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ORIGINAL ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 4  |  Page : 386-392  

Burden and management of obstetric fistula in South-East Asian region countries: A systematic review and meta-analysis


1 Professor, Indian Institute of Public Health – Delhi, Gurgaon, Haryana, India
2 Additional Professor, Indian Institute of Public Health – Delhi, Gurgaon, Haryana, India
3 Research Associate, Indian Institute of Public Health – Delhi, Gurgaon, Haryana, India
4 Director, Indian Institute of Public Health – Delhi, Gurgaon, Haryana, India
5 WHO Respresentative to Maldives, World Health Organization, Male, Maldives

Date of Submission20-Mar-2020
Date of Decision30-May-2020
Date of Acceptance25-Jun-2020
Date of Web Publication11-Dec-2020

Correspondence Address:
Sanjay Zodpey
Indian Institute of Public Health, Plot 47, Sector 44 Institutional Area, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_200_20

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   Abstract 


Background: Each year, between 50,000 and 100,000 women worldwide develop obstetric fistulae. Approximately 2 million girls across Asia and Africa are estimated to be affected by this condition. However, there is no reliable data on its prevalence in South-East Asia region (SEAR). Objectives: The objective of this study is to systematically review and synthesize the data on the prevalence and management of obstetric fistula in SEAR. Methods: We searched for the literature that described the prevalence and management practices of obstetric fistula in SEAR. We followed the PRISMA guidelines to select the articles for the review. The quality and relevance were assessed by two reviewers independently using the SIGN checklist. A total of five articles and reports were selected for the review. To review the management practices, we found 63 original studies that were included in the review. Results: We found five community-based studies estimating the prevalence of obstetric fistula in SEAR; 3 studies were from India, one from Bangladesh and one from Nepal. The pooled prevalence according to self-reports was 1.11 (3 studies including 671,133 participants, 95% confidence interval [CI] 1.09, 1.14) per 100 women. The pooled prevalence of obstetric fistula based on the clinical examination was 0.10 (3 studies involving 4547 participants, 95% CI 0.01, 0.20) per 100 women. The value was close to the pooled estimate based on the smaller studies. Conclusion: More studies are needed to estimate reliable community-based prevalence data and also need to develop evidence-based management guidelines.

Keywords: Maternal morbidity, obstetric fistula, rectovaginal fistula, vesicovaginal fistula


How to cite this article:
Neogi SB, Negandhi H, Bharti P, Zodpey S, Mathur A. Burden and management of obstetric fistula in South-East Asian region countries: A systematic review and meta-analysis. Indian J Public Health 2020;64:386-92

How to cite this URL:
Neogi SB, Negandhi H, Bharti P, Zodpey S, Mathur A. Burden and management of obstetric fistula in South-East Asian region countries: A systematic review and meta-analysis. Indian J Public Health [serial online] 2020 [cited 2021 Jan 24];64:386-92. Available from: https://www.ijph.in/text.asp?2020/64/4/386/303092




   Introduction Top


An obstetric fistula is an abnormal opening between the vagina and bladder and/or rectum, through which urine and/or feces continually leak.[1] Each year, between 50,000 and 100,000 women worldwide develop obstetric fistulae and approximately 2 million girls across Asia and Africa are affected by this condition.

It is most often caused by unrelieved, prolonged, and obstructed labor, and other rare causes include iatrogenic causes, harmful traditional birth practices, and sexual violence. It leads to long-term debilitating condition, associated with a range of physical, social, and economic consequences, including complex urological injury, vaginal scaring and stenosis, urinary incontinence, fecal incontinence, secondary infertility, musculoskeletal injury, foot drop, chronic skin irritation, social stigmatization, isolation, stress, anxiety, psychological depression, loss of social support, divorce, worsening poverty, and malnutrition and premature death.[1],[2],[3],[4],[5],[6]

Access to high-quality maternity care has eliminated fistula from high-income countries, but it is still prevalent in resource-poor nations.[7],[8] The treatment of obstetric fistula can be conservative or surgical.[2] Fistulae can also be repaired at minimal cost using the low technology surgical operations, yet even these basic services are unavailable in developing countries.[2]

Fistulae are expected to have the high prevalence where maternal mortality is high, but there remains uncertainty around the actual estimates.[4],[5],[6] Worldwide, the prevalence estimates of obstetric fistula range from 654,000 cases to 2 million cases and an annual incidence of 50,000–100,000 cases.[3] The results from a systematic review suggest a pooled prevalence of 1.20/1000 women of reproductive age in low- and middle-income countries.[4] However, there is a limited systematic data on the burden of obstetric fistula and no review of management practices surrounding it in South-East Asia region (SEAR).[5],[4] Therefore, our objective was to systematically review and synthesize the data on the prevalence and management of obstetric fistula in SEAR.


   Materials and Methods Top


We searched for the literature that described the prevalence and management practices of obstetric fistula in SEAR (Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste).

Eligibility criteria

Any primary research study documenting the prevalence and management practices of obstetric fistula in SEAR was considered for the inclusion in this review. The articles published in the English language without any restriction on the year of publication were included.

Information sources

We identified studies by searching Medline database using PubMed platform till January 2018. The search strategy is included as [Appendix 1]. We scanned the reference list of articles and consulted experts in this field over E-mail. We hand searched journals in the field of Obstetrics and Gynecology from National Medical Library of India. We also sent E-mails to select the organizations and associations in SEAR working in Maternal and Child Health to gather information on the prevalence and management of fistula.



Search strategy

We used the following search terms (fistula/obstetric/reproductive/gynecological/labor/delivery/childbirth/VVF/vesicovaginal/RVF/rectovaginal/genital tract/vaginal/female genital tract/vesicovaginal/genitourinary) to build the search strategy [Appendix 1]-Search strategy Medline: PubMed].

Study selection

The search strategy yielded 922 articles. The title and abstract of these results were independently reviewed by two reviewers (PB, TS). If abstract was missing, only title was taken into consideration. Eight disagreements were mutually resolved; in case when there was no consensus between the two reviewers a third reviewer (HN) was consulted. Subsequently, 367 articles were shortlisted for full-text review which was assessed independently two reviewers (PB, HN) using critical appraisal checklist (based on CEBM critical appraisal and SIGN checklist). Three disagreements were resolved with a third reviewer (SN). Four additional reports and cross-references identified from the list cross-reference of these articles were included for full-text review. After full-text review of 367 articles, 5 article/reports were found to report the prevalence data and 63 articles were included for the management practices surrounding it in SEAR. The study selection process is depicted in [Figure 1].
Figure 1: Flow of study selection.

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We included studies irrespective of sample size and design. Most of the studies reported the number of patients treated presented as case reports or case series. Studies without a denominator were excluded. Studies with a denominator estimated the prevalence either based on the clinical examination or on self-reporting of the condition by individuals within a study. The final selection of studies was based on the following parameter: (i) Clear description of the study population; (ii) study settings have been described adequately; (iii) the sample population is selected using robust sampling methods; and (iv) clear description of case definition. The case definition used was constant leakage of feces or urine from the vagina and/or supported by per speculum or clinical examination by a gynecologist.

Data items and data collection process

Information was extracted from all included literature on the prevalence and management strategies of obstetric fistula in SEAR. Data were extracted by two reviewers in tabulated form from all the included.

Meta-analyses were conducted using STATA version 11 (StataCorp LLC, Texas, USA) using random effects model. Analyses were done summarizing the prevalence of fistula among women. It was expressed as pooled prevalence. All studies were stratified by case definition of fistula, whether case ascertainment was based on self-reporting by patients or clinical examination by a health provider. We tested heterogeneity using the Chi-square and the I2 statistic. The results were not weighted for calculating the meta-analytic estimate.


   Results Top


Review of the prevalence of obstetric fistula in SEAR

We found only five studies documenting the prevalence of obstetric fistula in SEAR.[6],[7],[9],[10] Out of these, three were based in India and one in Bangladesh and one from Nepal [Table 1]. We found no study reporting the prevalence from any other SEAR countries and no studies reporting hospital-based prevalence of obstetric fistula. The included studies were all community-based, cross-sectional studies.
Table 1: Prevalence of obstetric fistula in South-East Asian region based on self-reports and clinical examination

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The prevalence of fistula in community-based studies based on self-reporting of the condition by the respondents ranged from 0.5 to 1.69 for every 100 women of reproductive age with a median of 1.5. The prevalence based on the clinical reports varied from 0.08 to 0.3 per 100 women with a median of 0.1.

The sample sizes in included studies varied considerably between 385 respondents to more than 30,000 respondents. One study which was based on a national level survey had a sample size greater than 6 lakhs. Among the included studies, a prospective cross-sectional study conducted in the state of Karnataka in India in 1994 estimated a prevalence of 0.5 when self-reported by the patients and 0.3% when clinically examined by the gynecologist in a sample of 385 women who were predominantly rural; the response rate was 86%.[9] Another community-based, cross-sectional study conducted in the Nasik district of Maharashtra found a prevalence of 0.08% in tribal and nontribal women, but the dropout rate was high in this study as only 1167 out of 1560 women volunteered for clinical examination.[10] District Level Household and Facility Survey-3 (DLHS-3, 2007–2008) from India found an overall prevalence of 1.5% using a self-reported questionnaire; the range of fistula prevalence was found between 0.3% in to 3.4% in different states.[9] From Bangladesh, only one community-based prevalence study estimating the prevalence was found in this review; 1.69% women reported fistula in a sample of 31889 women from six districts of Bangladesh in a rapid survey.[7]

The pooled prevalence according to self-reports was 1.11 (3 studies including 671133 participants, 95% confidence interval [CI] 1.09, 1.14) per 100 women. Meta-analyses included one large population-based study having 69% weight probably inflated the pooled estimates. When this study was excluded, the pooled prevalence reduced to 0.17 (32329 participants, 95% CI 0.13, 0.22).

The pooled prevalence of fistula based on the clinical examination was 0.10 (3 studies involving 4547participants, 95% CI 0.01, 0.20) per 100 women. The value was close to the pooled estimate based on the smaller studies.

The pooled prevalence of 1% and I2 statistics for heterogeneity of 0.00% was calculated using STATA 11,[8] as depicted in [Figure 2], [Figure 3], [Figure 4].
Figure 2: Pooled prevalence of obstetric fistula (per 100 women) based on self-reports.

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Figure 3: Pooled prevalence of obstetric fistula (per 100 women) based on self-reports (excluding District Level Household and Facility Survey results).

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Figure 4: Pooled prevalence of obstetric fistula (per 100 women) based on the clinical records.

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Review of current management in practices surrounding obstetric fistula South-East Asia region

We found 63 original articles documenting the management of fistula. Out of these 53 studies were from India, two from Thailand, six from Korea, and one from Nepal. Four studies were case reports and other 59 were surgical case series. Most of these articles were the retrospective review of hospital records.

Treatment options

Review of these articles suggests the use of two major management strategies; conservative and surgical. Spontaneous closure of fistula using conservative management by catheter drainage that ranged from 4 to 6 weeks was reported, this method is usually used in simple fistulas caused due to prolonged labor.[12],[13]

The other strategy of surgical repair was reported to be done predominantly through transabdominal route,[14] transvaginal route,[15] or combined approach along with interposition of various types, namely mucosal or peritoneal flap[13] or omental flap[15] or perivesical fat[16] or martius flap[13] or bladder mucosa graft[17],[18] or genitogluteal fold fat pad flap[19] boari flap[20] mobilized vaginal flap[21],[22] broad ligament flaps[23] to avoid recurrence;[24] out of these martius flap in transvaginal and omental flaps in transabdominal are the most reported interposition flaps used. However, repair was also reported to be performed without any flap reinforcement.[14],[25],[26],[27]

Apart from the above-mentioned techniques, minimally invasive laparoscopic surgical techniques were also documented by some studies.[14],[28],[29],[30],[31],[32],[33],[34] Laparoscopy with O connor's technique was found to be the most common approach in these studies; O connor's technique was mostly documented in supratrigonal fistula.[32],[35] Most of these laparoscopic procedures were documented to be performed by very experienced surgeons and had good success rate.[36]

Choice of technique

Surgical repair was the most widely used management technique. It was usually used in mature or recurrent fistulas having either traumatic origin or posthysterectomy or postlower segment cesarean section procedure or postradiotherapy. Transabdominal approach is preferred in cases of complex fistulas.[37] Transvaginal approach is preferred in vaginally accessible supratrigonal fistulas and fistulas of gynecological origin, but some surgeons also prefer it for complex and complicated fistulas.[38],[39],[40],[41] Combined approach was reported to be used in cases were one approach gave a failed outcome or in cases of fistula involving trigone.[17] Few studies reported the use of transvesical repair in patients of VVF.[28],[42]

A study capturing data of 230 cases over 28 years in Thailand based showed transperitoneal extraperitoneal technique, retrovesical approach in 13%, transvaginal approach in 8.7%, fulguration 3.4%, and 3% of the cases were closed by catheterizing for 4–6 weeks.[12] In another study from the republic of Korea surgical correction using techniques such as miles procedure, urethroplasty, ureteroneocystotomy, use of transurethral pointed electrode, and use of microcoils for ureteral occlusion was reported in the cases of fistulas postsurgery for cancer or radiotherapy of the genital tract. Studies reported the use of Latzko repair or vaginal reconstruction using ileum, use of psoas hitch in India, and use of labial fat graft in Nepal.[43],[44],[45],[46],[47],[48],[49],[50] It is difficult to interpret which the method is used most often in SEAR. This indicates that there is country wise variability in type of fistula repair method employed and preferred.

The best route for the surgery is debatable. However, one study documenting 10 years' experience of 132 cases in single center in India reported the significant successful outcome of abdominal repair over vaginal repair,[15] but another study showed higher success rate of vaginal repair.[51] However, none of these studies accounted for any confounders such as severity of the fistula.[5]

Therefore, factors such as surgical complication are also taken into consideration by surgeons before selecting the option. As both the methods had some associated complications, namely bowel injuries, bowel adhesions, paralytic ileus and abdominal wound infection, hematuria, and urinary tract infection as reported in abdominal and vaginal route repairs.[15],[24]

Outcome of the management

Although surgical methods for complex fistulas revealed a fairly good success rate, the recurrence of fistula and urinary incontinence were still reported as a major post-operative menace during follow-up visits.[52],[53] Such cases were either managed by a prolonged catheterization or repeat surgical procedure or urinary diversion techniques.[15],[43],[51],[54],[55]

Other rare techniques employed were laser welding reported in one case in a study from India[56] and robotic repair in three studies.[57],[58] In cases of ureterovaginal fistulas, ureteral stenting and ureteral reimplantation were reported as a management option in one study.[59]


   Discussion Top


The pooled prevalence according to self-reports was 1.11 per 100 women, while that based on the clinical examination was 0.10 per 100 women.

Information on the prevalence of obstetric fistula in SEAR except India, Bangladesh, and Nepal is rare, and more information is needed to assess the burden. There is no record of data in Korea and other SEAR countries on the prevalence.[43] India is the only country that reported the prevalence of fistula in a nation-wide survey.[7] Another recent review reported an estimated pooled prevalence of 1.20% in low- and middle-income countries; however, this review included only two studies from South Asia, and data of DLHS-3 from India were not included in this review.[4]

There are very few studies in our review to arrive at robust estimates. Hospital-based studies describe the case series of patients treated without any denominators. However, the studies considered in our review followed more or less consistent definitions, be it in self-reports or clinical examination and all were cross sectional in nature.

Our estimates are much higher than the estimates given by the WHO or in the meta-analysis conducted for low- and middle-income countries.[5] One reason could be because self-reports would always give higher estimates. On the other hand, there is a stigma attached to this condition and women might not report it during the household survey. In developing countries, community-based prevalence studies would yield more accurate estimates if clinical examination is done. However, these are subject to more refusals and hence may introduce a selection bias. For example, in a community-based study in India, 1560 women were interviewed, but 1176 (75%) volunteered for clinical examination.[8] Moreover, given the rarity of the condition, a large sample size would be required to arrive at accurate estimates that may not be a feasible option. Medical records also grossly underestimate the prevalence and incidence of obstetric fistula.[60] Despite the inherent limitations of self-reports, it is often the only resource.

Bhatia JC et al. showed that based on self-reporting, the prevalence was 0.5% which dropped to 0.3% (by 40%) when corroborated with the clinical examination.[6] Barring the analysis where DLHS was included, pooled prevalence based on self-reports or clinical examination were similar.

All the studies had included urban and rural respondents, although rural respondents were predominant. DLHS, a large population-based survey, having the highest weight has an adequate mix of the urban and rural population and is based on a nationally representative sample.[7] Among the Indian states, Assam recorded the highest prevalence of fistula. Occurrence of fistula reflects the prevailing situation of health services. DLHS also provides an opportunity for nationwide continuous surveillance of obstetric fistula.

In our study, duration of the time since the fistula occurred could not be analyzed because the reports were not available. No information on the mode of delivery was available; hence, we could not comment whether fistula happened because of difficult or prolonged labor. The heterogeneity in the prevalence was low.

This review captures a snapshot of a wide range of management practices in SEAR. The existing studies lack methodological rigor as most of them were retrospective case series with different case, procedure, and outcome definitions. There is a lack of uniformity and a common consensus because most of the fistula surgeons have developed their own procedures through their experience and there is a high scope of surgeon's own subjective opinion.[61],[62] These studies showed that varieties of techniques are employed but transvaginal, transabdominal, and combined are the most widely used. The choice of technique is highly dependent on size, site and clinical context of fistula, and expertise of the surgeon. However, we need to identify the most effective and efficient method for fistula closure and successful management of residual incontinence.[63]

The authors have even reported the success and failure rates of the techniques but according to their own subjective definitions of outcome measures. Thus, it is difficult to draw any conclusion from the present literature on the issue of best procedure for this condition.

Most of these studies were based in the tertiary care hospital highlighting an underlying lack of fistula repair facilities in other levels of care. This is also suggested by a study from India documenting that most women who suffer from fistula due to any obstetric complication at peripheral centers are referred to tertiary care hospitals as there is a lack of awareness about even simple fistula closure technique such as catheterization.[64] Another study documented 717 fistula repair in 24 medical colleges, and none was done in any district hospital.[65] There are no evidence-based management training guidelines or programs for skill enhancement among health service care providers making access to treatment a major concern.[65]

The other lacunas identified were lack of standardized classification system for grading fistula and variability in its management. At present, 25 different fistula grading classifications used and two systems for prognostic classification are being.[63],[66],[67],[68]

Estimation of the burden of obstetric fistula is still a challenge in developing countries. Therefore, there is a dire need to conduct further studies and develop a standard and appropriate method for finding out the prevalence in SEAR. Initiation of hospital-based registries may provide true estimate provided the denominator is explicitly defined. There is also a need to develop an evidence-based decision-making guideline for caregivers at the country level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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