NEW YORK (Reuters Health) – Recurrence of female genital fistula and adverse pregnancy-related and child health outcomes are frequent after fistula repair in Guinea, and interventions are needed to safeguard the health of women who become pregnant after such repair, an international research team says.
“Female genital fistula is a devastating maternal complication of delivery in developing countries,” Dr. Alexandre Delamou of Gamal University of Conakry in Guinea and colleagues write in The Lancet Global Health, online September 20.
To assess the incidence of fistula recurrence and other outcomes after successful fistula closure in Guinea, the team recruited 481 women (mean age at surgery, 34) from 2012 through 2014 and followed them for a median of 28 months. Of the women, 28% were recruited prospectively (i.e., at hospital discharge).
Seventy-three fistulas recurred, for a cumulative incidence of 71 per 1,000 person-years (incidence proportion, 18.4%).
Of 447 women who were continent at hospital discharge, 24 had post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23.1 per 1,000 person-years, or 10.3%.
Among 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106.0 per 1,000 person-years, or 28.4%. Of the 67 women with at least one post-repair pregnancy, 51 (76%) had at least one antenatal care visit for the first post-repair pregnancy.
Of the 50 women who had delivered by the time of follow-up, nine had elective cesarean section. Among the 50 deliveries, there were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death.
“Fistula surgery does not end the suffering of women who get this condition in Guinea and probably in other similar developing countries,” Dr. Delamou told Reuters Health by email.
“We found, for instance, that two out of 10 deliveries result in stillbirth because most of these women do not deliver with a skilled birth attendant,” he said. “This is a social injustice if we consider the suffering that they experienced when living with the fistula or seeking repair surgery.”
“In addition, it is known that most of these women . . . lost their babies when they developed the fistula,” he observed, “so imagine the trauma that a second loss would create in their lives and those of their families.”
“We found that a group of women are particularly at risk of developing recurrence after fistula surgery, including women who had a damaged urethra, a damaged bladder neck or who presented with vaginal scarring at the time of fistula (surgery),” he noted.
“Such women have between two and three times more at risk of experiencing recurrence after repair compared to women without such characteristics,” he said. “Therefore, they need more attention when they leave the hospital after repair.”
“Women from less developed countries need more support for maternal and child health,” Dr. Delamou stressed. “Improving access to and quality of obstetric care can prevent them from developing fistula.”
“For those who develop fistula, it is important to include post-repair interventions to ensure the results achieved during surgery are maintained after repair. Governments also need to fight poverty and address gender issues that are the distant roots of fistula,” he concluded.
Dr. Jeremy Wright of the University of Surrey in Guilford, UK, author of an accompanying commentary, told Reuters Health, “Obstetric fistula remain a problem in low-income countries. Surgery without long-term care has a very high morbidity and late mortality.”
“Improvements in obstetric care leading to a lower maternal mortality ratio is mirrored in a reduction in fistula rates,” he said by email. “Although fistula rates overall are falling, an increasing number are iatrogenic and associated with cesarean section.”
Is the study relevant to women in high-income countries? “Yes and no,” Dr. Wright said.
“Obstetric fistula is very rare in high-income countries,” he noted, “but with increasing cesarean rates and repeated cesareans leading to a condition called placenta percretia, and uncontrolled hemorrhage leading to emergency hysterectomy and subsequent bladder trauma, the problem is becoming more prevalent.”
SOURCES: http://bit.ly/2y2jHzs and http://bit.ly/2xk3zWA
Lancet Glob Health 2017.
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