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.
Citation
Master of medicine degree in obstetrics and gynaecologyPublisher
University of Nairobi College of Health Sciences