Childbirth Injury Research Articles

Patient characteristics, surgery outcomes, presumed aetiology and other characteristics of fistula surgeries and related procedures supported by Fistula Foundation from 2019 to 2021: a multicentre, retrospective observational study

ObjectivesObstetric fistula is a devastating childbirth injury primarily caused by prolonged, obstructed labour. It leaves women incontinent, severely stigmatised and isolated. Fistula repair surgery can restore a woman’s health and...

GP's role in supporting women with anal incontinence after childbirth injury: a qualitative study.

Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs. To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries. A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care. This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries (n = 41); and second, focus groups with GPs (n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined. Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication. The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting.

The mechanism of adipose mesenchymal stem cells to stabilize the immune microenvironment of pelvic floor injury by regulating pyroptosis and promoting tissue repair

Pelvic organ prolapse (POP) has a high incidence rate among Chinese women. Repeated mechanical stimulation is an important factor causing POP, but the injury mechanism has not yet been elucidated. The purpose of this study is to explore the related mechanisms of pelvic floor supporting tissue damage caused by mechanical force and the application of stem cell therapy. First, we obtained vaginal wall and sacral ligament tissue samples from clinical patients for examination. Pelvic floor support tissues of POP patients displayed high expression of inflammation and immune disorders. Then, we constructed a rat model of childbirth injury. In vivo and in vitro experiments investigated the key mechanism of pelvic floor support tissue injury caused by mechanical force. We discovered that after mechanical force, a large number of reactive oxygen species (ROS) and macrophages rapidly accumulated in pelvic floor tissues. ROS stimulated macrophages to produce NLRP3 inflammatory complex, induced the release of interleukin (IL-1β) and pyroptosis and exacerbated the inflammatory state of damaged tissues, persisting chronic inflammation of fibroblasts in supporting tissues, thus causing the pelvic floor's extracellular matrix (ECM) collagen metabolic disorder. Resultingly impeding the repair process, thereby causing the onset and progression of the disease. Through their paracrine ability, we discovered that adipose mesenchymal stem cells (ADSCs) could inhibit this series of pathological processes and promote tissue repair, asserting a good therapeutic effect. Simultaneously, to overcome the low cell survival rate and poor therapeutic effect of directly injecting cells, we developed a ROS-responsive PVA@COLI hydrogel with ADSCs. The ROS-scavenging properties of the gel could reshape the site of inflammation injury, enhance cell survival, and play a role in subsequent treatment. The findings of this study could serve as a basis for early, targeted intervention therapy for POP and representing a promising approach.

BIRTH INJURY, DUCHENNE-ERBʼS OBSTETRIC PALSY. DIAGNOSIS AND TREATMENT (LITERATURE REVIEW)

Obstetric practice dates back thousands of years, providing assistance to women in labor is often complicated by the rapid course of labor, pelvic presentation of the fetus, shoulder dystocia with a possible clavicle fracture. Damage to CV–CVI roots, classic Duchenne–Erb palsy, accounts for 46 % of the total number of obstetric palsies. Objective. To analyze the scientific and medical literature in order to identify historical scientific and practical information about the study of childbirth injuries, and, in particular, Duchenne–Erb's obstetric palsy. Methods. To study and analyze sources of scientific and medical information, publications from Google search engines, electronic databases PubMed, Google Scholar, archival medical journals. Results. The first data on obstetric paralysis were provided by Duchesne in 1872, highlighting thorough reports on upper extremity muscle damage. Subsequently, in 1874, Erb performed electrical stimulation of the affected muscles, finding out the zone of neurological damage. The history of the development and formation of this scientific issue is quite ambiguous, because it borders on two medical fields: neurosurgery and orthopedics. According to literary sources, it is obvious that the pathohistology and pathophysiology of the direct injury zone (roots CV–CVI), delayed changes in the function of the upper limb, and the latest diagnostic technologies simplify the understanding of the presentation. The existing methods of operative interventions allow physicians to improve the child's life. However, the question remains open regarding the use of certain operative interventions in relation to the child's age and further rehabilitation. Conclusions. Despite a significant stratum of scientific and practical research on Duchenne–Erb's obstetric palsy, there are still a number of questions regarding the diagnosis and treatment of children with this abnormality. The search for improving the functional state of the upper limb in children should continue.

Women's experiences of anal incontinence following vaginal birth: A qualitative study of missed opportunities in routine care contacts.

This study aimed to explore experiences of women with anal incontinence following a childbirth injury, and to identify areas of missed opportunities within care they received. This is a qualitative study involving semi-structured interviews. Participants were recruited via five hospitals in the UK, and via social media adverts and communication from charity organisations. Women who have experienced anal incontinence following a childbirth injury, either within 7 years of sustaining the injury, or if they identified new, or worsening symptoms of AI at the time of menopause. Main outcomes are experiences of women with anal incontinence following childbirth injury, and missed opportunities within the care they received. The following main themes were identified: opportunities for diagnosis missed, missed opportunities for information sharing and continuity and timeliness of care. Anal Incontinence following a childbirth injury has a profound impact on women. Lack of information and awareness both amongst women and healthcare professionals contributes to delays in accurate diagnosis and appropriate treatment.

Brain-Derived Neurotrophic Factor Is Indispensable to Continence Recovery after a Dual Nerve and Muscle Childbirth Injury Model.

In women, stress urinary incontinence (SUI), leakage of urine from increased abdominal pressure, is correlated with pudendal nerve (PN) injury during childbirth. Expression of brain-derived neurotrophic factor (BDNF) is dysregulated in a dual nerve and muscle injury model of childbirth. We aimed to use tyrosine kinase B (TrkB), the receptor of BDNF, to bind free BDNF and inhibit spontaneous regeneration in a rat model of SUI. We hypothesized that BDNF is essential for functional recovery from the dual nerve and muscle injuries that can lead to SUI. Female Sprague-Dawley rats underwent PN crush (PNC) and vaginal distension (VD) and were implanted with osmotic pumps containing saline (Injury) or TrkB (Injury + TrkB). Sham Injury rats received sham PNC + VD. Six weeks after injury, animals underwent leak-point-pressure (LPP) testing with simultaneous external urethral sphincter (EUS) electromyography recording. The urethra was dissected for histology and immunofluorescence. LPP after injury and TrkB was significantly decreased compared to Injury rats. TrkB treatment inhibited reinnervation of neuromuscular junctions in the EUS and promoted atrophy of the EUS. These results demonstrate that BDNF is essential to neuroregeneration and reinnervation of the EUS. Treatments aimed at increasing BDNF periurethrally could promote neuroregeneration to treat SUI.

North-central Nigerian women’s experiences of obstetric fistula risk factors and their perceived treatment services: An Interpretive Description

BackgroundAn obstetric fistula also known as vesico vaginal fistula (VVF), or recto-vaginal fistula (RVF) is an abnormal opening between the urogenital tract and intestinal tract caused by prolonged obstructed labour; when the head of the baby presses on the soft tissues in the pelvis leading to loss of blood flow to the women’s bladder, vagina, and rectum. This can cause necrosis of the soft tissues resulting in debilitating fistula formations. AimThis study aimed to uncover North-central Nigerian women’s experiences of obstetric fistula and their perceived treatment services. DesignQualitative, interpretive descriptive methodology underpinned by symbolic interactionism involving face-to-face semi-structured interviews was used to explore North-central Nigerian women’s experiences of obstetric fistula and their perceived treatment services. SampleA purposive sample of 15 women who had experienced obstetric fistula at a repair Centre in North-central Nigeria were eligible. ResultsFour themes emerged from North-central Nigerian women’s experiences of obstetric fistula and their perceived treatment services i) I was left alone in the room ii) Waiting for the one vehicle in the village iii) I never knew about labour until that very day iv) and We kept following the native doctors and sorcerers. ConclusionThe findings from this study highlighted the depth of women’s experiences from the devastating complication of childbirth injury in North-central Nigeria. Analysis of insights from women’s voices directly affected by obstetric fistula demonstrated that in their views and experiences the themes identified were majorly responsible for their fistula status. Thus women need to raise their collective voices to resist oppressive harmful traditions and demand empowerment opportunities that will improve their social status. Government should improve primary healthcare facilities, train more midwives and subsidise maternal care for antenatal education and birth services spending for childbirth women may result in improved childbirth experiences for women in rural and urban communities. Tweetable AbstractReproductive women call for increased accessibility to healthcare services and the provision of more midwives to mitigate obstetric fistula in North-central Nigerian communities.

Effects of mesenchymal stem cells and heparan sulfate mimetics on urethral function and vaginal wall biomechanics in a simulated rat childbirth injury model

Introduction and hypothesisNew treatments are needed for pelvic floor disorders. ReGeneraTing Agent® (RGTA®) is a promising regenerative therapy. Therefore, the objective of this study was to compare regenerative abilities of mesenchymal stem cells (MSCs) and RGTA® on regeneration after simulated childbirth injury in rats.MethodsRats underwent pudendal nerve crush and vaginal distension (PNC+VD) or sham injury. Rats that underwent PNC+VD were treated intravenously with vehicle, MSCs or RGTA® 1 h, 7 days, and 14 days after surgery. Sham rats received 1 ml vehicle at all time points. After 21 days, urethral function and pudendal nerve function were tested. Vaginal tissues were harvested for biomechanical testing and histology. Biaxial testing was performed to measure tissue stiffness.ResultsPNC+VD decreased urethral and pudendal nerve function compared with sham. Vaginal wall stiffness was significantly decreased in longitudinal and transverse tissue axes after PNC+VD compared with sham. MSC or RGTA® did not restore urethral or pudendal nerve function. However, MSC treatment resolved loss in vaginal wall stiffness in both tissue axes and improved collagen content within the vaginal wall. RGTA® treatment increased vaginal wall anisotropy by increasing relative stiffness in the longitudinal direction. PNC+VD (with vehicle or MSCs) enhanced elastogenesis, which was not observed after RGTA® treatment.ConclusionsTreatment with MSCs facilitated recovery of vaginal wall biomechanical properties and connective tissue composition after PNC+VD, whereas treatment with RGTA® resulted in anisotropic biomechanical changes. This indicates that MSCs and RGTA® promote different aspects of vaginal tissue regeneration after simulated childbirth injury.

Advanced maternal age and adverse obstetrical and neonatal outcomes of singleton pregnancies

ObjectiveTo assess the impact of advanced maternal age on pregnancy and childbirth outcomes of singleton pregnancies. Study designWe retrospectively assessed singleton pregnant mothers who gave birth at Khaleej-e-Fars Hospital in Bandar Abbas, Iran, from January 2020 to January 2022. Demographic and obstetrical factors include educational level, medical insurance, residency place, access to prenatal care facilities, number of prenatal care visits, smoking status, gestational age, parity, infertility, maternal comorbidities, preeclampsia, eclampsia, preterm birth, low birth weight (LBW), intrauterine growth restriction (IUGR), macrosomia, placenta abnormalities (previa/acreta), placenta abruption, chorioamnionitis, meconium fluid, fetal distress, methods of delivery, rate of cesarean section (CS), perineal lacerations, postpartum hemorrhage, childbirth injury, shoulder dystocia, congenital malformation, neonatal asphyxia, and unfavorable maternal and neonatal outcome were compared between two groups. The Chi-square test assessed the relationship between categorical factors and maternal age groups. The influence of advanced maternal age on the risk of unfavorable pregnancy outcomes was evaluated using bivariate and multivariate logistic regression. ResultsOf 8354 singleton deliveries, 22.2% belonged to advanced-age mothers. Advanced-age mothers had less education than those aged 20–34 years old. Chronic hypertension, cardiovascular disease, overt diabetes, and thyroid dysfunction were more prevalent among advanced-age mothers. Compared with mothers aged 20–34 years, mothers aged 35 years and higher had a significantly higher risk of gestational diabetes (aOR: 3.18, 95%CI: 1.56–6.95), preeclampsia (aOR: 2.91, 95%CI: 1.35–4.72), placenta abnormalities (aOR: 1.09, 95%CI: 0.77–1.94), CS (aOR: 3.16, 95%CI: 1.51–3.87), postpartum hemorrhage (aOR: 1.94, 95%CI: 1.24–2.61), intensive care unit admission (aOR: 1.36, 95% CI: 1.15–1.99), LBW (aOR: 1.35, 95%CI: 0.97–2.96), preterm birth (aOR: 2.36, 95%CI: 1.65–4.83), stillbirth (aOR: 1.18, 95%CI: 1.01–3.16), and neonatal intensive care admission (aOR: 2.09, 95%CI: 0.73–3.92). According to bivariate regression, the risk of meconium fluid was lower in advanced-age mothers; however, the result of multivariate logistic regression found no correlation between advanced age and the Incidence of meconium fluid. ConclusionAdvanced-age mothers are at increased risk of adverse pregnancy and childbirth outcomes, which persist even after adjusting for several potential confounders.

Brain-Derived Neurotrophic Factor Is an Important Therapeutic Factor in Mesenchymal Stem Cell Secretions for Treatment of Traumatic Peripheral Pelvic Injuries.

Traumatic neuromuscular injury to the pudendal nerve and urethra during childbirth does not regenerate well and contributes to stress urinary incontinence in women. Mesenchymal stem cells (MSCs) can improve neuroregeneration via their secretions, or secretome, which includes brain-derived neurotrophic factor (BDNF). In this study, we investigated whether BDNF is a key factor in the secretome of MSCs for the facilitation of functional recovery following a dual simulated childbirth injury. BDNF knockdown (KD) MSCs were created using an anti-BDNF shRNA lentivirus vector. A scrambled sequence was used as a transduction control (scrambled). Cells were cultured for 24 h before media was concentrated 50x to create concentrated conditioned media (CCM) containing MSC secretome. CCM of unmanipulated MSCs was screened for high BDNF expression (high BDNF CCM). Concentrated control media (CM) was created by concentrating media not conditioned by cells. Female Sprague-Dawley rats underwent bilateral pudendal nerve crush and vaginal distension (Injury) or sham injury. One hour and 1 week after injury, sham injured rats received CM, and injured rats received CM, high BDNF CCM, KD CCM, or scrambled CCM (300 μl intraperitoneally). Three weeks after injury, rats underwent leak point pressure (LPP) and pudendal nerve sensory branch potential (PNSBP) recordings. The urethra and pudendal nerve were harvested for anatomical assessment. ANOVA followed by the Student-Newman-Keuls test determined significant differences between groups (p < 0.05). BDNF KD CCM had significantly decreased BDNF concentration compared to scrambled CCM, while the concentration in high BDNF CCM was significantly increased. LPP was significantly decreased in CM and KD CCM treated animals compared to sham injury, but not with scrambled or high BDNF CCM. PNSBP firing rate showed a significant decrease with CM treatment compared to sham injury. Neuromuscular junctions in the urethral sphincter in KD CCM, scrambled CCM, and high BDNF CCM were healthier than CM treated rats. While anatomical and nerve function tests demonstrate regeneration of the pudendal nerve with any CCM treatment, LPP results suggest it takes longer to recover continence with reduced BDNF in CCM. BDNF in MSC CCM is an important factor for the acceleration of recovery from a dual nerve and muscle injury.

Characterizing persistent urinary incontinence after successful fistula closure: the Uganda experience

Obstetric fistula is a devastating childbirth injury. Despite successful closure of the fistula, 16% to 55% of women suffer from persistent urinary incontinence after surgery. This study assessed the type and severity of persistent incontinence after successful fistula closure and its impact on the quality of life of Ugandan women post-fistula treatment. This cross-sectional study enrolled women with a history of obstetric fistula repair who continued to have persistent urinary incontinence (cases, N=36) and women without incontinence (controls, N=52) after successful fistula closure. Data were collected in central and eastern Uganda between 2017 and 2019. All the participants completed a semistructured questionnaire. Cases underwent a clinical evaluation and a 2-hour pad test and completed a series of incontinence questionnaires, including two novel tools designed to assess the severity of incontinence in low-literacy populations. Cases were more likely to have acquired a fistula during their first delivery (63% vs 37%, P=.02), were younger when they developed a fistula (20.3±5.8 vs 24.8±7.5 years old, P=.003), and were more likely to have had >2 fistula surgeries (67% vs 2%, P≤.001). Cases reported a much higher rate of planned home birth for their index pregnancy compared to controls (44% vs 11%), though only 14% of cases and 12% of controls actually delivered at home. Cases reported higher rates of pain with intercourse (36% vs 18%, P=.05), but recent sexual activity status (intercourse within the previous six months) was not significantly different between the groups (47% vs 62%, P=.18). Among cases, 67% reported stress incontinence, 47% reported urgency incontinence, and 47% reported mixed incontinence. The cough stress test was successfully done with 92% of the cases, and of these, almost all (97%) had a positive cough stress test. More than half (53%) rated their incontinence as "very severe," which was consistent with objective findings. The 24-hour voiding diary indicated both high urinary frequency (average 14) and very frequent leakage episodes (average 20). Two-hour pad-tests indicated that 86% of cases had >4 g change in pad weight within 2 hours. Women with more severe incontinence reported a more negative impact on their quality of life. The mean score of the International Consultation on Incontinence Questionnaire-Quality of Life was 62.77±12.76 (range, 28-76, median=67), with a higher score indicating a greater impact on the quality of life. There was also a high mental health burden, with both cases and controls reporting high rates of suicidal ideation at any point since developing fistula (36% vs 31%, P=.67). Women with obstetric fistulas continue to suffer from severe persistent urinary incontinence even after successful fistula closure. Both stress and urgency incontinence are highly prevalent in this population. Worsening severity of incontinence is associated with a greater negative impact on the quality of life.

Five-year results of no-fault compensation related to childbirth injuries in Taiwan

ObjectiveIncreasing obstetric medical litigations had great impacts in health care system resulted in lower recruitment of residents and higher medical cost of defensive medicine in Taiwan. In order to reduce medical litigation, the “Childbirth Accident Emergency Relief Act” was implemented in June 2016. This study presented five-year results of a novel childbirth accident compensation system. Materials and methodsThe purpose of the Relief Act was to establish a national relief system to ensure timely relief, reduce medical disputes, promote the partnership between patient and medical personnel. The compensations included maximal 2 million NTD for maternal death, maximal 0.3 million NTD for neonatal and fetal deaths, and 3, 2, and 1.5 million NTD for maternal or neonatal profound, severe, and moderate disabilities, respectively. Puerperal hysterectomy was included with maximal 0.8 million NTD compensation. ResultsSince June 30, 2016 to June 30, 2021, there were 1340 applications reviewed by Committee and 1258 were approved with total relief of 744.7 million NTD (26.6 million USD) with approve rate of 93.9%. It took an average of 109.8 days to start application from childbirth and 102.4 days to get compensation from application. 66.1% of accident victims agreed this system can restore doctor–patient relationship by immediate care and assistance from medical institutions. ConclusionThe Relief Act is the first government leading compensation system to establish a national relief system. It was enacted to reduce medical disputes, promote the partnership between patient and medical personnel, and enhance health and safety of women during childbirth. A no-fault compensation would be an efficient alternative disputes resolution to childbirth accidents.

Childbirth-Associated Fistula and Perineal Tears Repaired on Outreach Campaigns in Remote Democratic Republic of Congo.

PurposeTo describe the demographics and evaluate the repair of childbirth-associated injuries leading to incontinence in patients in remote Democratic Republic of Congo (DRC).Patients and MethodsFour surgical outreach campaigns were organised between March 2018 and October 2019. These campaigns specifically targeted women with incontinence secondary to childbirth-associated injuries. Patients were recruited on a voluntary basis, and locations included Katako-kombe (Sankuru province), Wamba (Haut Uelé province), Karawa (North Ubangi province) and Kipaka (Maniema province). Necessary care was provided along with informal teaching with local healthcare professionals.ResultsA total of 481 patients,14–71 years old with a mean of 32 years of age, were included in this study. The average duration of incontinence associated with a childbirth injury was 6.8 years. Vesicovaginal fistulas (277/481; 57.6%) and perineal tears (148/481; 30.8%) were predominant, while the combination of vesicovaginal and rectovaginal fistulas were seen in only 5 (1.0%) patients. Vaginal delivery (259/481; 53.9%), caesarean section (120/481; 25.0%) and laparotomy (hysterectomy) (102/481; 21.2%) were identified as the causes of the fistulas treated during the surgical campaign. Vesicovaginal fistulas were more likely to require complex repairs, as compared to rectovaginal fistulas and perineal tears (P-value <0.0001). As well, vesicovaginal fistulas were less likely to result in successful resolution of the incontinence when compared to rectovaginal fistulas and perineal tears (P-value < 0.0001).ConclusionVesicovaginal fistulas are predominant among childbirth injuries encountered in remote DRC with poorly managed vaginal deliveries being the leading cause. Cure rate of fistulas and perineal tears is high during outreach campaigns; however, long-term follow-up is limited. There remains a need to train and mentor rural medical professionals in the DRC on adequate management of obstetric emergencies.

Hematometrocolpos secondary to distal vaginal obstruction following childbirth: A Case Report from Monze Mission Hospital, Monze, Zambia

Vaginal outlet obstruction commonly occurs with congenital anomalies resulting in accumulation of menstrual blood in the vagina or both vagina and uterine cavity. Childbirth injuries such as cervical, vaginal and perineal lacerations as well as episiotomies are common and may result in complications like vaginal stenosis and excessive perineal scarring. Reported here is a rare case of complete occlusion of the vaginal introitus secondary to a badly healed injury resulting from childbirth.

A novel tropoelastin-based resorbable surgical mesh for pelvic organ prolapse repair.

Pelvic organ prolapse is a common condition that affects 1 in 4 women across all age groups. It is mainly caused by vaginal birth injury and can be exacerbated by obesity and increased age. Until recently, treatment strategies often used non-degradable synthetic meshes for reconstructive surgery. However, owing to their frequent, unacceptable rate of adverse events such as mesh erosion, transvaginal meshes have been banned in many countries. Recent reports have highlighted the urgent need for biocompatible design of meshes for a safe and effective treatment in the long term.This study reports the design and evaluation of a novel, elastin based degradable mesh using an ovine model of POP as a potential surgical treatment. Elastin is a protein component of the ECM and provides elasticity to tissues throughout the body. Tropoelastin, the monomer subunit of elastin, has been used with success in electrospun constructs as it is a naturally cell interactive polymer. Biomaterials that incorporate tropoelastin support cell attachment and proliferation, and have been proven to encourage elastogenesis and angiogenesis in vitro and in vivo.The biological properties of tropoelastin were combined with the physical properties of PCL, a degradable synthetic polymer, with the aim of producing, characterizing and assessing the performance of continuous tropoelastin:PCL electrospun yarns. Using a modified spinneret electrospinning system and adjusting settings based on relative humidity, four blends of tropoelastin:PCL yarns were fabricated with concentration ratios of 75:25, 50:50, 25:75 and 0:100. Yarns were assessed for ease of manufacture, fibrous architecture, protein/polymer content, yarn stability - including initial tropoelastin release, mechanical strength, and ability to support cell growth. Based on overall favorable properties, a mesh woven from the 50:50 tropoelastin:PCL yarn was implanted into the vagina of a parous ewe with vaginal wall weakness as a model of pelvic organ prolapse. This mesh showed excellent integration with new collagen deposition by SEM and a predominant M2 macrophage response with few pro-inflammatory M1 macrophages after 30 days. The woven tropoelastin:PCL electrospun mesh shows potential as an alternative to non-degradable, synthetic pelvic organ prolapse mesh products.

Obstetric fistula stress: concept paper

Introduction: Preventing and managing obstetric fistula contributes to the achievement of the Sustainable Development Goal three (3) of improving maternal health. Obstetric fistula is one of the most serious and tragic childbirth injuries. It leaves women leaking urine, faeces or both, and often leads to chronic medical problems with underlying stress, depression, social isolation and deepening poverty. Most women will not seek treatment but rather isolate themselves leading to complications. Also, and quite disturbing, most women do not know that the anomaly can be corrected. According to WHO (2005), an estimate of 50,000 to 100,000 women are found to be developing obstetric fistulae each year. In developing countries, in particular, more than two million women living with obstetrical fistulae are under the age of 30. In poor countries, the youngest patients are 12-13 years, between 50 to 80% of women are younger than 20 years in developing countries. Therefore, it is of utmost importance to equip women so as to prevent early marriage, adolescent pregnancies, endorse the importance of educating a girl child and the importance of hospital delivery and antenatal care services. Methodology: Walker & Avant’s (2011), eight (8) step classic procedure for concept analysis was adopted in analyzing the concept of obstetric fistula stress. Literature search was done in 3 weeks and out of the 30 reviewed only 12 articles were selected for analysis. Google scholar search engine was used to assess journals and papers. Results: Literature focused on defining the attributes of obstetric fistula, which are early marriages, teenage pregnancies, late antenatal booking and home deliveries. Obstetric fistula was defined as a hole that develops between the birth canal and bladder and/or rectum, it is caused by prolonged, obstructed labour without access to timely, high-quality medical treatment. It leaves women leaking urine, faeces or both, and often leads to chronic medical problems with underlying stress, depression, social isolation and deepening poverty. Conclusion: Obstetric fistulae affect the woman as she becomes emotionally, physically and psychologically stressed. She becomes a social outcast, worsened by at times a fruitless, prolonged and exhaustive, painful labour. Most men end up divorcing these women as the sexual activity is affected, further deepening the impact of the injury and its associated loss and accompanying stress. The development of an obstetric fistula is directly linked to obstructed labour, one of the major causes of maternal and neonatal morbidity and mortality. Medium to low income countries can manage obstetric fistulae by advocating for a delayed age of first pregnancy, encouraging the cessation of harmful traditional practices and promoting timely access to maternity and obstetric care, and when present disseminating information of its repair by simple surgery. It is therefore of vital importance that women be prepared to avoid early marriage, teenage pregnancy, appreciate the importance of educating a child, and have access to hospital care provisions and prenatal care services.

The Relationship Between Self-fulfilling Prophecies and Social Reintegration Among Obstetric Fistula Patients in Different Repair Categories at St. Joseph Kitovu Hospital, Uganda

Background: Obstetric fistula is a debilitating childbirth injury. Patients live in despair and self-stigmatize. Studies highlight beliefs and perceptions about the cause of the disease and how it can be cured. Experiences among both treated and untreated patients are also discussed vastly but there is limited information on negative perceptions and beliefs among obstetric fistula patients towards their spouses, families, and communities and how these affect social reintegration. This study determined the relationship between self-fulfilling prophecies and social reintegration among obstetric fistula patients in different repair categories. Methods: A cross-sectional mixed-methods survey was done among the obstetric fistula patients (n=398) at St. Joseph Kitovu Hospital in Uganda. Also, 12 key informants participated. A semi-structured questionnaire and an in-depth interview were used to get data from the patients. The interviews covered patients’ expectations and beliefs on reacceptance, interaction, self-satisfaction and comfort with others. The hypothesis: “there was a significant relationship between self-fulfilling prophecies and social reintegration among obstetric fistula patients in different repair categories” was tested by Pearson chi-square at a 95% confidence interval. Results: Accordingly, 51.5%, 14.4% and 9.0% of the 398 participants felt that their spouses, communities, and parents respectively would not reaccept them. Again, 33.6% were not satisfied with their lives and 47.7% felt uncomfortable around others. A major difference was observed in the relationship between their self-perceived stigma, sense of loss, self-worth, achievement, the expectation of reacceptance, perception of others’ attitudes towards them, labeling, moods, self-satisfaction, comfort with others and social reintegration. A relationship with the patients’ repair category was noted across all variables: P-values less than 0.001 at a 95% confidence interval. Conclusion: A relationship was found between the patient’s negative beliefs, perceptions, and social reintegration. Negative beliefs and expectations could be transformed into positive ones through the promotion of personal hygiene and comprehensive counseling.

Childbirth Injuries: an issue fraught with risks from the health care and medicolegal perspectives.

Birth injuries caused by medical negligence are a real threat for mothers and their children, which can entail catastrophic, life-changing consequences, permanent disability, or even death. Families almost always seek redress from doctors and/or facilities, but in order for a birth injury malpractice claim to be successful, it needs to be proven that the medical care providers owed a duty to the child and that they were derelict in that duty and did not meet the proper standard of care; Furthermore, a causal relationship needs to be established between injury sustained by the child and the physician's or provider's breach of duty to the child. Relevant scientific articles have been collected by drawing upon medical search engines and archives such as Medline, Cochrane Central, Scopus, Web of Science, Science Direct, EMBASE and Google Scholar, through December 2019, using keywords such as "birth injuries", "malpractice", "claims". Moreover, the Authors have delved into legal databases (Justia, Lexis, De Jure, Leagle), identifying 6 meaningful instances of court cases centered around birth injuries with severe consequences, all stemming from malpractice and negligence. Ultimately, it can be concluded that demonstrable and adequately documented compliance with well-established guidelines and/or best practices are a determining factor in the legal defence of health care operators; that in turn can go a long way towards discouraging meritless claims and frivolous lawsuits, which constitute a challenging issue raising health care costs in many countries.

Capacity building in female pelvic medicine and reconstructive surgery: Global Health Partnership beyond fistula care in Ethiopia.

Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it. Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia. This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum. We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

Addressing the fistula treatment gap and rising to the 2030 challenge.

Obstetric fistula is a neglected public health and human rights issue. It occurs almost exclusively in low‐resource regions, resulting in permanent urinary and/or fecal incontinence. Although the exact prevalence remains unknown, it starkly outweighs the limited pool of skilled fistula surgeons needed to repair this childbirth injury. Several global movements have, however, enabled the international community to make major strides in recent decades. FIGO's Fistula Surgery Training Initiative, launched in 2012, has made significant gains in building the capacity of local fistula surgeons to steadily close the fistula treatment gap. Training and education are delivered via FIGO and partners’ Global Competency‐based Fistula Surgery Training Manual and tailored toward the needs and skill level of each trainee surgeon (FIGO Fellow). There are currently 62 Fellows from 22 fistula‐affected countries on the training program, who have collectively performed over 10 000 surgical repairs. The initiative also contributes to the UN's Sustainable Development Goals (1, 3, 5, 8, 10, and 17). The UN's ambitious target to end fistula by 2030 will be unobtainable unless sufficient resources are mobilized and affected countries are empowered to develop their own sustainable eradication plans, including access to safe delivery and emergency obstetric services.