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Vesicovaginal fistula repairs at Aberdeen Women’s Centre in Sierra Leone

This is one of the stories from the September 2012 issue of International News. Alyona Lewis and colleagues describe the great work being done for women with vesicovaginal fistulae in a fistula centre in Sierra Leone.

Use the table below to access other stories in this issue.

Editorial In their own words: 12 stories of vesicovaginal fistulae
The problem of obstetric fistula: a personal view Provision of fistula services and programmes
Update on the FIGO/RCOG and partners competency-based fistula training manual The problem of continuing urinary incontinence after obestetric vesicovaginal surgery
Creating a balanced narrative about women living with fistulae Moving beyond incontinence
Vesicovaginal fistulae in Nepal Vesicovaginal fistulae in Bangladesh
Vesicovaginal fistula repairs in Tanzania transportMYpatient: overcoming the barrier of transport costs
Obstetric fistula surgery in Uganda Journal club

 

Obstetric fistula is an unknown condition in developed countries, but is sadly still all too common in many of the poorest countries in the world, where access to maternity care is not available to many young mothers. Sierra Leone is one such place. It is ranked one of the lowest-income countries in the world and is still recovering from a brutal civil war, which officially ended in 2002.

With a population of just over 6 million people, most of them aged under 40 years old, Sierra Leone has some of the poorest health indicators in the world, with a life expectancy of 47.5 years for both sexes; an infant mortality rate of 89 per 1000 live births; an under-five mortality rate of 286 per 1000 live births and a maternal mortality ratio of 1600 per 100 000 births and even higher maternal morbidity. According to the National Health Strategic Plan 2011–2015, there are estimated to be only five obstetricians and 111 midwives in active service in the country. The majority of women therefore receive little or no antenatal care and deliver at home or in a rural health centre with possibly only an untrained traditional birth attendant to assist them.

Many of the women giving birth in these conditions are already at a disadvantage because of a combination of young age, poor diet and chronic infection with malaria and gut parasites, all leading to poor nutritional state and possibly an inadequate pelvis for vaginal delivery. In many cases, after days of painful labour, their baby will be stillborn and the woman will find herself leaking urine and/or faeces from the vagina as a result of prolonged pressure of the baby’s head against the back of the pubic bone causing ischaemic necrosis of the intervening soft tissues and creating either a vesicovaginal fistula or a rectovaginal fistula.

In the past these women had no possibility of treatment and remained in their villages, where they became outcasts because of the bad smell, and were often left in huts on the floor. However, fistulae can be cured and there are now two centres in Sierra Leone offering such services for free.

Patient at Aberdeen Women's Centre in Freetown, Sierra Leone 

One of the vesicovaginal fistula wards at Aberdeen Women's Centre in Freetown, Sierra Leone

One centre is the Aberdeen Women’s Centre which began as an offshoot of the Mercy Ships Sierra Leone charity, but is now an organisation in its own right, with funding from EngenderHealth and the Gloag Foundation in partnership with the Sierra Leone Ministry of Health. The centre is continuing the work that began with Mercy Ships Sierra Leone in 2005, after the first cases were identified and treated by international workers operating in the government hospital at the end of the war.

There are now two full-time surgeons working in the fistula centre at Aberdeen Women’s Centre, with visiting international staff joining them at regular intervals during the year when extra complex cases will be undertaken. There is a comprehensive team of staff employed in the centre, including an outreach team who visit rural areas throughout Sierra Leone to raise awareness about the condition and screen for patients suitable for treatment.

There are also radio messages in all the local languages and a toll-free hotline number for people to call to get further information and arrange to be visited for screening. In March 2012 a ‘fistula camp’ was held for the first time, when large numbers of patients were screened and then brought to Aberdeen Women's Centre, with 52 operations being performed over 2 weeks.

Aberdeen Women’s Centre has been gradually increasing capacity for screening and treating patients, and now performs over 200 operations per year. In 2011, 324 patients were screened for obstetric fistulae and 238 underwent fistula surgery. Figure 1 indicates the cause of the fistulae seen at Aberdeen Women’s Centre in 2010 and 2011. The vast majority were caused by prolonged obstructed labour. Figure 2 indicates the number of days the women spent in labour. The majority of babies were stillborn as shown in Figure 3.

Figure 1: Cause of fistulae seen at Aberdeen Women’s Centre, Freetown, Sierra Leone

Graph showing causes of fistula at Aberdeen Women's Centre, Freetown, Sierra Leone

Figure 2: Number of days spent in labour for women treated for fistulae at Aberdeen Women’s Centre, Freetown, Sierra Leone

Graph showing number of days spent in labour for women treated for fistulae at Aberdeen Women's Centre, Sierra Leone

Figure 3: Fetal outcome in fistula cases seen at Aberdeen Women’s Centre in Freetown, Sierra Leone

Graph showing fetal outcome in fistula cases seen at Aberdeen Women's Centre, Sierra Leone

Figure 4: Duration of fistulae in patients treated at Aberdeen Women’s Centre in Freetown, Sierra Leone, in 2010 and 2011

Graph showing duration of fistulae in patients treated at Aberdeen Women's Centre, Sierra Leone, in 2010 and 2011

A few patients require secondary surgery if not completely cured the first time. In 2011, the total number of primary fistula cases seen was 161, compared with 215 primary cases seen in 2010.

It is possible that there was previously a backlog of cases resulting from many years of women going unseen and untreated in rural areas. Some patients reported that their fistula (or ‘piss problem’ as it is called in Krio) dates back to an event many years previously. In fact, data collected at the unit suggest that women are now presenting earlier with the problem (Figure 4).

More treated women are being seen for follow-up, such that the total number of secondary fistula cases seen in 2011 was 77, compared with 43 secondary cases seen in 2010.

The surgery varies in nature, depending on the extent of damage, from mid-vaginal repair of a small vesicovaginal fistula to major bladder or bowel repair, urinary diversion, ureteric reimplantation, Kelly’s plication and slings (for urinary stress incontinence).

Patients attending an occupational therapy session at Aberdeen Women's Centre, Sierra Leone

Patients attending an occupational therapy session at Aberdeen Women’s Centre, Sierra Leone

The fistula unit at Aberdeen Women’s Centre recognises that the damage done by fistulae is more than a gynaecological problem. There is almost always accompanying psychological trauma and social problems linked with becoming an outcast and having no financial support. Some women also suffer with foot drop from nerve damage in obstructed labour, or have contractures and muscle wasting resulting from lack of movement during their confinement. The unit therefore also provides counselling, physiotherapy and occupational therapy to help them to rebuild their lives and look forward to a healthy and productive return to their community. On the day of their discharge the patients all attend a ‘gladdi gladdi’ (happy happy) ceremony with a new dress and a ticket home to start their new lives.

Patients waiting to go home in new dresses, Aberdeen Women's Centre, Sierra Leone

Patients waiting to go home in new dresses, Aberdeen Women’s Centre, Sierra Leone

Gladdi Gladdi celebration of new starts, Aberdeen Women's Centre, Sierra Leone

Gladdi Gladdi celebration of new starts, Aberdeen Women’s Centre, Sierra Leone

Outcomes postoperatively are generally good, with up to 85% of patients being continent at 1-year follow-up. Those who are not cured will be considered for further surgery or alternative management. There are also reasonable obstetric outcomes for those wishing further pregnancy, with up to 20% of patients who have had a fistula going on to have a normal pregnancy and healthy baby delivered by caesarean section. At Aberdeen Women’s Centre there is also a maternity unit where patients who have had a fistula will receive free antenatal care and planned delivery. All patients receive health education about future pregnancies and are offered family planning.

Of course, the key to better women’s health in the future is preventing fistulae from happening in the first place. This requires a concerted national and international effort to strengthen maternity health services in countries such as Sierra Leone; recognising maternal health as a priority and providing access to skilled birth attendants who are able to recognise the signs of obstructed labour and refer for early intervention. It also requires education for women to enable them to advocate for their own rights and to know that in pregnancy and labour they do not have to suffer in silence as their mothers and grandmothers have done.

Alyona F Lewis MD, Senior Medical Officer/Obstetric Fistula Surgeon, Aberdeen Women’s Centre, Freetown, Sierra Leone

Carolyn Ford MRCOG, MBChB, DTMH, Obstetrician and Gynaecologist, Aberdeen Women’s Centre, Freetown, Sierra Leone

Tagie Gbowuru Mansaray, Medical Officer and Fistula Surgeon Trainee