Conservative treatment of fresh obstetric fistula by early bladder catheterization in Burundi: Where are the patients? Wilma van den Boogaard, Aristide Bishinga, Geert Morren Médecins Sans Frontières – Brussels Operational Centre, Burundi
Results
Conclusion
Obstetric fistula (OF), most often due to unrelieved obstructed labour, continues to be a devastating complication of childbirth in developing countries where there is limited access to sufficient and timely obstetric care (Muleta, 2006).
July 2010 - December 2012, 64 (9%) of 743 women
In GFC, three in ten patients with VVF averted the need for surgery due to the offer of conservative treatment.
The resulting urinary and/or faecal incontinence not only leads to loss of dignity but women are often ostracised by their communities and even by their families (Waaldijk, 2004).
Of these women, conservative treatment was successful in 17 (27%) cases, after a median of 31 days of bladder catheterization (IQR 28-40 days).
Introduction
presenting with a VVF at GFC were eligible for conservative treatment. The median time since developing their VVF was 19 days (Interquartilerange, IQR 9-25 days).
The remaining 47 (73%) women remained incontinent despite bladder catheterization (median catheterization-time= 48 days, IQR 40-56 days).
The most common type of OF occurs between the vagina and bladder - a vesicovaginal fistula (VVF). While surgical repair is the cornerstone of treatment, preliminary evidence shows that around 28% of VVFs may close without surgery if the bladder is catheterised at an early stage (Waaldijk, 1997), ideally directly after the causal event or at least within three weeks of it (Bazi, 2007). This approach is known as “conservative treatment”. Due to the nature of the early intervention, it may avoid long-standing physical and psycho-social suffering faced by obstetric fistula patients.
The two major challenges around conservative treatment are 1) relatively late insertion of the catheter which influences outcomes and 2) low recruitment rate of women with FOF. Revised and decentralized strategies are needed with community involvement to ensure that all patients who develop a FOF are immediately catheterized at health centre level and then referred to GFC. Locally adapted measures to increase patient recruitment are also needed and these will be discussed;
FOF Case finding strategies June 2010 - December 2012
#
Project/study objectives
50
80
40
60
30
40 %
20 10
20
0
0 self refferal
• In 2010, Médecins Sans Frontières (MSF) set up a permanent and free-of-charge, Obstetric Fistula Centre in Gitega province (GFC), which to date has operated on more than 1000 patients. • Bladder catheterization was offered as primary treatment to all patients arriving at GFC within 6 weeks of their traumatic delivery. • Case finding of women with OF relied on the following strategies: radio messages, a telephone hotline, country-wide training of medical staff, and awareness raising through local social networks in one province. • We describe the preliminary outcomes of women receiving conservative treatment at GFC and the operational challenges of early patient recruitment for such treatment.
radio
# %
HC/Hosp MSF staff Unknown Modes
Transport support to reach GFC was required by 54 (84%) women. The main operational challenges were: i) early detection of fresh obstetric fistula (FOF), and ii) low recruitment of women suffering from FOF (considering a 0.2-0.5% incidence rate this should have been 10 patients per month)
Acknowledgment We thank the whole MSF Gitega team for their dedication in order to restore dignity for all affected women in Burundi.
References Muleta, M. (2006) Obstetric Fistula in Developing Countries: A Review Article / J Obstet Gynaecol Can 2006;28(11):962–966
• This study satisfied the criteria for analysis of routine data by both the National Ethics Committee in Burundi and the MSF Ethics Review Board.
Waaldijk, 2004 The immediate management of fresh obstetric fistulas./ American Journal of Obstetrics and Gynecology (2004) 191, 795e9 www.elsevier.com/locate/ajog Waaldijk, K. (1997) Immediate indwelling bladder catheterization at postpartum urine leakage--personal experience of 1200 patients / Tropical Doctor 1997 Oct;27(4):227-8. Bazi, T. (2007) Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: review of the evidence / Int Urogynecol J (2007) 18:329-333 DOI 10.1007/s00192-006-0194-7