Abstract
SummaryBackgroundFemale genital fistula is a devastating maternal complication of delivery in developing countries. We sought to analyse the incidence and proportion of fistula recurrence, residual urinary incontinence, and pregnancy after successful fistula closure in Guinea, and describe the delivery-associated maternal and child health outcomes.MethodsWe did a longitudinal study in women discharged with a closed fistula from three repair hospitals supported by EngenderHealth in Guinea. We recruited women retrospectively (via medical record review) and prospectively at hospital discharge. We used Kaplan-Meier methods to analyse the cumulative incidence, incidence proportion, and incidence ratio of fistula recurrence, associated outcomes, and pregnancy after successful fistula closure. The primary outcome was recurrence of fistula following discharge from repair hospital in all eligible women who consented to inclusion and could provide follow-up data.Findings481 women eligible for analysis were identified retrospectively (from Jan 1, 2012, to Dec 31, 2014; 348 women) or prospectively (Jan 1 to June 20, 2015; 133 women), and followed up until June 30, 2016. Median follow-up was 28·0 months (IQR 14·6–36·6). 73 recurrent fistulas occurred, corresponding to a cumulative incidence of 71 per 1000 person-years (95% CI 56·5–89·3) and an incidence proportion of 18·4% (14·8–22·8). In 447 women who were continent at hospital discharge, we recorded 24 cases of post-repair residual urinary incontinence, equivalent to a cumulative incidence of 23·1 per 1000 person-years (14·0–36·2), and corresponding to 10·3% (5·2–19·6). In 305 women at risk of pregnancy, the cumulative incidence of pregnancy was 106·0 per 1000 person-years, corresponding to 28·4% (22·8–35·0) of these women. Of 50 women who had delivered by the time of follow-up, only nine delivered by elective caesarean section. There were 12 stillbirths, seven delivery-related fistula recurrences, and one maternal death.InterpretationRecurrence of female genital fistula and adverse pregnancy-related maternal and child health outcomes were frequent in women after fistula repair in Guinea. Interventions are needed to safeguard the health of women after fistula repair.FundingBelgian Development Cooperation (DGD), Institute of Tropical Medicine of Antwerp (ITM), and Maferinyah Training and Research Center in Rural Health (Guinea).
Highlights
Substantial international mobilisation towards achievement of a fistula-free generation has resulted in improved manage ment of fistula cases,[3] with high incidence of closure at time of hospital discharge[4,5,6] and accomplishment of more than 100 000 surgical fistula repairs in subSaharan Africa and south Asia.[7,8]
We found two recent reviews and two additional original studies reporting on fistula recurrence and pregnancy after repair of female genital fistula
We included women with a single genital fistula confirmed to be closed via dye test at the time of discharge from one of the three repair hospitals supported by EngenderHealth, who resided in Guinea.[27]
Summary
Female genital fistula generally occurs after prolonged obstructed labour, resulting in continuous and un controlled leakage of urine or faeces, among other debilitating sequelae.[1,2] Over the past decade, substantial international mobilisation towards achievement of a fistula-free generation has resulted in improved manage ment of fistula cases,[3] with high incidence of closure at time of hospital discharge[4,5,6] and accomplishment of more than 100 000 surgical fistula repairs in subSaharan Africa and south Asia.[7,8]. As more women access fistula treatment worldwide,[9] attention during the post-repair period is important to ensure health after surgery. There are many data for residual fistulas or failed repairs, few data exist for recurrent fistulas after a successful repair—this paucity might be for various reasons, including varying study designs and case definitions or length of follow-up.[10,11,18,19] data for fertility or pregnancy and childbirth after successful fistula repair are scarce, especially from robust studies that are able to provide a precise estimate of pregnancy and delivery outcomes.[10,14,18,20,21,22] A review[23] in subSaharan Africa found that the risk of adverse maternal
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