces the incidence of high risk pregnancies, and abortions by increasing contraceptive use and reducing fertility. As girls stay in school longer, the average age at marriage tends to rise, as does the average age at first birth(24)
Hospital deliveries occur, but late and when tissue damage has taken place. This could be attributed to reluctance to accept hospital maternity services in time. For example, if labour becomes obstructed and all local methods fail, a woman may be taken to hospital only if consent is given by either her husband, the village chief, or sometimes her mother in-law (14).
There are controversies surrounding the role of FGM in obstetric fistula. The indirect role is that once FGM has been done the girl is married off and pregnancy follows and this could lead to obstetric fistula . The direct role is where the victim has undergone infibulation with severe healing and fibrosis. There is delayed second stage where the presenting part is stuck in the perineum for a long time and this could lead to the development of fistula(1,21,23).
In East Africa, the maternal mortality rate is estimated at 750-­820 per 100,000 births and fewer than 15% of these women had received antenatal care (21). Genitourinary fistula is a common complication of childbirth, occurring in 3-4 per 1000 deliveries(22). The most common risk factors leading to obstetric fistula are first delivery and prolonged labour (24). 
Most of the repair is vaginally under regional anaesthetic, and the success rate is more than 90%. Despite this high success rate, persistent urinary and faecal incontinence is commonly reported following surgery (22). Observational studies reported 10-12% (24).
The most common risk factors were prolonged labour and first delivery, a large number of fistulae being associated with emergency Cesarean section and instrumental delivery for obstructed labour(23).  Obstetric fistula lies along a continuum of problems affecting women's reproductive health, starting with genital infections ending in maternal mortality. Because of its disabling nature and dire consequences - social, physical and psychological -  it is the single most dramatic aftermath of neglected childbirth(8). Its prevention must ultimately lie in a profound change in the status of women. This change must involve, among other things, recognition of women's value, starting with adequate nutrition in childhood and continuing with access to primary education as a very minimum. It must include the eradication of harmful traditional practices like female genital mutilation and raising the age of marriage, giving women other ways of achieving social status than early child bearing(19,21).  In Kenya FGM has been outlawed since 2002 and compulsory free primary education has been introduced.  Early marriage (before 18 years of age) is prohibited, use of condoms as a contraceptive and prevention of sexually transmitted illness and the provision of essential obstetric care has been strengthened (1).

Conclusion

Prolonged labour is a major causative factor to obstetric fistula. The majority of fistula in this setting occur in women who are 20 years and below. The majority of obstetric fistula occur in primigravida who have no formal education or have attained primary education at the lowest level and have no occupation. Infibulation being the severe form of female genital mutilation could be a factor contributing to obstetric fistula in this study setting.

Study limitations

The study was hospital based hence some patients could have been missed and a population based study could have been ideal but not visible in poor settings . Hospital records and poor record keeping are a source of inaccurate information.

Acknowledgements

I would like to thank Geneva Foundation for Medical Education and Research for selecting me to attend this course and the Societè Medicale Beaulieu for sponsoring me. My regards to Dr Luc de Bernis from Reproductive Health WHO for guarding me through this research and Dr Isaac Malonza of Reproductive Health WHO for his critic of the research. Dr Regina Kulier of the Geneva Foundation for her tireless efforts to make sure that this report was presented in time and to my colleagues for their patience with me during the entire study period. Last but not least for the patience of my daughter Melanie and wife Carolyne and the Almighty God for keeping me well despite the cold weather.

Table 1: Socio-demographic characteristics of fistula patients

Table 2: Labor and obstetric outcomes

References

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4. Mustafa,AZ,Rushwan,HME. Acquired genitourinary fistulae in   Sudan(1979).Sudan Journal of Obstet and Gynecol,78,1039-43.

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20. [No authors listed]Nigeria task force alerts public to fistula hazards. Safe Mother. 1994 Mar-Jun;(14):9.[PubMed]

21. Mahran M. Medical dangers of female circumcision. IPPF Med Bull. 1981 Apr;15(2):1-3. [PubMed]

22. [No authors listed]. Vesico-vaginal fistula. What is an obstetric fistula? Safe Mother. 1999;(27):4, 8. [PubMed]

23. [No authors listed]. Vesico-vaginal fistula -- a major cause of unnecessary and avoidable suffering. Safe Mother. 1999;(27):1. [PubMed]

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