Obstetric Fistula is a form of genital fistula resulting from the process of delivery. It is an abnormal communication between the female genital tract and the lower urinary tract forming the urogenital fistula with consequent leakage of urine through the vagina and/or the lower gastro-intestinal tract forming the faecal genital fistula which allows leakage of faeces through the vagina. The commonest of the fistulas is the vesico-vaginal fistula (VVF) .
Obstetric fistula is a public health issue in the developing world. It is a major public health concern in Nigeria. It is a disease with tremendous socio-economic and health implications and consequences . It tells the untold story of high rate of maternal mortality in developing countries.
Generally, the obstetric fistula patient is often poor, uneducated, unhappy and abandoned. The disease takes away their dignity and is often associated with great psychological burden. Other associated problems may include infertility, menstrual irregularities, vaginal stenosis dyspareunia, apareunia, difficulty in walking, begging and cheap prostitution . Generally, victims often end up as destitute if the incontinence is not relieved. They are socially, mentally, emotionally and sometimes physically challenged .
Obstetric fistula is associated with a high fetal wastage rate, leaving victims in a profound state of despair from childlessness, incontinence and abandonment. Obstetric fistula practice manual in Nigeria reported a fetal wastage rate of 96% .
This childlessness often arose from fetal distress and consequent stillbirth resulting from prolonged obstructed labour, intrapartum neglect and different levels of delays in labour.
The problem with prolonged obstructed labour is that it causes squeeze between the fetal bone and maternal pelvic bone anteriorly and the sacrum posteriorly leading to ischaemia which subsequently leads to necrosis and sloughing off of the tissue thereby causing fistula. The halt in labour progress, the long duration of labour with increase squeeze of the fetal skull results in fetal hypoxia/anoxia and consequent fetal distress which results to stillbirth.
A cross-sectional retrospective study done in Kassala hospital, Sudan showed perinatal mortality of 35.7% . A retrospective case review study done at Kitovu hospital in Uganda showed stillbirth of 69% and early neonatal death of 12%. A hospital based cross-sectional study done at Jimma University Teaching Hospital in Ethiopia showed stillbirth rate of 85.7%.
Despite all these findings, few if any study have described the fetal wastage pattern for different types of obstetric fistula.
The general aim and objective of this study is to evaluate the fetal wastage pattern among different types of obstetric fistula at the National Obstetric Fistula Centre, Abakaliki. The specific objective will be to evaluate the overall fetal wastage pattern for obstetric fistula during the study period and to evaluate specific fetal wastage pattern for different types of obstetric fistulae.
2. Materials and Method
A one year retrospective study was conducted at the National Obstetric Fistula Centre, Abakaliki from 1st January 2016 to 31st December 2016. The centre is located in Abakaliki, South-East Nigeria and offers free services to women with genital fistulas. The centre is also a designated research centre for urogenital fistula. Her bed space capacity is 96.
Sample size: The sample size was calculated using a statistical formula based on the proportion of 0.211% for women with obstetric fistula from a study by Ijaiya et al. in Ilorin Nigeria , and a confidence level set at 95% with an error margin of 0.05.
n is the sample size
1.96 is a known constant (Standard normal deviate corresponding to 95% confidence level).
P is the proportion of women with OF in a study by Ijaiya et al. = 0.211% = 0.00211.
Q is 1 − P (proportion of the persons free from the disease = 0.998.
E is the error margin = 0.05 = 0.00211/0.000651.
Calculated minimum sample size = 3.22. A 10% attrition rate was allowed giving a total of 5 patients for the minimum sample size. However, the case notes of 203 patients were reviewed during this study period to give a better representation.
Sampling Technique: Population study was done using the case notes of all the patients that were treated in the hospital for the year 2016.
Data collection: The data was collected and analyzed using SPSS version 22.
Ethical approval was obtained from the ethical committee of the National Obstetric Fistula Centre, located in Abakaliki, for the study. The study adhered to the tenets of Helsinki declaration.
The mean age from this study is 38 ± 12.1 years. Majority of the patients are in the reproductive age group (78.8%), the highest age range is between 30 - 39 years which is 39.4%, the least age range is 70 - 79 years which is 2.9%. Majority of the patients are in a monogamous marriage setting (56.2%). Most of the patients did not have any formal education (24.1%), while majority had senior secondary education (32.5%). Majority of the patients are Ibo (73.4%), followed by Urhobo & Ibibo (5.4%) respectively. Majority of the patients are farmers (35%), which is followed by self employed (32.5%) (Table 1).
Table 1. Socio-demographic variable.
The table below showed types of obstetric fistula and the fetal outcome. From the table, the incidence of intracervical fistula was highest (17.2%), followed by circumferential defect 14.8%. The incidence of RVF was 9.4%. The least was urethral loss 1%. There was high fetal wastage (82.76%) amongst the obstetric fistula patients. The fetal wastage was highest with patients with large extensive fistula, Urethral loss and multiple fistula which were 100% respectively. There was only 15% fetal wastage rate among women with rectovaginal fistula (Table 2).
From Table 3 below, 18 patients had Juxtaurethral fistula, out of which a patient (5.6%) had a livebirth and 17patients (94.4%) had stillbirth. Twenty three patients had midvaginal fistula, out of which a patient (4.3%), had livebirth and 22 patients (95.7%) had stillbirth. Thirty five patients had Intracervical Fistula, 5 patients (14.3%) had livebirth while 30 patients (85.8%) had stillbirth. Nineteen patients had Vesicouterine fistula, 3 (15.8%) had livebirth, while 16 (84.2%) had stillbirth. Also, for Ureteric fistula, 7 patients were identified, a patient (14.3%) had livebirth while 6 patients (85.7%) had stillbirth. Thirteen patients had Large/extensive fistula, all of them (100%) had stillbirth. Nineteen patients had Rectovaginal fistula, 16 of the patients (84.2%) had livebirth, while 3 of them (15.8%) had stillbirth. Two patients had urethral loss and the two (100%) had stillbirth. Thirty patients had circumferential fistula, 2 of the patients (6.7%) had livebirth, while 28 patients (93.3%). Eight patients had vault fistula, out of which 3 (37.5%) had livebirth, while 5 (62.5%) had stillbirth. Three patients had multiple fistula, the 3 (100%) had stillbirth.
From the simple bar chart below, intracervical fistula (17.2%) was the highest, followed by circumferential defect 14.8%. The least was circumferential fistula with urethral loss (1%) (Figure 1).
Table 2. Types of obstetric fistula and fetal outcome.
Table 3. Pattern of fetal outcome amongst different types of fistulae.
Figure 1. Simple bar chart showing types of obstetric fistula.
The mean age from this study was 38 years. This age falls within the reproductive age group. This falls within the age ranges of related studies done in Abakaliki  and Ethiopia . However, it is different from the mean age of 16 years recorded in the North-Central part of Nigeria .
The fetal wastage from is study was 82.76% while the livebirth was 17.24%. This is similar to the work done in Ethiopia  and Uganda . It is also similar to the documentation in the Obstetric Fistula Manual Doctor’s version in Nigeria. However, it is different from the findings in Sudan  which was 35.7%. Seventy percent of the stillbirth were delivered via Spontaneous vertex delivery (SVD), while 11% of the stillbirth were delivered through Emergency Caesarean Section (EMCS). This is because most patients with prolonged obstructed labour present with intrauterine fetal death (IUFD), hence, the preferred choice of SVD.
Twelve different types of fistula were identified in this study using anatomical classifications by Lawson. This is similar to the findings in the studies done at Abakaliki, Kano, and Sokoto in Nigeria. It is also similar to studies done in Sudan and Ethiopia. Large extensive fistula, urethral loss and multiple fistula had the highest fetal wastage of 100% respectively. This could suggest that the magnitude of tissue loss and organ damage connotes severity and adverse fetal outcome. The fetal wastage in patients with mid-vaginal fistula was 95.7%. This was followed by Juxtaurethral fistula 94.4%, Juxtacervical fistula 88.5%, Intracervical fistula 85.8%, Ureteric fistula 85.7%, Vesicouterine 84.2%, Vault fistula 62.5%. Rectovaginal fistula had the least fetal wastage of 15.8% and the highest livebirth of 84.2%. This could be due to reduced impact on the fetus in RVF because of the presence of more maternal soft tissues and reduced maternal bony impact .
The findings showed a high fetal wastage rate amongst women with obstetric fistula. There is high fetal wastage across different types of obstetric fistula. Rectovaginal fistula had the best outcome in terms of livebirths.
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