The fourth delay in obstetric fistula: A Kenyan perspective

Abstract

BackgroundObstetric fistula is a severe medical condition in which a hole develops between either the bladder or the rectum and the vagina after prolonged neglected childbirth leading touncontrolledleakage of urine and/or stool. Surgery usually restores anatomic integrity and physiologicalfunction, and is routinely recommended between 8 and 12 weeks from onset of leakage.Much is known about the three delays that lead to this severe form of maternal morbidity. However, little work has been done to characterize the fourth delay i.e. the period from the routinely recommended 12 weeks for repair to the actual time of definitive treatment,and the temporal sequence of the psychosocial and sexual consequences that ensue.Scientific urgency in the management of obstetric fistula is not well documented. ObjectiveTo establish the duration of delay experienced by obstetric fistula patients before definitivetreatment, its causes as reported by the patient, and the impact this delay has on the onsetof selected psychosocial and sexual consequences relative to the duration of leakage. Mainoutcome measures The duration in years from onset of leakage to definitive treatment and,relative to this duration, the rate of occurrence of the following psychosocial and sexual sequelae:divorce, premature termination of education, suicidal ideation, abandoning sexual activity,social alienation, loss of income and physical abuse. DesignA multi centre hospital based cross sectional survey. SettingKenyatta National Hospital and five affiliated hospital based obstetric fistula repair unitsin Kenya. Methods Three hundred and four women with obstetric fistula presenting or referred for surgerybetween June 2009 and November 2009 at the participating obstetric fistula repair unitswere screened for eligibility. One hundred and fifty eligible patients were systematically sampled, interviewed and data collected using a provider administered questionnaire. Analysis,which consisted of all the one hundred and fifty sampled participants, was done usingSPSS version 17.0 and EPI info version 3.5.1. ResultsThe mean duration of urine leakage was 9 years (range 3 weeks to 47 years). One hundredand forty women (93%) had delayed access to definitive surgery. The main reason fordelayed repair was fmancial constraints (37%). Three quarters of the study participants (78%) presented to a health facility seeking definitive treatment within 12 weeks from developmentof obstetric fistula. In univariate analysis, older age at development of fistula significantly correlated with delayed repair (p = 0.01). The incidence' of most of the consequencesunder study peaked between 9 months and 1 year from onset of leakage. Those delayed in repair were 2.6 times more likely to develop the psychosocial and sexual consequencesunder investigation ( 95% CI 1.9 - 6.9 ). At multivariate analysis, age at onset of fistula significantly explained delayed repair (p value = 0.004 ). On logistic regression, patientswho delayed in getting repaired had a 50 % more probability (exponent 0.40) of developingone or more of the selected sequelae (p = 0.025 ). Conclusion and recommendation: Delayed defmitive treatment for obstetric fistula is a key determinant of the morbidity that ensues due to urine or stool leakage. Where it is not possibleto repair a patient by the routinely recommended 12 weeks, surgery within 9 months of onset of obstetric fistula significantly reduced the odds of developing the associated psychosocialand sexual consequences under investigation in this study.