Nigerian gynaecologists have finally admitted that the growing number of obstetric fistula cases (holes developed between the vagina and rectum or bladder) are as a result of surgical errors caused by doctors and healthcare professionals during medical procedures, most often, during caesarean sections (CS).
They conceded to this fact after several hospital-based studies proved that there is now an increase in iatrogenic fistulas, giving rise to more maternal morbidity and mortality.
Some of the studies were explained in a presentation by Prof. Oladosu Ojenbgede, during a ‘hands-on training on VVF repair workshop’ at the 51st annual scientific conference of The Society of Gynaecology and Obstetrician of Nigeria (SOGON) held at Usmanu Danfodiyo University Teaching Hospital (UDUTH), with support from USAID Fistula Care Plus project.
Dr Olatunji Lawal, who gave the presentation on behalf of Prof. Ojengbede, said a systematic review of articles on fistula done in Nigeria by Ijaiya et al in 2010, in Maiduguri, showed that CS is now among the causes of rising cases of obstetric fistula.
In the study; ‘About 10 per cent of obstetric fistula cases were caused by CS, about 9 per cent were caused by surgical trauma, about 1 per cent by traumatic vaginal laceration from Port Harcourt clinic.
Dr Lawal revealed that at University College Hospital Ibadan (UCH), a 5-year review of obstetric fistula cases was also conducted. “In the studies, about 150 fistula cases were studied, out of these, about 14% were iatrogenic and they had a ureteric injury while about 25% had uretero-cervical-vaginal fistula likely iatrogenic.
The largest review of iatrogenic fistula ever done was by Rasen et al in 2014. They reviewed 5959 cases across about 11 countries and tried to look at how many fistulas occurred from iatrogenic causes. From that review, they discovered about 805 iatrogenic fistulas. They also found that 80 per cent of these iatrogenic fistulas occurred after procedures to address obstetric complications- frequently C-Section, followed by hysterectomy and repair of a ruptured uterus. These procedures were performed by all cadres of health staff”, he stated.
In 2016, Fistula Care Plus Project released a statement document to address this issue called ‘rising trend in iatrogenic fistula. They reviewed all the countries they were in partnership with- about 18 countries, where they looked at the incidents of iatrogenic fistulas and the commonest cause. From the paper, about 42% of the intergenic fistulas came from CS alone. From the graph presented, Nigeria had a 14% rise in iatrogenic fistula.
Concurring with this studies, Chief Consultant Fistula Surgeon, and former Commissioner for Health Zamfara State, Dr Saad Idris, said; “Iatrogenic fistula is fistula that we health practitioners cause during medical procedures. if we can do a safe caesarean section, fistula can be wiped out.
Unfortunately, we have some studies showing 26 per cent cases of iatrogenic fistulas occurring in many hospitals. I have gone to some centres in the southern part of the country and seen where some 30 patients were operated and 20 developed an iatrogenic fistula. It is becoming commoner too in the northern part of the country”.
According to him, training and continuous training is key to eliminating iatrogenic fistula.
“We have to make sure that SOGON tries and train the medical students and house officers. This is because most of the CS done at the general hospitals are not done by specialists. So we should tailor the training not only to the specialists but also to the younger medical officers.
We have realised that early marriage is no longer one of the predisposing factors to developing fistula, so laying emphasis on early marriage alone is wrong. Because sometimes you will see a woman who has delivered eleven times and develops fistula on the 12 time. So any woman at any age can develop fistula if during delivery she fails to go to a place where she can get safe CS. A woman can attend all the ante-natal, go for a C-Section and still develop fistula so it is the time we tell ourselves the truth. The government need to strengthen the health system in order to prevent maternal mortality and morbidity”, he said.
In her presentation, Dr Sadiya Nasir, from the National Obstetric Fistula Centre, Babbar Ruga, Kastina, revealed that in some centres, there has being a record of 13 per cent of iatrogenic fistulas and this is a cause for concern.
She said; “in our centre, we did a two-year review of the fistula cases and we got about 20 per cent of the cases being iatrogenic. But that could be because our centre is a referral centre”.
According to the lead facilitator, Prof. Oladosu Ojengbede, there are now more cases of iatrogenic fistulas.
“Ordinarily, fistulas are supposed to come as a result of complications of difficult labour, but when women have fistula as a result of surgical interventions for some gynaecological condition such as fibroid or prolapse, that is iatrogenic. This shouldn’t be. It is true that every surgery has some element of risk attached to it, but the alarming rate we are seeing this iatrogenic fistula is of great concern to us”, he noted.
According to the Lancet study, C-Section is a necessary intervention for prolonged obstructed labour and prevention of fistula.
But the CS should be done by someone who is competent and should be safely done, Prof. Ojengbede said. He further explained that; “what we are seeing now is either the person doing it is not proficient enough and is not able to safely do it hence the person ends up establishing a hole between the reproductive system and the bladder, leading to fistula. This shows the poor quality of care received by some women and is a step back on the level of care given by such doctors.
That is why we are making it a wake up call to all professional bodies, that people should be made aware that this is a problem that needs to be addressed. This is why this is come up at SOGON -a professional body for gynaecologists so that they can caution their members on the quality of training they provide for their members, be it resident doctors, medical students and others”.
During the training, doctors were told that the primary approach to prevent iatrogenic fistula is prevention.
“we don’t want it to happen at all so the careful study of the anatomies might help the surgeon in preventing this kind of complications. The reproductive and urinary tract act is closely related anatomically so this close relationship exposes the urinary tract to injury during pelvic surgeries. The knowledge of these two anatomy parts play an important part in preventing injury during obstetrical and gynaecological surgeries, Dr Lawal, said.
Doctors had an opportunity to do a hands-on fistula surgery during the session. One of the two patients, Fatima Umar, 20 years, had a fistula which developed 6 months ago as a result of prolonged obstructed labour. She was repaired successfully.
“Initially the fistula tends to look very simple but after the dissection, it turns out to be a very wide one involving a technical procedure. The reason is that the fistula was trying to close but it couldn’t close. Immediately we opened the initial opening, it turned out to become a wider fistula in between the urethra and the bladder so it became a little bit complicated.
We had to do an extensive dissection and made sure we corrected the defect so that the fistula can be closed. I can say she is a very lucky woman”, the lead surgeon, Dr Idris, said.
Explaining the surgery procedure he said; “we used a combined technic developed over the years, we dissected the vaginal wall out from the bladder and urethra, then we did a step by step surgery. We started closure from the angles, then in between, we applied a suture to make sure it is closed. We dilated the urethra, passed the catheter and did a dye test, to confirm that the operation is successful. I also developed a method of putting in a suture at the pubic bone to support the inner suture that we did.
“Now that the woman is dry, we don’t advise her to deliver vaginally again, because when you have a scar tissue, the place is no longer going to be like before. And probably the reason why she developed the fistula was because she had a big baby which was bigger than the pelvic or maybe because of a smaller pelvic so she can develop another fistula if she tried a vaginal delivery. We advocate such women to deliver through Safe C-Section”.
Now that women are beginning to heed the call to deliver at health centres, these fistula surgeons say there is need to ensure that women receive quality health care by providing safe CS and preventing iatrogenic fistulas.
The Guardian News