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An Agenda for An Agenda for Epidemiological Research and Epidemiological Research and

Clinical Management of Clinical Management of Obstetric FistulaObstetric Fistula

John Kelly FRCOG FRCS OBEJohn Kelly FRCOG FRCS OBEFistula Surgeon to many countries in the developing worldFistula Surgeon to many countries in the developing world

Honorary Senior LecturerHonorary Senior LecturerDept of Public Health & Epidemiology Dept of Public Health & Epidemiology

University of BirminghamUniversity of Birmingham

What is the evidence ?What is the evidence ?

FrequencyFrequency of occurrenceof occurrence

Unknown

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What is the evidenceWhat is the evidence

AetiologyAetiology

Obstructed labour

PRESSURENECROSIS

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4

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What is the evidence ?What is the evidence ?

Risk factorsRisk factorsLack of access to appropriate emergency obstetric care 7 days per week, 24 hours per day

? Younger age? Low parity

Refs: Kelly J & Kwast BE Int Eurogynecol J 1993; 4:278-281Miller S et al J Midwifery Womens Health 2005; 50: 286-294

What is the evidence: What is the evidence: TreatmentTreatment

Randomised controlled trials– Prophylactic antibiotics– Surgical Techniques

Tomlinson & Thornton Br J Obstet Gynaecol. 1998 Apr;105(4):397-9

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Effects of PovertyEffects 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):7-13Kelly J 2004 J Obstetrics & Gynecology 24:117-118

Prevention Prevention and and

TreatmentTreatment

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Prevention and TreatmentPrevention and Treatment

1855 New York Fistula Hospital (Sims)

1895 Converted to a General Hospital

Strategies to reduce maternal mortality should also reduce maternal morbidity

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The most important single factor in prevention of maternal mortality and morbidity is access to

appropriate emergency obstetric care

Problems in rural areasProblems in rural areas

Doctors, nurses, midwives prefer to work in urban areas

Migration

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Initiatives which may work Initiatives which may work where obstetric fistula are where obstetric fistula are

commoncommon

Involve non-doctors and others with appropriate (initial and in-service)

training

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Ensure they are recognised,

accountable members of health care team

TTBAs

Clinical officers (licentiates)

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Nigeria Nigeria –– Dr M BrennanDr 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 Maternal deaths before and after introduction of trained after introduction of trained

TBAsTBAs

5813457020183-97

79081006479-82

Rate per 100,000

BirthsNumberYear

St. Mary’s Hospital, Urua, Akpan

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Community survey of Community survey of maternal deaths before & after maternal deaths before & after

introduction of TTBAsintroduction of TTBAs

322912 villages without TTBAs

296421 villages with TTBAs

After(83-87)

Before(79-82)

Ada-Ogar AM, et al 1996: Postgraduate Doctor, Africa, 18, 86-90

Study DesignStudy Design

Cluster randomised controlled trial Unit of randomisation taluka (sub-district)Simple cluster randomisation sampling schemeComputer generated procedure3 intervention and 4 control talukas

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ResultsResults

19,557 women recruited May to October 1998Intervention 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

Control 9443 women (79% of est eligible), all but 11 followed up, 9250 babies born

Primary Outcomes

*Singleton births only

Indicator Interventionn (%)

Control n (%)

Cluster Adjusted

Odds ratio 95% CI

p

Perinatal death*

823 (8.47) 1077 (11.9) 0.70 (0.59-0.82) <0.001

Maternal

death

27 (0.27) 34 (0.36) 0.74 (0.45-1.23) 0.24

Neonatal

death*

340 (3.50) 439 (4.88) 0.71 (0.62-0.83) <0.001

Stillbirth* 483 (4.97) 638 (7.10) 0.69 (0.57-0.83) <0.001

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ConclusionsConclusions

This model of training and integrating TBAs with improvements to existing services was effective in reducing perinatal mortality

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 Zambia –– Dr M TyndallDr M Tyndall

Urban maternity clinic run by midwives who adhere to strict guidelines

Radio linkage

Dedicated ambulance

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Lusaka Lusaka ––Number of deliveries per yearNumber of deliveries per year

32,34110,5251998

2,20023,4961982

Urban maternity clinic

Teaching hospital

Corcoran B, et al. 1999: Evaluation Report, Lusaka Urban Maternity Clinics Project. Dublin, Evaluation & Audit Unit, Irish Aid

Maternity Waiting AreaMaternity 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

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Maternal mortality and Maternal mortality and stillbirth ratestillbirth rate

SB rate

MM rate

21.91.7

1539.0148.3

Direct to Hospital

Maternity Waiting Area

Effect of a Maternity Waiting Area Effect of a Maternity Waiting Area on maternal mortality and stillbirth on maternal mortality and stillbirth

in rural Ethiopiain rural EthiopiaThe 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

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LISTEN TO THE LISTEN TO THE PATIENTPATIENT

CONSUMER CONSUMER OPINIONOPINION

Ruptured uterusRuptured uterusOUTCOME

SB 239 (97.6%)NND 1LIVE BIRTH 5 (2.0%)

MAT. DEATHS 13 (5.3%)FISTULA 26 (10.8%)

TOTAL 245

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PrimigravidaePrimigravidae

Ruptured uterus 0.8 %

V.V.F. 63 %

Operative procedureOperative procedure

Repair 238

Hysterectomy 6

Slough 1

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Ruptured uterus followRuptured uterus follow--upup

21Vag delivery followed by CS

42Two subsequent vag deliveries

3030One subsequent vag delivery

63Two subsequent CS

7575One subsequent CS

BabiesMothers

TreatmentTreatment

Where woman has no living children and / or desires more children, repair of

uterine rupture is culturally acceptable and medically

safe, with PROVISOSFekadu et al 1997: Lancet 349, 622.Kelly et al 1998: J Obs & Gyne, 18, 50-52.

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Research on managementResearch on managementof fistulaeof 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

StaffExpertise

COMPASSION

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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).

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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.

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V.V.F.V.V.F.--Techniques in addition to Techniques in addition to basicsbasics

%Reconstruction of urethra 428 14.5Reanastomosis of urethra 403 13.6to bladder

Reimplantation of ureters 391 13.2Martius graft 385 13.0Gracilis graft 30 1.0No additional 1321 44.7

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TYPE OF FISTULA REPAIRTYPE OF FISTULA REPAIR

%Vesico-vaginal 2202 71.7

Recto-vaginal 114 3.7

Both vesico-vaginal 756 24.6& recto-vaginal

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