Rehabilitation and reintegration programming adjunct to female genital fistula surgery: A systematic scoping review.

BACKGROUND: Female genital fistula is associated with significant physical, psychological, and economic consequences; however, a knowledge and practice gap exists around services adjunct to fistula surgery. OBJECTIVES: To examine rehabilitation and reintegration services provided adjunct to genital fistula surgery, map existing programming and outcomes, and identify areas for additional research. SEARCH STRATEGY: We searched the published and grey literature from January 2000 to June 2019. Two reviewers screened articles and extracted data using standardized methods. SELECTION CRITERIA: Research and programmatic articles describing service provision in addition to female genital fistula surgery were included. DATA COLLECTION AND ANALYSIS: Of 3047 published articles and 2623 unpublished documents identified, 26 and 55, respectively, were analyzed. MAIN RESULTS: Programming identified included combinations of health education, physical therapy, social support, psychosocial counseling, and economic empowerment, largely in sub-Saharan Africa. Improvements were noted in physical and psychosocial health. CONCLUSIONS: Existing literature supports holistic fistula care through adjunct reintegration programming. Improving the evidence base requires implementing robust study designs, increasing reporting detail, and standardizing outcomes across studies. Increased financing for holistic fistula care is critical for developing and supporting programming to ensure positive outcomes.

Obstetric Fistula Repair in Sub-Saharan Africa: Partnering to Create Sustainable Impact for Patients and Trainees.

Obstetric fistula, an abnormal connection between a woman's genital tract and urinary tract or rectum, can be physically and psychosocially debilitating. We describe a sustainable obstetric fistula surgical trip model that includes providers from Women and Infants Hospital at Brown University. These surgical trips provide pre-operative, surgical, and post-operative care to patients with fistulae at Kibagabaga Hospital in Kigali, Rwanda. To ensure patients are prepared for the recovery process after fistula surgery, the team created a post-operative education curriculum that includes illustrative visual aids and teaching guides translated into Kinyarwanda, focusing on topics including urinary catheter care, wound care, and pain management. Through this program, the team is committed to restoring women's dignity through fistula repair as well as providing a model for delivery of sustainable surgical care in low-resource settings. Involvement of trainees into a global health team like this can benefit both the trainee and the patients served.

Obstetric fistula: The role of physiotherapy: A report from the Physiotherapy Committee of the International Continence Society.

AIMS: To discuss the role of physiotherapy in the management of women who have suffered an obstetric fistula, referring to research findings when appropriate and available, and the experiences of clinical specialists in the field. METHODS: The experiences of physiotherapists who have worked in countries where obstetric fistula is prevalent, and the limited literature available, were considered in producing this consensus document on behalf of the ICS Physiotherapy Committee. RESULTS: The role of physiotherapy both pre- and post-fistula repair was identified, and is multi-faceted. Women may have general rehabilitation needs based on the obstructed labor itself and subsequent care. All affected women may benefit from pelvic floor muscle assessment, education and exercises to optimize the outcome of their surgery; further pelvic floor physiotherapy may be indicated for those who experience persistent genitourinary dysfunction following closure of the fistula. CONCLUSIONS: Further robust research is required to confirm the effectiveness of physiotherapy in the management of women who have suffered an obstetric fistula and the optimum development of such services. Based on the available literature and the experience of physiotherapists in the field, there was consensus within the ICS Physiotherapy Committee that patient outcomes can be improved if physiotherapy is provided as part of the multidisciplinary team. Physiotherapy should not be overlooked when fistula services are being developed.

One-year follow-up of women who participated in a physiotherapy and health education program before and after obstetric fistula surgery.

OBJECTIVE: To investigate whether the positive impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery was maintained after 1 year. METHODS: The present follow-up analysis included 108 women who underwent obstetric fistula surgery at a center in Tanguiéta, Benin, between March 2011 and March 2012, and who had received a structured program of physiotherapy and health education before and after surgery. After discharge, follow-up visits were made 3, 6, and 12 months after surgery. The Ditrovie scale was used to measure quality of life (QoL), and continence and performance of the physiotherapy exercises were assessed. RESULTS: Mean QoL score was 36.9 (range 16.0-49.0) before surgery. Overall, 84 women were followed up for 1 year. Their mean QoL score had improved significantly to 18.5 (range 10.0-47.0; P<0.001). Between hospital discharge and 1 year, the number of women with a closed fistula increased from 48 (57.1%) to 53 (63.1%) and the number with urinary stress incontinence reduced from 11 (13.1%) to 9 (10.7%). CONCLUSION: Results obtained after surgery and physiotherapy were maintained at 1 year, and QoL had improved significantly. When women are encouraged to continue exercises, improvements are also seen in residual stress incontinence.

Impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery.

OBJECTIVE: Surgery is the only successful treatment for most obstetric fistulae. The present study measured the impact of a structured program of pre- and postoperative physiotherapy and health education on the outcome of surgery for obstetric fistula. METHODS: We compared the postoperative outcomes of 2 consecutive groups of women with obstetric fistulae who were recruited and followed-up by 2 local nongovernmental organizations at a hospital in Tanguiéta, Benin. The first group of women (n=99) had fistula repair using standardized techniques. The second group (n=112) had a standardized surgical approach plus a structured program of pre- and postoperative health education and physiotherapy. RESULTS: The program had a significant positive impact on recovery in general and on urinary incontinence in particular. After physiotherapy, the odds of recovery were 2.72 times greater for women in the physiotherapy group than for control patients, and the probability of postoperative stress incontinence was considerably higher for patients in the control group than for those in the physiotherapy group (P<0.001). CONCLUSION: A structured program of health education and physiotherapy by experienced nurses and physiotherapists improves the likelihood of a successful outcome after surgical repair of obstetric fistula.

The fistula crisis in sub-Saharan Africa: an ongoing struggle in education and awareness.

This article examines the social and physical causes of obstetric fistulas, as well as resulting social and psychological consequences. Preventative strategies are addressed using Niger as a microcosm for this devastating condition that affects two million women worldwide.

Ethiopia: an epidemiological study of vesico-vaginal fistula in Addis Ababa.

A 10% sample was drawn from 3000 records on vesicovaginal fistulae operations performed at the Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries and their content were analyzed. In 88% of the cases under review the operation was classified as successful. The results of this study underline the tremendous maternal health gains which can be achieved by appropriate obstetric care in case of obstructed labour. It also reinforced the need for early detection and referral of high risk births among the very young mothers who are likely to experience an obstructed labour, the loss of the child, vesico-vaginal fistulae and possibly a ruptured uterus. In the absence of likely increases in the availability of transport, the building of waiting homes at maternal clinics is encouraged so that women can await delivery in the vicinity of a referral centre. There is a need for increased attendance of delivery by trained personnel as well as for continuing education for both staff and traditional birth attendants. It is further recommended to train former patients as helpers for the dedicated care which needs to be extended to the unfortunate, and often stigmatized victims.

PIP: Vesicovaginal fistula (VVF) associated with obstructive labor is highly prevalent throughout many developing countries with poor access to health services. Prevalence of the condition is highest among young primigravida. The Addis Ababa Fistula Hospital for Poor Women with Childbirth Injuries was opened in 1975 and cares for approximately 500 fistula patients per year. There is open access to the facility, in which women are treated with respect and dignity. Upon completion of the operation to correct her fistula, each woman is given sufficient means to return home. She also receives a fistula card which contains essential information for her future obstetric and gynecological care. A sample of 309 records was drawn randomly from the total of 3000 records of vesicovaginal operations performed at the hospital during the period 1983-88, and analyzed. The women were of average age 22.4 years in the range of 9-45 years. 82% travelled at least 700 kilometers for treatment, walking an average of twelve hours and spending an average of 34 hours in a bus. More than 50% of the women were rejected by their husbands after the fistulae developed, leaving them without means. In 52% of cases, admission occurred within six months of fistula development, although 4% of women came only 10-20 years after developing their fistulae. 88% of cases reviewed were cured completely, 6% continued to suffer from urinary stress incontinence, and in 6% of cases the operation failed to produce the desired results. These results demonstrate the enormous maternal health gains which can be achieved with appropriate obstetric care in the case of obstructed labor. They also reinforce the need for early detection and referral of high-risk births among very young mothers who are likely to experience an obstructed labor, child loss, VVF, and possibly a ruptured uterus. Unless transport can be made readily available to women with VVF, waiting homes should be built at maternal clinics so that women can await delivery in the vicinity of a referral center. Trained personnel need to be more often in attendance during delivery, while staff and traditional birth attendants should receive continuing education. It is further recommended that former patients be trained to help provide care to women with VVF.

Social work practice with childbirth-injured women in Nigeria.

Nigerian social workers in health care settings have been actively involved in the treatment of women in northern Nigeria who suffer from childbirth injury during obstructed labor. The patient population studied suffers from vesicovaginal fistula (VVF), a debilitating and chronic condition whereby a woman leaks urine uncontrollably and experiences grave social consequences. Crisis intervention, social rehabilitation, fighting stigma, and discharge planning similar to the American professional model were functions of the social workers in addressing the needs of this patient population. Implications for practice and the universality of social work skills are discussed.

Reproductive performance after the repair of obstetric vesico-vaginal fistulae.

Between 1966 and 1976, 148 out of 162 patients with obstetrically acquired vesico-vaginal fistulae were successfully repaired in Lagos University Teaching Hospital. The reproductive performance of these patients after repair has been reviewed with special regard to menstruation, satisfactory coitus and childbearing. Before the repair of the fistulae 66 patients (40.6%) had secondary amenorrhoea ranging from 4 months to 15 years. There were 3 cases each of oligomenorrhoea and cryptomenorrhoea. After repair menstruation returned within 6 months in 58 patients. Secondary amenorrhoea is thought to be due to a combination of severe malnutrition, anaemia, endometritis, psychological upsets and occasionally endocrine malfunction due to focal anterior pituitary necrosis. Repair of the fistulae worsened gynatresia in 17 cases. Twelve patients had dyspareunia and 3 others had apareunia. Thirty-one patients achieved 38 pregnancies after repair. Thirty-two infants were delivered by lower segment Caesarean section. There were 5 vaginal deliveries and one abortion. The average birth weight was 2.96 kg. The corrected perinatal mortality was nil. Five cases had a recurrence of the fistulae after delivery and 2 others had stress incontinence. Electric lower segment Caesarean section is the ideal method of delivery.